POST TRAUMATIC STRESS

DISORDER
PRESENTED BY:DR.A.GODSON,MD
 INTRODUCTION
Disorder driven by pathogenic memories of
past danger.
Symptoms must last for more than a month
Acute stress disorder, which occurs earlier
than PTSD
 EPONYMS OF PTSD
Civil War-Irritable heart
World War I-shell shock
/Effort syndrome
World war II combat stress
syndrome
Vietnam War- brought the
concept of PTSD.
Gulf war syndrome
PTSD entered the DSM-III in
1980
 Common feature shared by all
syndromes
Fatigue, fainting
Shortness of breath,
Palpitations,
Headache, dizziness,
Excessive sweating,
Disturbed sleep,
Difficulty in
concentration
Forgetfulness
 EPIDEMIOLGY
Lifetime prevalence -8 percent in general
population
5 to 15 percent -subclinical forms of the
disorder.
Among high-risk groups -5 to 75 percent.
10 to 12 percent among women
5 to 6 percent among men.
Higher in women, single, divorced, widowed,
socially withdrawn, of low socioeconomic level
 Sexual assault-higher impact
Sudden unexpected death
of a loved one and road
traffic accidents
Men -more traumatic
events
Women - higher impact
events.
 COMORBIDITY
Depressive disorders
Substance-related disorders
Anxiety disorders
Bipolar disorders
ETIOLOGY
 Stressor
Prime causative factor
Stressors of human design-rape and violent
assault, are usually more pathogenic
Sudden, unexpected, and life-threatening
events
Disasters related
 Risk factors for being exposed to
trauma
Less than a college education
Being male
History of childhood conduct
problems
Family history of psychiatric
illness
Extroverted
More neurotic
 Risk factors for PTSD Among those
exposed to trauma
Female, neuroticism
Lower social support
Lower IQ
Pre-existing psychiatric
illness
Family history of mood,
anxiety, or substance
abuse disorders
Neurological soft signs
 PREDICTORS
Previous exposure to trauma
Peritraumatic responses
Negative interpretations of one's acute
responses
Borderline, paranoid, dependent, or antisocial
personality disorder traits
Presence of childhood trauma
Inadequate family or peer support system
Recent stressful life changes
Recent excess alcohol intake
 GENETICS
1/3rd of variance in
symptoms is genetic
Trauma exposure-little or
no effect on measures of
IQ &neurocognitive
functioning
Similarity in the test
scores between co-twins
implies genetic influence
on cognitive performance
Above average cognitive
ability -protect
 Psychodynamic Factors
Trauma has reactivated a previously quiescent, yet
unresolved psychological conflict
The subjective meaning of a stressor may determine
its traumatogenicity.
Traumatic events can resonate with childhood
traumas.
Inability to regulate affect can result from trauma.
Somatization and alexithymia may be among the after
effects of trauma.
Common defenses -denial, minimization, splitting,
projective , dissociation, and guilt
Mode of object relatedness involves projection and
introjection
 COGNITIVE FACTORS
Affected persons cannot process or rationalize
the trauma that precipitated the disorder.
They continue to experience the stress and
attempt to avoid experiencing it by avoidance
techniques.
Less decline in vividness, emotional intensity, and
accuracy of traumatic memories.
Exhibit difficulty retrieving specific memories
Difficulties of attentional control
 Emotional Stroop paradigm
Delayed naming
of the word's
colour
Heightened
stroop
interference for
trauma words in
PTSD
 Fear conditioning
Mowrer's two-factor conditioning theory
Traumatic stimuli (UCS) fear&arousal
UCS+CS fear response stimulus
generalization variety of stimuli become
triggers avoidance of CS negative
reinforcement by operant conditioning
prevents extinction of conditioned fear
responses maintains the problem.

 Noradrenergic System
Nervousness, increased blood
pressure and heart rate,
palpitations, sweating,
flushing, and tremors -
symptoms of adrenergic
drugs.
Increased 24-hour urine
epinephrine concentrations in
veterans
 Increased urine
catecholamine
concentrations in sexually
abused girls
Platelet alpha2- and
lymphocyte beta 2
adrenergic receptors are
downregulated
 Flashbacks after
yohimbine
administration
 HPA Axis
Low plasma and urinary
free cortisol
CRF challenge yields a
blunted ACTH response
DMST- enhanced
suppression of cortisol
Indicates hyper-
regulation of HPA axis
 Structural changes

Lower average volume

in the hippocampal
region
Structural changes in
the amygdale
 Exaggerated Startle Responses

