POST TRAUMATIC
STRESS DISORDER:
Lest We Forget
McMaster Mini Med School
March 24, 2009
Jon Davine, MD, CCFP, FRCP(C)
Associate Professor, McMaster University
PTSD
• “Invented” 1980 in DSM
• Started with Vietnam war vets
• Quintesential environmental disease, as
must have environmental stress
POST TRAUMATIC
STRESS DISORDER (PTSD)
• 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.
POST TRAUMATIC
STRESS DISORDER –
RE-EXPERIENCING
• The traumatic event is persistently reexperienced in
one or more of the following ways:
– recurrent and intrusive distressing recollections of
the event, including images, thoughts or
perceptions (recurring thoughts).
– recurrent distressing dreams of the event
(nightmares).
– acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the
experience, illusions (flashbacks).
POST TRAUMATIC
STRESS DISORDER - TRIGGERS
– Intense psychological distress at exposure
to cues that symbolize or resemble an
aspect of the traumatic event.
– Physiological reactivity on exposure to
cues that symbolize or resemble as aspect
of the traumatic event.
– Can become a panic attack.
– e.g., very upset if hears the squeal of
brakes.
POST TRAUMATIC
STRESS DISORDER - AVOIDANCE
• Persistent avoidance of stimuli associated
with the trauma:
– 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
– e.g., avoid driving
POST TRAUMATIC
STRESS DISORDER - AROUSAL
• Persistent symptoms of increased
arousal (not present before the trauma),
as indicated by two (or more) of the
following:
– difficulty falling or staying asleep
– irritability or outbursts of anger
– difficulty concentrating
– hypervigilance
– exaggerated startle response
POST TRAUMATIC
STRESS DISORDER
• duration of the disturbance is more than
one month
• the disturbance causes clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning.
TRAUMATIC EVENT
RE-EXPERIENCE
AVOIDANCE/NUMBING
UNABLE TO FUNCTION
MONTH
AROUSAL (HYPERAROUSAL)
POST TRAUMATIC
STRESS DISORDER
• Specify if:
– Acute: if duration of symptoms is less than three
months
– Chronic: if duration of symptoms is three months
or more
• Specify if:
– with delayed onset: if onset of symptoms is at
least six months after the stressor.
– Can happen with sexual abuse.
PTSD: Subtype Specifiers
PTSD Symptoms
Chronic PTSD (> 3 months)
Acute
Stress 1
Disorder
Acute
PTSD
(< 3 months)
3
Time from Trauma (months)
6
Delayed
Onset
PTSD
SCREENING QUESTIONS
Thus, in screening for PTSD, ask:
• Do you keep re-experiencing the event?
Nightmares
Flashbacks (“daymares”)
– Can be like hallucinations
Can’t stop thinking about it.
– Can look like obsession
• Do things that remind you of the event bring out a
huge response?
– Can look like panic attacks
SCREENING QUESTIONS
• Do you avoid things that remind you of the event?
• Are you personally more anxious since the event?
– ?decreased sleep, concentration
– more irritable
– startle easily
• Has it gotten in the way of your life?
Psychiatric Comorbidity
(lifetime)
Panic
9.9%
Alcohol
Abuse / Dependence
39.9%
Major Depression
48.2%
PTSD
Social Phobia
29.9%
Kessler et al, Arch Gen Psychiatry 1995
GAD
15.9%
Agoraphobia
19.25%
LIFETIME PREVALENCE OF
PTSD APPROXIMATELY 10%
• Breslan et al ‘91
– 9.2%
• National Comorbidity Survey ‘91 (NCS)
– 8.7%
– 5-6% males
– 10-14% females
• Detroit Area Survey of Trauma ‘96
– 14%
– 10% males
– 18% females
EXPOSURE TO TRAUMATIC
EVENTS
• Lifetime exposure to traumatic events
– 40-69%. Only 10% get PTSD
• Higher in males/females
1.2 : 1
EXPOSURE TO TRAUMA
• Trauma type
NCS
Male
Female
Rape
0.7
9.2
Sexual Assault
2.8
12.3
Combat
6.4
0.0
Witnessing Violence
35.6
14.5
Accidents
25.0
13.8
Car Accidents
32.8
23.5
Threatened with a weapon
19.0
6.8
Physical attack
11.1
6.9
Natural Disaster
18.9
15.2
Learning about trauma to others 63.1
61.8
