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What Advanced Practice Nurses

Need to Know About PTSD

Presentation for Regional Conference: Towards Excellence in Advanced Practice

Nursing.April 16, 2009

Sarah Acland MD.

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What is PTSD ? Normal response to abnormal events: - fear, autonomic symptoms, numbing, dissociation

In PTSD: these reactions are abnormally prolonged and cause significant interference in any or all aspects of the person’s life.

Anyone who undergoes severe enough, or prolonged enough trauma, can develop PTSD.

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Response -

Fight Flight Freeze!

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Acute Stress Disorder

Criteria are the same as for PTSD.

Fewer symptoms are needed for diagnosis

DURATION: from 2 days to 4 weeks after event.

Almost everyone will have to some degree.

Treatment is purely supportive: Listening, validation, presence, compassion.

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DSM 5 Post-traumatic stress disorder

A. Exposure

B. Intrusion Symptoms

C. Avoidance of Stimuli

D. Distortions

E. Arousal

F. Duration

G. Distress

H. Exclusion

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Exposure to Trauma (one)Actual or threatened death, injury, or sexual violence.

1. Directly

2. Witnessed

3. Learning it happened to significant person

4. Repeated or extreme exposure to aversive details

(esp. work related)

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Intrusion symptoms (one)1. Intrusive memories

2. Nightmares

3. Dissociative reactions (flashbacks)

4. Intense distress at exposure to triggers

5. Marked reactions to cues that recall the event

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Avoidance (one or both)

1. Efforts to avoid memories, thoughts or

feelings associated with the event

2. Efforts to avoid external reminders that arouse

such feelings.

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Distortions (two)

1. Inability to remember important aspect of event

2. Persistent negative beliefs about self or world

3. Distorted beliefs about cause (blame)

4. Persistent negative emotional state

5. Diminished interest in significant activities

6. Feeling detached from others

7. Inability to experience positive emotions

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Arousal (two) 1. Irritability, verbal and physical aggression

2. Reckless or self-destructive behavior

3. Hypervigilance

4. Exaggerated startle response

5. Concentration problems

6. Sleep disturbance

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Duration

More than one month

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Distress and Exclusion

1. Clinically significant distress in functioning o 2. Not due to substance or other condition

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Dissociation Experience“walled-off” from consciousness Coping mechanism or symptom? Definite risk factor for PTSD Possibly results from increased glutamate. May involve sensation, image, behavior,

meaning, affect, or all five.

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How does this differ from DSM IV?

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Presenting Symptoms May present with one major symptom: “phobia” – avoidance of situation or place “panic attacks” – may be re-experiencing “mood swings” – possibly anger outbursts “can’t concentrate” – hyperarousal “depression” – “pain” “can’t sleep”

These are all real problems, but may be the tip of a PTSD iceberg.

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Differential DiagnosisAnxiety disordersSleep disordersMood disordersSomatization – “hysteria”

ADDSubstance abuse“Schizophrenia”Borderline personality disorder

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Co-existing substance abuse and PTSD

58% of veterans in SA treatment have lifetime PTSD.

47% - 77% of male veterans with PTSD have lifetime SA.

For civilians the rates are not as high.

Indicates more severe pathology and a more chronic course.

Should be treated together for best results.

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Trauma – Simple and Complex

Simple trauma – single event

eg: rape, earthquake etc,

car accident

Complex trauma – prolonged, inescapable.

eg: torture, child abuse,

war, combat

Complex trauma tends to cause more severe effects,

especially if perceived as malicious.

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“Complex PTSD” Prolonged subjection to total control and repeated abuse.

chronic suicidal thinking amnesia unstable relationships episodes of rage -or hypersexuality depression, isolation anxiety and panic lack of concentration

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And.....guilt, shame, defilementintrusive memories and dreamsself-mutilationdissociation, DIDlack of trust, paranoid thinkingrevenge fantasies, identification with

captorsalcohol and substance abuse/addiction

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Morbidity and Mortality Disorders that increase in presence of PTSD: Physical illness – even after exclusion of, for example,

alcohol and drug abuse

Depression and anxiety disorders Accidents Pain syndromes Alcohol and drug abuse

Mortality also increases – from cardiovascular disorders, accidents and suicide

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PTSD – Prevalence(in USA)

DSM-IV-TR (2000) 1 – 14 % Detroit (1998) Men 10%, Women 18% Detroit (1991) Men 6%, Women 11% NVVRS (1980) Men 31%, Women 27%

-higher in Army, & with longer exposure to combat.

