Prevalence of Anxiety & Mood Disorders
in a Community Population
Posttraumatic Stress Disorder
Science & Practice
Marie-Claude Laplante PhD
Fear & Anxiety Disorders Clinic
Department of Clinical & Health Psychology
University of Florida
Prevalence Rate (%)
Lifetime
12-month
Anxiety & Mood Disorders
DSM-IV WMH-CIDI (2007)
Any Anxiety Disorder
31.2
Specific Phobia
12.5
9.1
Social Phobia
12.1
7.1
Posttraumatic Stress Disorder
6.8
3.6
Generalized Anxiety Disorder
5.7
2.7
Panic Disorder
4.7
2.7
Obsessive- Compulsive Disorder
Any Mood Disorder
Major Depressive Disorder
19.1
2.3
1.2
21.4
16.9
9.7
6.8
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Overview
•
•
•
•
•
•
Definition of Trauma & PTSD
Assessment of PTSD
Epidemiology of Trauma & PTSD
Risk Factors for Trauma & PTSD
A Theoretical Model of the Etiology of PTSD
Association between PTSD and Psychological &
Physical Health
• Overview of Cognitive-Behavioral Treatment for PTSD
& its Effectiveness
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
•
(1) intrusive memories
(2) nightmares
(3) flashbacks
(4) upset by reminders
(5) physiological reactivity upon exposure to reminders
C. Persistent avoidance of stimuli associated with the trauma
& numbing of general responsiveness (3+)
–
–
–
–
–
–
–
•
• Exposure to a traumatic event
• Persistent re-experiencing of the trauma
• Persistent avoidance of stimuli associated with the
trauma and numbing of general responsiveness
• Persistent symptoms of increased arousal
• Symptoms are present more than 1 month
• Symptoms cause significant distress or interference
with important areas of functioning.
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
B. Persistent re-experiencing of the trauma (1+)
–
–
–
–
–
•
PTSD
DSM-IV Key Diagnostic Features
(1) avoids thoughts or feelings
(2) avoids reminders
(3) inability to recall aspect of trauma
(4) loss of interest
(5) detachment or estrangement
(6) restricted range of affect
(7) sense of foreshortened future
D. Persistent symptoms of increased arousal (2+)
– (1) insomnia
– (2) irritability or anger
– (3) difficulty concentrating
– (4) hypervigilance
– (5) jumpy or easily startled
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
PTSD
Earlier Definition of Trauma in the DSMs
• Existence of a recognizable stressor that would evoke
significant symptoms of distress in almost everyone
– DSM-III, 1980
• The person has experienced an event that is outside
the range of usual experience and that would be
markedly distressing to almost anyone
– DSM-III-R, 1987
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
1
PTSD
PTSD
DSM-IV (1994) Definition of a Trauma
DSM-V (2012?) Proposed Definition of Trauma
A1. Exposure to an extreme traumatic stressor involving:
• Experienced
• Witnessed
• 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 directly experienced or witnessed an event or events
that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
Proposal that “confronted with” be eliminated in DSM-IV
Spitzer, First & Wakefield, 2007
A2. Intense fear, helplessness, or horror
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
PTSD
Assessment of PTSD
SEMISTRUCTURED
DIAGNOSTIC INTERVIEW
SELF-REPORT PTSD
QUESTIONNAIRE
•
•
•
•
•
•
•
•
CAPS
SCID
ADIS-IV
SI-PTSD
PSS-I
•
•
•
PTSD Checklist
Impact of Event Scale
Mississippi Scale for CombatRelated PTSD
Keane PTSD scale of the MMPI-2
Penn Inventory for Posttraumatic
Stress
Posttraumatic Diagnostic Scale
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Lifetime Trauma Exposure
Evaluating the Prevalence of Trauma
• Using a list of events compared to using a single question,
and using a long vs a short list, yields higher prevalence
estimates of trauma exposure and higher estimated of the
average number o traumas per exposed person.