Sudden unexpected death
61.1
59.0
TRAUMA
• Extended from war, earthquakes,
assaults
• MVA’s; grief; workplace incidents
• Legitimate cause for disability
CONDITIONAL RISK
OF PTSD
• 9% all trauma
• Females > males 2:1 (adjusted for
trauma type)
CONDITIONAL RISK
FOR PTSD
Trauma Type
%PTSD
Assaultive violence
Raped
Shot or stabbed
Badly beaten up
Serious car accident
Learning about trauma
to others
Sudden unexpected death
of a close friend or relative
Any trauma
20.9
49.0
15.4
31.9
6.1
0.2
14.3
9.2
CONDITIONAL RISK
FOR PTSD
Females Males
26.5 vs
12.2
Molestation
Threatened with
a weapon
32.6
Assaultive Violence 35.7
vs
vs
1.9
6.0
Risk Factors for PTSD Development
PeriTrauma
PreTrauma
PostTrauma
PTSD
Pre-Trauma Risk Factors
• Female gender
• Previous trauma / younger age at time
of trauma
• Childhood abuse
• Trait neuroticism / poor coping style
Brewin et al, J Consult Clin Psychol 2000
Peri-Traumatic Risk Factors
Influencing PTSD
• Nature of trauma (personal assault)
• Severity of trauma / chronicity of trauma
Brewin et al, J Consult Clin Psychol 2000
Post-Trauma Risk Factors
• Lack of social support
• Lack of appropriate early treatment or
access
to services
Yehuda et al, Biol Psychiatry1998
LONGITUDINAL COURSE
• 53% recovered at three months.
• 58% recovered at nine months.
• 15-25% unrecovered after years. I
often see this with people from war
zones.
Longitudinal Course of PTSD
Symptoms
6% recovered
53% recovered
58% recovered
15-25%
UNRECOVERED
Weeks
3 months
Shalev & Yehuda, Psychological Trauma 1998
9 months
YEARS
NEUROBIOLOGY
– Studies have shown decreased size of the
hippocampus in brain studies.
– “Seat of Memory”
– Different pathways
– “Sabretooth Tiger” example re evolutionary
advantage, but now…..
PTSD Treatment Options
Psychosocial
CBT (exposure)
Anxiety management
Psychoeducation
EMDR
(controversial)
Pharmacological
SSRIs
NSRI
CONTROVERSY
• must you re-explore the trauma --NO
• when is the most appropriate timing-WHEN THE PATIENT IS READY
CBT - Psychoeducation/Supportive
Counselling
– Normal to be upset and have symptoms
– PTSD symptoms does not mean “going
crazy”
– provide client with corrective information
(psychoeducation)
– It’s very common (10%)
– Treatment can help
CBT-Imaginal Exposure, a
Behavioural Treatment
• This is healing. It gets rid of the power of the
event
• Literally, talking about the very thing you’d
rather not talk about
• This is the hallmark of therapy
CBT- In-Vivo Exposure
Therapy
• Behavioural homeworks involve
exposure to avoided activities
• Usually done as hierarchy
• Can pair it with muscle relaxation
• Must stay in the activity until calm. Don’t
stop activity while still anxious
• E.g. driving a car after an accident
COGNITIVE THERAPY
• Challenge automatic thoughts with
evidence for and against
• Re-formulate to more realistic ones
• e.g. all men will assault me
• e.g. I will always have an accident
CAUTION!!
• I tell people talking about the difficult
event is healing…..as long as they feel
ready to do it
• If they feel it’s too much, I say “wait until
you feel ready, and then we’ll do it”
ANXIETY MANAGEMENT
TRAINING
Give client skills to handle anxiety:
– e.g. relaxation training, deep muscle
– breathing retraining
Recommendation for
Pharmacotherapy
for PTSD
First-line
Fluoxetine, paroxetine, sertraline, venlafaxine
XR, (SSRI’s, NSRI)
Second-line
Fluoxamine, mirtazapine, moclobemide,
phenelzine
Adjunctive: resperidone, olanzapine
EXAMPLE: SEXUAL ABUSE
• ask regarding nightmares, flashbacks,
avoidance, triggers, mood
• “not your fault”, “metaphorically bound and
gagged”
• “if there’s anything I ask you that you would
rather not answer, you don’t ...”
• support. Validate feelings e.g. anger, hatred
• normalize issue of self esteem, trust,
intimacy, sexuality
• pressure cooker analogy