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Prevalence in Iraq VetsThe incidence increases over time, and is higher if complicated by TBI – about 7%

40% of post-9-11 vets will ultimately have PTSD.

This is a total of roughly 490,000 people.

After screening, 30% of vets referred to MH.

After diagnosis, < 50% received treatment.

Treatment leads to remission in 30 – 50 %

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In a population of one million,

if 4% suffer from PTSD,

that equals 40,000 people.

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PTSD : Risk FactorsDevelopment of PTSD:

pre-trauma factors: PH or FH of mental illness.

previous personality, and experiences.

Maintenance of PTSD depends more on

events during and after trauma, social

support, group solidarity and attitudes.

Dissociation during the event is a strong

predictor of PTSD.

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PTSD Risk Factors Younger age, female gender, minority status, poor

education, previous trauma, childhood adversity.

- all depending on which population.

Stronger factors: psych. history, childhood abuse,

family psych. history.

More important: factors during & after event:

severity & duration, lack of support, additional life stress.

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HISTORY

W. H.R. Rivers

1864 – 1922

First effective

treatment of

“Shell-Shock”.

After him, soldiers

were no longer shot for

“cowardice”.

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Neurobiology of PTSD PTSD is a physical illness, an

exaggeration of normal response: Threat is perceived by sensory neurons,

registered in the cortex, proceeds to the limbic system of the

mid-brain, specifically the hypothalamus, and from there the reaction is mediated

by the autonomic nervous system.

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Autonomic Nervous SystemSympathetic N. S. Parasympathetic N.S.pallor

rapid breathing

rapid heartbeat

sweating

tremor

enlarged pupils

increased BP and temp

gut and bladder overactivity

fear

flushing

slow breathing

slowed heartbeat

warm,dry skin

slowed gut activity

small pupils

normal BP and temp

calm exterior

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The Limbic System

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In PTSD the sympathetic symptoms

persist, and are not balanced by the

parasympathetic system.

At the same time the memory of

trauma remains subcortical and is not

fully integrated into normal event

memory.

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Normal Response to Threat

Fight! Flight! F-r-e-e-z-e

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Hypothalamic-pituitary-adrenal Axis

Normal Situation – alarm spreads from amygdala to hypothalamus, triggers the SNS, releasing nortriptyline, and starts off the flight/fight reaction.

The pituitary stimulates the adrenals to release cortisol - a slower reaction - and this brings the alarm reaction gradually to an end.

In PTSD, cortisol release is blocked or deficient. Alarm reaction continues, leading to re-experiencing.

Holocaust survivors and others with PTSD have been found to have low urinary cortisol excretion.

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Neurotransmitters Catecholamines: Epinephrine and NE: sympathetic

activators. Urinary excretion is increased Cortisol and CRH (HPA): modulate SNS. CRH is

increased, whereas cortisol may be increased or decreased. May inhibit PFC memory.

Glutamate/GABA: Excitatory/inhibitory. Glutamate flooding initially, with imbalance. Low GABA may lead to helplessness.

Serotonin (5-HT): Low, increasing amygdala activity. Increased fear behaviors, decreased memory trace.

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STRE--E—E—E--TCH!

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Pharmacological Treatment Serotonin – SSRIs Improve symptoms Improve anxiety Promote GABA and calm down amygdala,

reducing rage, aggression, impulsivity, SI. Promote neurogenesis (as do all anti-

depressants.)

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Pharmacological Treatment5HT / noradrenaline enhancers.

Effexor, Cymbalta, both effective but not as anxiolytic as one hoped.

Tricyclics – Elavil, Sinequan, effective and cheap; also sedative. 5-HT

Monamine oxidase inhibitors – Phenelzine, effective but risky, esp in alcohol abusers.

None is as effective for PTSD as the SSRIs

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Pharmacological Treatment

Adrenergic System: Beta-blocks: propranolol etc. Alpha-1 block: prazocin Alpha-2 agonist: clonidineAll these anti-adrenergic agents reduce arousal

& re-experiencing

Prazocin: nightmares, also in daytime for flashbacks.

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Pharmacological TreatmentGaba/glutamate system: mainly anti-

convulsants Depacote : increases GABA Tegretol : increases GABA Lamictal : inhibits glutamate

D-Cycloserine: enhances glutamatergic function: neuroplasticity & new memory formation.