• A list of events has become the standard measurement
procedure, incorporated in current version of the major
structured interviews:
– The WHO-CIDI
– The DIS for DSM-IV
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Criterion A2- event involved
intense fear, horror or helplessness
68%
%
% met
criterion
A2
National Comorbidity Survey, 1995
Breslau, 1998
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Detroit Area Survey of Trauma, 2001
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
2
Lifetime Prevalence of
Specific Traumas
Prevalence of Trauma- Age
*
*
*
(Breslau et al., 1998)
Breslau, N. et al. Arch Gen Psychiatry 1998;55:626-632.
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Copyright restrictions may apply.
Prevalence of Trauma Exposure
among Youth (<16)
Prevalence of Trauma Exposure
among Youth
VULNERABILITY FACTORS
•Poverty
•Parental history of drug/alcohol problems
•Parental history of arrest
•Parental violence to spouse or children
•Parental history of psychiatric treatment
•Current maternal depression
•Parental mental illness present
•One or both parental figures did not graduate
from high school
•One or both parental figures unemployed
•Household partly/wholly dependent on welfare
•Four or more children in household
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Risk Factors for
Exposure to Trauma
Conditional Risk- PTSD
%
*
*
*
*
(Breslau et al., 1998)
(Brewin ey al., 2000)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
3
Prevalence of PTSD
in Different Populations
Prevalence of PTSD
by age cohort
6.8%
10
Lifetime
9.2
9
8.1
8
12-month
7
%
6
6.3
4
3.6%
5.3
5
4
3.5
3
2.8
2
1
1
0
18-29
(Brewin ey al., 2000)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
45-59
60+
(NCS-R, 2007)
PTSD & Gender Differences
PTSD & Gender Differences
meta-analysis N=40 studies
meta-analysis N=40 studies
Are gender differences due to a higher risk of PTE among women?
OR
30-44
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Are gender differences due to women being more likely to experience certain kinds
of PTE that might be associated with a greater vulnerability to develop PTSD?
OR
Tolin, 2008
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Tolin, 2008
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Gender Differences in the Prevalence
of Specific Types of Trauma [PTE]-
Gender Differences in the
Prevalence of PTSD-
meta-analysis N=64 studies
meta-analysis N=216 studies
Could the increased risk of PTSD among women be attributed to a higher risk of
sexual assault and child sexual abuse?
OR
OR
NS
NS
Tolin, 2008
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
NS
NS
Tolin, 2008
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
4
Meta-Analyses of Risk Factors for PTSD
* 77 studies *
Risk Factors- severity of trauma
medium
small
(Goenjian et al., 1995)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
(Brewin ey al., 2000)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Meta-Analyses of Nondemographic
Predictors of PTSD Diagnosis & Symptoms
* 2,647 studies & 476 potential predictors *
Resilience Factors in PTSD
medium
small
Hoge et al., 2007
(Ozer ey al., 2003)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
September 11, 2001: 2-3 years later
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
September 11, 2001: 2-3 years later
PTSD Risk Factor- Age
OR
DiGrande
et al., 2008
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
5
September 11, 2001: 2-3 years later
September 11, 2001: 2-3 years later
PTSD Risk Factor- Gender
PTSD Risk Factor- Race
OR
OR
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
September 11, 2001: 2-3 years later
September 11, 2001: 2-3 years later
PTSD Risk Factor- Income
PTSD Risk Factor- Education
OR
OR
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
September 11, 2001: 2-3 years later
September 11, 2001: 2-3 years later
PTSD Risk Factor- Marital Status
PTSD Risk Factor- Caught in dust cloud
OR
OR
*
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
6
September 11, 2001: 2-3 years later
PTSD Risk Factor- Injured on 9/11
OR
September 11, 2001: 2-3 years later
PTSD Risk Factor- Witness horror on 9/11
OR
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
September 11, 2001: 2-3 years later
September 11, 2001: 2-3 years later
PTSD Risk FactorEvacuation/time gone from residence
PTSD Risk FactorInvolved in rescue & Recovery Effort
OR
OR
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
September 11, 2001: among those