Larger EMG eye blink

responses to a sudden
auditory stimulus
Increased HR
 NEUROIMAGING
PET Studies-less anterior cingulate activation
during the emotional Stroop task
fMRI experiment- attenuated rostral anterior
cingulate activation when exposed to war-
related words
Dysfunction in the medial prefrontal cortex
and amygdala
Hypoactive medial PFC loss of inhibition
on amygdala hyper-responsive amygdala
DSM-IV-TR Diagnostic Criteria for
Posttraumatic Stress Disorder
The person has been exposed to a traumatic event
in which both of the following were present:
The person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
The person's response involved intense fear,
helplessness, or horror.
Note: in children, this may be expressed instead
by disorganized or agitated behavior
The traumatic event is persistently re-experienced in
one (or more) of the following ways:
Recurrent and intrusive
distressing recollections of
the event, including
images, thoughts, or
perceptions. Note: in
young children, repetitive
play may occur in which
themes or aspects of the
trauma are expressed.
Recurrent distressing
dreams of the event.
Note: in children, there
may be frightening
dreams without
recognizable content.
 Acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback
episodes, including those that occur on awakening or
when intoxicated). Note: in young children, trauma-
specific reenactment may occur.
Intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
Physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the
trauma), as indicated by three (or more) of the following:

Efforts to avoid thoughts, feelings, or conversations

associated with the trauma
Efforts to avoid activities, places, or people that arouse
recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant
activities
Feeling of detachment or estrangement from others
Restricted range of affect (e.g., unable to have loving
feelings)
Sense of a foreshortened future (e.g., does not expect to
have a career, marriage, children, or a normal life span
Persistent symptoms of increased arousal (not present
before the trauma), as indicated by two (or more)

Difficulty falling or staying asleep

Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
 Duration of the disturbance (symptoms in Criteria B, C,
and D) is more than 1 month.
The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With delayed onset: if onset of symptoms is at least
6 months after the stressor
 DSM-IV ICD-10 research diagnostic
criteria.

Avoidance/numbing cluster Not included

of symptoms - requiring a Patient could be diagnosed
minimum of three as having PTSD in the
Increased arousal is absence of hyperarousal
necessary symptoms if amnesia is
Minimum symptom present
duration of 1 month Not included
Significant distress or Not included
impaired functioning
PTSDs in Children and Adolescents
High rates war related
trauma, kidnapping,
severe illness or burns,
bone marrow
transplantation, natural
and man-made disasters
Underestimated in
children and adolescents.
Family factors
Parents' responses to
traumatic events
 Reenactment and Reexperiencing
Reexperience the traumatic
event in the form of
distressing, intrusive thoughts
or memories, flashbacks, and
dreams
Nightmares, flashbacks also
play a role
Traumatic play, a specific form
of reexperiencing seen in
young children, consists of
repetitive acting out of the
trauma or trauma-related
themes in play

 Older children may

incorporate aspects of the
trauma into their lives in
a process termed
reenactment.
Impulsive acting out
secondary to anger,
sexual acting out,
substance use, and
delinquency
Regressive behaviors,
such as enuresis or fear of
sleeping alone
 Gulf War Syndrome

Began in 1990 and ended

in 1991
Irritability, chronic
fatigue, shortness of
breath, muscle and joint
pain, migraine headaches,
Digestive disturbances,
rash, hair loss,
forgetfulness, and
difficulty concentrating .
Amyotrophic lateral
sclerosis (ALS)
 11/9/01

Terrorist activity
destroyed the world trade
center in new york city
and damaged the
pentagon in washington.
Survey found a
prevalence rate of 11.4
percent for PTSD and 9.7
percent for depression in
US citizens 1 month after
11/9
 Tsunami

December 26, 2004.

Many survivors continue
to live in fear and show
signs of PTSD
Fishermen fear venturing
out to sea
Children fear playing at
beaches they once
enjoyed
Trouble sleeping in fear of
another tsunami
 Hurricane