Adjunct to CBT

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Pharmacological TreatmentAtypical anti-psychotics: Dopamine,

serotonin blockade: Risperdal Seroquel – Seroquel XR Abilify Zyprexa

Useful for aggression, nightmares, some

hyperarousal. Best as adjuncts.

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Pharmacological Treatment

Glucocorticoids: hydrocortisone.Given in high doses in the acute situation,

for septic shock or cardiac surgery, it seems to prevent the later development of PTSD.

(also, possibly, beta-blockers and morphine)

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Pharmacological TreatmentGABA agonists: Benzodiazepines:.

Not recommended because: Sedation, memory impairment, ataxia Risk of dependency Exacerbation of depression Cause rebound anxiety. (Alprazolam) May be useful short-term for sleep.

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Psychological Treatment“Exposure is the only modality for which

evidence is sufficient…..” Aim is to replace negative repeating circuits with

positive memories and ideas. The unmodified sensory memories then can be

released into the pre-frontal cortex, where they are available to normal cognition and increased understanding.

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Treatment Principles

Establish therapeutic alliance Establish safety Assist patient in own recovery Use “safe places” Validate the experience Celebrate progress

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Do no harm

re-traumatizing – eg premature questions triggering flashbacks, panic attacks ignoring therapeutic boundaries dis-empowering – eg making decisions colluding in unhealthy behavior pathologizing

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AVOID:

rescue – making decisions for patient advice closed questions filling-in memories high expectations

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Acute Stress Disorder

Criteria are the same as for PTSD.

Fewer symptoms are needed for diagnosis

DURATION: from 2 days to 4 weeks after event.

Almost everyone will have to some degree.

Treatment is purely supportive: Listening, validation, presence, compassion.

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Stages of Recovery

Safety

Remembrance and mourning

Reconnection with everyday life

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Immediate Response Emphasis on essentials: safety, food, shelter, and

above all, clear INFORMATION. Non-invasive listening, not too much talk. Address specific stressors. Reduce arousal: relaxation, reframing, meds. Critical Incident Debriefing: NO -

- group technique may be helpful later, not acutely. Don’t pathologize – Don’t normalize. Be aware of cultural norms.

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Early InterventionAim is to prevent later development of PTSD social support increased functional capacity positive coping, healthy behaviors grief management coping with repeated threat allow survivors to heal at own pace

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Established PTSD

CBT EMDR Energy Psychology

(These are exposure – based therapies)

Neurofeedback

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-how to avoid triggering

observe closely for signs of agitation,

tension, breaks in eye contact. use “safe places”, “anchors”. teach patient to use them let patient teach you when to back off

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Don’t get hurt

In flashback, you may be perceived as

enemy or perpetrator. Vicarious traumatization: Be aware of your feelings and dreams Seek supervision as necessary

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Problems in Treatment Alcohol and Drug Abuse/ Addiction Often an attempt to stifle symptoms. Must be treated concurrently with PTSD,

or relapse will occur. Traditional 12-step programs may be

intolerant of PTSD members. Very high incidence of physical ill-health.

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Problems in Treatment

Borderline personality disorder: Very often trauma related, even PTSD Unstable and hard to involve in treatment Very often comorbid with addiction Lack resources on which to build Tend to carry multiple MH diagnoses

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Having said all these dire and gloomy things, let me finish by saying that people with PTSD are the most completely fascinating and ultimately rewarding people to have as patients.

Thanks for your attention, and thank you too, to all those with PTSD with whom I have been associated.

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References Handbook of PTSD: 2007, Friedman,

Keane, & Resick Trauma and Recovery: 1997, Judith

Herman The Body Remembers: 2000, Babette

Rothschild IASC Guidelines on Mental Health and Psychosocial

Support in Emergency Settings, IASC 2007

Patterns of Avoidant Coping....2003, unpublished dissertation, Karen L Grantz

National Center for PTSD

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Reference – energy psychology:

David Feinstein (2008) Energy Psychology in Disaster Relief; Traumatology: 14 (1), 124 – 137

David Feinstein (2012) Acupoint stimulation in treating psychological disorders: Evidence of efficacy. Review of General Psychology. Advance online publication

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Sarah Acland

Louisville KY April 2014

sarahaclandmd@yahoo.com

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Thank You!

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