Epidemiology, Etiology, & Treatment
What is PTSD?
•Anxiety disorder•Traumatic stressor•Core features:•Reexperiencing•Avoidance•Numbing•hyperarousal
Traumatic Stressor
•DSM-III – Beyond normal range of human experience
•DSM-IV –experiences, witnesses, or is exposed to an event that is life threatening, that causes serious injury or that leads to a subjective response of intense fear,
helplessness, or horror.PTSD is unique among mental disorders• Symptoms are directly linked to traumatic stressor
Historical OverviewDiagnostic category in DSM-III
IssuesSymptoms aloneSocial ConstructionUnreliability of memory Euro-American category
But
• Traumatic neurosis (Oppenheim in 1892)
• Fright neurosis or schreckneurose (Kraeplin in 1896)
•WWs I & II•Shell shock•Combat fatigue•War neurosis
•DSM-I: GSR
• DSM-II: Transient situational disturbances
Epidemiology
Four levels
•Prevalence of Trauma Exposure•Risk Factors for Trauma Exposure•Prevalence of PTSD•Risk and Protective Factors
Prevalence of Trauma ExposureCommon or uncommon?
•NCS ≥ 60.7% of men; ≥ 51.2% have had at least 1 traumatic event in their lifetime
•Most common traumatic events•Witnessing•Natural disasters•Life-threatening accidents•Rape•Sexual molestation•Physical abuse•Childhood neglect
Risk Factors For Trauma Exposure
Random or non-random?•Gender •Age•Prior exposure•Preexisting personal characteristics•CDD•Pretrauma substance use•Genetic Vulnerability
Prevalence of PTSDSeveral factors
•PTSD ratio of women to men is 2:1 in USA
•Different among VTV – •Higher for men •Roles, stressors, education levels
•Demographics •Age •Ethnicity •Population
•Gender•Trauma type – 32 % of rape; 26% of criminal victims•Closeness to Traumatic event - WTC
Prevalence of PTSD
• International data varies•Economies and PTSD•Political turmoil, wars, disasters
•PTSD manifests itself in similar manner across culture, language, region, race•Importance of this observation?
Risk and Protective Factors
Many are exposed but few develop PTSD
Ratio of 3:1
•Categories of Risk Factors•Trauma•Peri-and post-trauma events•Individual Characteristics
Risk and Protective Factors
Trauma •Type •severity
Peritrauma Fear, helplessness, horror (r =.26)•Dissociation: blanking out, altered sense of time•PTSD is exercerbated by cognitions of panic (fear of death, fear of losing control)•Posttrauma•Social support • PTSD SS vs SS PTSD
Individual CharacteristicsDemographics & Familial Psychopathology
Demographics: age, gender, race, SES, immediate response, marital status, psychiatric history, prior trauma, personality
Familial Psychopathology•VVTR (no genetic linkage); •In general population (small but sig.) – through D2 dopamine alleles•Environment
•(greater than genetics)
Predictor Effect
Direct•War-zone stressors, malevolent war-zone environment•Hardiness, structural social support (not sig. for w/men), functional social support, and recent stressors
Indirect •Traditional combat exposure – moderated by perceived threat
Etiological Theories
Multiple Theories•Classical Conditioning
– stimulus & response connection •Schema Theories
– faulty schemas that filter info•Emotional Processing Theory
- abnormal fear structures•Cognitive Theory
- (i) classical (ii) Ehler & Clark•Multiple Representation Structures
– (i) Dual – VAM & SAM – (ii) SPAARS – schematic, proporsitional,
analogue, & associative representational systems
Classical Conditioning
Triple vulnerability
Learned Alarm (or strong mixed emotions)
Generalized Psychological Vulnerability
True Alarm (or intense basic emotion – anger, distress)
Anxious Apprehension (focused on re-experiencing emotions)
Generalized Biological Vulnerability
Advance or Numbing or Emotional Response
Moderated by Social Support and Ability to Cope
Experience of Trauma
PTSD
Concern about CC
•Startle responses•Reexperiencing•Nightmares
Treatment
Approaches (influenced by Psychoanalysis)
•Exposure Therapies•Narrative therapies•CT•CPT•PE•IR (imagery rescripting)•IRT (imagery rehearsal therapy)
Concerns? •Anxiety Management Training•Stress innoculation techniques
Treatment
•Combination Treatments•E+AMT+ CR eg CPT•CBT•TF-CBT •DBT•“Power Therapies:” TIR, VK/D, EMDR – (concern?)•ACT•Interapy•VRE
•Pharmacotherapy
Pharmacotherapy
Challengemultiple rather than single neurobiological
systemsAssumption
Brain Circuitory Excessive activation of
Amygdala
Recurrent fear conditioning of ambiguous stimuli perceived as threatening
Disinhibition of Amygdala
Target Systems•Adrenergic•HPA•Serotonergic•Dopaminergic
Medication
Antidepressants•SSRI – sertraline, paroxetine, fluoxetine•TCA – amitriptyline, desipramine•MAOI - phenelzine
Antiadrenergic•prozasin
Antikindling •Carbamazepine
•Atypical antipsychotic•resperidone, quetiapine, olanzapine
Research
Efficacious in comparison to WLDecline in anxiety, arousal, & reliving Narrative therapy cf psychoeducationExposure (alone)Active therapies vs supportive therapiesPE (60-80%, Foa, Rothbaum, & Faurr, 2003)IRT 65% (Jacobson & Traux, 1991)VRE 15-67% (Rothbaum et al. 1999)
Limitation
Resources
Friedman, M., Keane, T, & Resick, P. (Eds.) (2007). Handbook of PTSD: Science and practice. New York: The Guilford Press.
Keane, T., Marshall, A., & Taft, C. (2006). Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome. Annual Review Clinical Psychology, Vol. 2, 161-197.
Vasterling, J., Brewin, C. (Eds.) (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York: The Guilford Press.
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