In August 2005, a
category 5 hurricane,
Hurricane Katrina,
ravaged the Gulf of
Mexico, the Bahamas,
South Florida,
Louisiana, Mississippi,
and Alabama
 Earthquake
On October 8, 2005, a 7.6
magnitude earthquake hit
South Asia, affecting
Pakistan, Afghanistan and
Northern India.
More than 85,000 casualties
have occurred .
Up to 3 million people were
left homeless.
Many cases of PTSD
developed among those
who experienced these
disasters
Recently in japan
 Torture
Defined as any deliberate
infliction of severe mental pain or
suffering, usually through cruel,
inhuman, or degrading treatment
or punishment.
Torture is distinct from most
other types of trauma because it
is human inflicted and
intentional.
physical -beatings, burning of the
skin, electric shock, or
asphyxiation
Psychological -threats,
humiliation, or being forced to
watch others, often loved ones,
being tortured.
 BRAIN WASH
Combine physical and
psychological aspects is
brainwashing.
Prevalence rates of
PTSD among survivors
of torture are about 36
percent
 DIFFERENTIAL DIAGNOSIS
Organic considerations -epilepsy, alcohol-use
disorders, and other substance-related disorders, Acute
intoxication or withdrawal from some substances
Panic disorder and generalized anxiety disorder: PTSD
associated with re-experiencing and avoidance of a
trauma
Borderline personality disorder, dissociative
disorders, and factitious disorders.- do not usually
have the degree of avoidance behavior, the autonomic
hyperarousal, or the history of trauma
Obsessive-compulsive disorder (OCD) and generalized
anxiety disorder.-PTSD concerns memorythe
intrusion of past stressors into the present. In contrast,
OCD concerns current and future threats
 Course and Prognosis
Symptoms can fluctuate ,most intense during
periods of stress.
Untreated, about 30 percent of patients recover
completely,
40 percent continue to have mild symptoms,
20 percent continue to have moderate symptoms
10 percent remain unchanged or become worse.
After 1 year, about 50 percent of patients will
recover
 Good prognostic factors
Rapid onset of the
symptoms
Short duration <6 months
Good premorbid
functioning
Strong social supports
Absence of other
psychiatric, medical, or
substance-related disorders
Poor prognostic factors
The very young
very old
Pre-existing psychiatric
disability, whether a
personality disorder or a
more serious condition
TREATMENT
 Some principles for management

Comorbid depression treat PTSD first.

Substance dependence should be addressed
first before treating PTSD
Support, encouragement to discuss the event,
and education about a variety of coping
mechanisms
Sedatives and hypnotics can be helpful.
 Pharmacotherapy

SSRIS-sertraline and paroxetine are

considered first-line treatments for PTSD
TCAS-Imipramine and amitriptyline .Dosages
same as those used to treat depressive
disorders, trial should last at least 8 weeks.
continue the pharmacotherapy for at least 1
year if respond well
 MAOIS -phenelzine ,trazodone are effective in
reducing re experiencing symptoms and
insomnia.,
Anticonvulsants :carbamazepine , valproate
Benzodiazepines-Benzodiazepines do not
appear to be effective although they may
show some effects on insomnia, irritability,
and general anxiety and arousal symptoms
 CBT
Education
about the symptoms of PTSD , treatment
rationales, Common reactions to trauma
,giving up behaviours that maintain the
problem such as avoidance and safety
behaviours.
Self-monitoring of symptoms
self-monitoring may in itself be therapeutic
 Exposure

Imaginal exposure.
In vivo exposure - going
to the site of the
traumatic event, driving
again after a road traffic
accident
Exposure is repeated until
the patient no longer
responds with high levels
of distress.
Helps in correcting
dysfunctional beliefs
about danger
 Cognitive therapy

For anxiety disorder focus on identification and

modification of misinterpretations that lead to
overestimation of threat and under estimation
of their coping abilities
But in PTSD the perceived threat arise from the
interpretation of trauma and its consequences.
The patient is encouraged to drop behaviour
and cognitive strategies that leads to negative
interpretation.
 Eye-movement desensitization
reprocessing
New and controversial treatment.
Patient is instructed to focus on a
trauma-related image and its
accompanying feelings, sensations,
and thoughts, while visually
tracking the therapist's fingers as
they move back and forth in front
of the patient's eyes.
After a set of approximately 24 eye
movements, cognitive and
emotional reactions are discussed
with the therapist.
Once the distress to traumatic
image is reduced coping
statements are also introduced
while the scene is being imagined.
Psychodynamic therapy
The goal of the treatment is to work through and
resolve an unconscious conflict which the
traumatic event is thought to have provoked.
Hypnotherapy
The goal of this treatment is to enhance control
over trauma-related emotional distress and
hyperarousal symptoms and to facilitate the
recollection of details of the traumatic event
The effect is below trauma focused CBT or EMDR
 Avoidance is one of
the main symptoms of
PTSD, and it can thus
take years for the
patient to seek help for
this condition
PTSD-NOT ALL WOUNDS ARE VISIBLE

THANK YOU