with probable PTSD or depression…
% who
received
counseling
after 9/11
(DiGrande et al., 2008)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Model of the Etiology of PTSD
Little new utilization
of mental health
services after 9/11
(Stuber et al., 2006)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Keane & Barlow, 2002
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
7
% of those with PTSD meeting
criteria for at least one other
psychiatric diagnosis
Association between
Trauma and Other Conditions
•
•
•
•
PTSD
Depression
Other Anxiety Disorders
Alcohol/Drug Abuse/Dependency
%
• Medical Illnesses
NCS, 1995
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
% of Current Additional Diagnoses in Patients with
Current Principal Anxiety & Mood Disorders (n=968)
PTSD & Substance Abuse
%
DSM-IV principal diagnosis
Current
additional
diagnosis
PD/A
SOC
GAD
OCD
SPEC
PTSD
MDD/
DYS
Overall
Any Axis I
60
46
68
57
34
92
71
57
Any anxiety/
mood disorder
59
45
65
53
33
92
70
55
Any anxiety
disorder
46
28
52
39
27
62
63
43
Any mood
disorder
31
29
36
32
10
77
17
28
(Brown et al., in press)
Deering, 1996
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
% of Current Additional Diagnoses in Patients with
Current Principal Anxiety & Mood Disorders (n=968)
Current
additional
diagnosis
PD/A
Major Depressive Disorder
Five (or more) symptoms present during the same 2-week period and representing a
change from previous functioning, and at least one of the symptom is #1 or #2
DSM-IV principal diagnosis
PD/A
SOC
GAD
OCD
SPEC
PTSD
MDD/
DYS
Overall
-
3
18
9
5
23
18
10
SOC
15
-
36
26
9
15
42
22
GAD
16/22
13/21
-
12/16
5/7
23/38
5/72
13/25
OCD
7
21
4
-
3
23
8
7
SPEC
15
8
12
12
15
15
14
13
PTSD
4
3
1
0
0
-
5
3
MDD
23
14
26
22
3
69
-
20
(Brown et al., in press)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
1.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood for most of the day, nearly every day
Markedly diminished interest or pleasure in most activities for most of the day,
nearly every day
Appetite change | weight gain/loss
Sleep difficulties
Psychomotor retardation/agitation
Fatigue or loss of energy
Feelings of worthlessness | Excessive, inappropriate guilt
Concentration difficulties | Indecisiveness
Thoughts of death | Suicidal thought, intent, or plan
The symptoms cause clinically significant distress or impairment in important areas of
functioning.
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
8
Associations between Depression,
Trauma Exposure, and PTSD
PTSD & Depression- prevalence
%
PTSD
MDD
PTSD Diagnosis
Neria, 2000
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Among trauma-exposed, the risk of
developing depression was 3x for those
with PTSD compared to without PTSD
Pre-Existing Depression and
Risk of Exposure to Trauma & PTSD
%
HR
HR
*
Breslau, 2000
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Risk of Onset of MDD
following Trauma, by Trauma TypePTSD vs. no PTSD
*
*
*
NS
Breslau et al., 2000
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Breslau, 2000
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
PTSD & Other DiagnosesShared Diathesis? Causal Effect?
• Recent studies indicate that trauma victims who
do not develop PSTD (that is most victims) are
not at a markedly elevated risk for the
subsequent first-onset of other psychiatric
disorders, compared with non-exposed
individuals.
Breslau, 2002
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
9
PTSD- Societal, Interpersonal, &
Psychosocial consequences
People who develop PTSD are more likely to:
• Utilize medical services inappropriately
• Earn less
• Divorce more often
• Become involved with the legal system
• Report greater dissatisfaction with their lives
• Have more trouble raising their children
• Change job frequently
PTSDadverse life course consequences
% elevated
odds
US National Comorbidity Survey
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Effect of PTSD on
Occupational Functioning
• Annual productivity loss estimated at $3 billion in the USA in
1997
• Similar to the amount of work impairment associated with
depression
• Less than the impairments associated with panic disorder with
agoraphobia
Is trauma associated
with poor health?
• More charted medical diagnoses
• Use more medical services
• Increased mortality
– Primarily due to external causes (accident, suicide) in war
veterans
Kessler et al., 1997
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Is PTSD associated
with poor health?
