Post Traumatic Stress Disorder

Acute Stress Disorder

Dr. A. Hadjebi

History

U. S. civil war : Soldier's heart syndrome 1900 s : Traumatic neurosis due to the

influence of psychoanalysis World war I : shell shock World war II : combat neurosis or

operational fatigue Vietnam war : post traumatic stress

disorder

History

PTSD: DSM-III (1980) ASD; DSM-IV (1994) PTSD in DSM-III: reexperience(1),psychic

numbing(2), other items(1), no duration criteria

PTSD in DSM-III-R is similar to DSM-IV-TR In ICD-10 PTSD & ASD are stress related

disoders

Epidemiology

Life time prevalence (8%) 30% of Vietnam veterans 25 % subclinical form of disorder In women : life time prevalence 10- 12% In men : life time prevalence 5- 6% PTSD is most prevalent in young adults Men's trauma : combat experience Women's trauma : assault or rape

Epidemiology

PTSD most likely to occur in single , divorced , widowed , socially withdrawn , low socioeconomic level

First degree biological relatives of persons with a history of depression have an increased risk for developing PTSD following a traumatic event

Comorbidity

About 2/3 having at least tow other disorders

Common comorbid conditions include : depressive disorders , substance related disorders , other anxiety disorders and bipolar disorders

Etiology

Stressor Risk factors Psychodynamic factors Cognitive – behavioral factors Biological factors

Noradrenergic system

Opioid system

Corticotropin – releasing factor and the

HPA axis

Psychological aspects of PTSD

Emotional response to trauma reminder Base line physiological activity Exaggerated startle reflex.

Diagnostic criteria for PTSD Exposure to a traumatic event The traumatic event is persistently

reexperienced Persistent avoidance of stimuli associated

with the trauma Persistent symptoms of increased arousal Duration of the disturbance is more than 1

month

Diagnostic criteria for PTSD

Significant distress or impairment in social, occupational or …

Specify if : acute : < 3 months

chronic : > or = 3 months With delayed onset

Diagnostic criteria for ASD

The disturbance last for a min. of 2 days and a max. of 4 weeks and occurs within

4 weeks of the traumatic events

PTSD in children and adolescents

Child risk factors include :

- demographic factors ( age,

socioeconomic status )

- life events

- psychiatric comorbidity

- parental psychopathology

- parental marital status

Gulf war syndrome Health problems- Irritability- Chronic fatigue- Shortness of breath- Muscle and joint pain- Migraine headaches- Digestive disturbances- Rash- Hair loss- Forgetfulness- Difficulty concentrating

Differential diagnosisorganic; head trauma, epilepsy,

alcohol use disorder Pain disorder Substance abuse Other anxiety disorders Mood disorders Borderline disorders Dissociative disorders malingering

Course and prognosis 30 % recover completely 40 % mild symptoms 20 % moderate symptoms 10 % remain unchanged Good prognosis is predicted by : - rapid onset of the symptoms - short duration of the symptoms - good premorbi functioning - strong social supports - absence of other psychiatric, medical or

substance – related disorders

Course and prognosis The very young and very old have more

difficulty with traumatic events than do these in midlife

PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and difficult to treat

Social support influence the development, severity and duration of PTSD

Treatment

Psychotherapy

Pharmacotherapy

Psychotherapy

Psychodynamic psychotherapy Cognitive – behavior therapy Group therapy Family therapy

pharmacotherapy

SSRIs : Sertraline and Paroxetine Buspirone TCA: Impramine, Amitriptyline Some studies indicate that pharmacotherapy

is more effective in treating the depression, anxiety and hyperarousal than in treating the avoidance and emotional numbing

Other drugs ; MAOIs ( Phenelzine ), Trazodone, Anticonvalsants, (carbamazapine, valpoarate ), clonidine, propranolol

Recommendation

Strongly recommend selective serotonin reuptake inhibitors (SSRIs) as first line agents for the treatment of PTSD.

Recommend tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as second-line treatments for PTSD.

Consider an antidepressant therapeutic trial of at least 12 weeks before changing therapeutic regimen.

Recommendation

Consider prazosin to augment the management of nightmares and other symptoms of PTSD.

Recommend medication compliance assessment at each visit.

Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely; however it is recommended that maintenance treatment should be periodically reassessed

Group Name Global imp.

Reexp. Avoid. Hyperarousal

SSRI

Fluoxetine

* * * *

Sertraline

* * *

Paroxetine

* * * *

TCAs * *

MAOIs * * *

Group Name Global imp.

Reexp. Avoid. Hyperarousal

Sympatholytic

* *

Prazosin

*

Propranolol

Novel Antidep.

Trazod. * * *

Nefaz. * * *

Group Name Global imp.

Reexp. Avoid. Hyperarousal

Anticonvul.

CBZ * *

Valpro. *

BDZ * *

Atyp.antipsy.

* *

Special considerations on sep. 11. 2001

3500 deaths and injuries 45% of adults reported symptoms of

stress , such as distressing recollections of the event, insomnia, nightmare,…

90% reported minor degrees of symptoms Susceptibility to symptoms was associated

with : female, nonwhite, having previous psychological illness, being close to disaster site

Special considerations on sep. 11. 2001

Over 80 % of parents reported that their children had one or more symptoms

Survey of Manhattan residents conducted 5 to 8 weeks after the world trade center collapsed:

- 9.8% (90000 ) people had PTSD or clinical depression

- 3.7% ( 34000 ) people met the criteria for both diagnosis