•
•
•
•
Poorer perceived health
More chronic health conditions
Poorer self-rated functional status
Higher use of the health care system
– 30% more visits
• Increased mortality
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Association of PTSD &
Physical Disorders in the Past Year
% Adjusted OR
Adjusted for mood
disorders, substanceuse disorders, and
sociodemographics,
and all other anxiety
disorders
NS
US National Comorbidity Survey, N=5,877, Age 15-54
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
10
Association of PTSD (vs GAD) &
Physical Disorders in the Past Year
% Adjusted OR
Presence of Chronic Pain Conditions
by Trauma Exposure & PTSD
%
Adjusted for mood
disorders, substanceuse disorders, and
sociodemographics,
and all other anxiety
disorders
NS
*
NS
US National Comorbidity Survey, N=5,877, Age 15-54
US National Comorbidity Survey- R, N=5,692, Age 18-87
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Presence of Cardiovascular Conditions
by Trauma Exposure & PTSD
%
Presence of Respiratory Conditions
by Trauma Exposure & PTSD
%
NS
NS
NS
US National Comorbidity Survey- R, N=5,692, Age 18-87
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Presence of Medical Conditions
by Trauma Exposure & PTSD
NS
US National Comorbidity Survey- R, N=5,692, Age 18-87
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Relationship between PTSD &
Medical Conditions when controlling
for the # of Lifetime Traumas
%
#
NS
NS
AOR
75% reported exposure
to at least one trauma
US National Comorbidity Survey- R, N=5,692, Age 18-87
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
PTSD status
US National Comorbidity Survey- R, N=5,692, Age 18-87
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
11
Theoretical Model relating
Trauma Exposure and PTSD to
Poor Physical Health
PTSD & Healthpublic health implications
• Trauma may substantially contribute to behavioral
factors that are the target of current public health
programs
– Smoking, exercise, risky sexual behavior
• Prevention is a key issue
• Reduce the likelihood of exposure to trauma through existing
public health campaigns (accident, child abuse)
• Secondary prevention: detection & treatment of PTSD
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Remission of PTSD
by gender & trauma type
PTSD CourseSeverity of PTSD symptoms among
rape victims over 12-wks
Median
time to
remission:
25-months
30
25
20
PTSD
non-PTSD
15
10
40% by
12-months
26% by
6-months
5
0
1
94%
2
3
4
65%
5
6
7
8
9
Assessment (wks)
52%
10
11
>1/3 persisted more
than 60 months
12
Breslau, N. et al. Arch Gen Psychiatry 1998;55:626-632.
47%
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Copyright restrictions may apply.
Overview of Prolonged Exposure
Therapy for PTSD
• PSYCHOEDUCATION about common reactions to
trauma
• BREATHING RETRAINING
• IMAGINAL EXPOSURE to the trauma memories
• IN VIVO EXPOSURE to situations the individual is
avoiding because of trauma-related fear.
A meta-analysis of data from controlled trials
of various forms of CBT for PTSD
- 26 studies E
ff
e
c
t
s
i
z
e
(Foa & Meadows, 1997)
(Bradley, 2005)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
12
Proportion no longer meeting criteria for
PTSD at posttreatment
- 26 studies -
Does the Addition of Cognitive Restructuring
to Prolonged Exposure Enhance Outcome?
%
(Foa et al, 2005)
(Bradley, 2005)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Do patients drop out prematurely from
exposure therapy for PTSD?
-25 studies-
Does imaginal exposure
exacerbate PTSD symptoms?
35
No Exacerbation
30
Exacerbation
25
20
%
15
NS
*
10
5
0
Pretreatment
Week2
Week4
Week6
30
Week8
Posttreatment
Dropout
20
16.7
15
N=336
10
N=222
N=338
N=143
N=543
0
Exacerbation
No Exacerbation
(Foa et al, 2002)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Do CBT experts achieve better outcome than
Master’s level counselors?
12
25 controlled studies
(Hembree et al, 2003)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Generalizability to the Population of PTSD
- 26 studies -
CBT experts
10
Master's level
counselors
8
*
6
4
*
2
0
PTSD
Symptoms
Depression
Work
Social
Functioning Functioning
(Foa et al, 2005)
(Bradley, 2005)
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
Marie-Claude Laplante, Ph.D. _____________________________________________________________________________________
13