PTSD: From Assessment to
Treatment
Jeannine Kubiak, Ph.D.
Staff Psychologist
Orlando Veterans Affairs
Medical Center
June 2010
Nosological History
• VA diagnostic manual included
psychological manifestations exhibited by
veterans
• Diagnostic and Statistical Manual of
Mental Disorders (1952)
– Gross Stress Reaction covered victims of stress
• Diagnosis dropped from DSM-II (1968)
• DSM-III (1980) christened the name
Post-Traumatic Stress Disorder
– Traumatic event: a catastrophic stressor that
was outside the range of usual human
experience
• War, torture, rape, atomic bombings, natural
disasters, man-made disasters (airplane
crash, industrial explosion, motor vehicle
accident)
• Did not encompass normal life stressors
such as divorce, serious illness, financial
problems
DSM-IV (1996) and
DSM-IV-TR (2000)
• Exposure to “a traumatic event”
• Exposure by
– Direct personal experience
– Witnessing
– Learning about (family member or “other
close associate”)
Traumatic Event under
DSM-IV-TR
• Examples of traumatic event :
– being diagnosed with a life-threatening illness
– learning that one’s child has a life-threatening
illness
– seeing a dead body or body parts
– generalized fear of death or injury
– severe verbal abuse
– For children, a parent’s death
Necessary criteria
• Response to the stressor must involve:
– Intense fear
– Helplessness OR
– Horror
– Children: disorganized or agitated behavior
• Persistent re-experiencing of the traumatic
event
• Persistent avoidance of stimuli associated
with the trauma
• Numbing of general responsiveness
• Persistent symptoms of increased arousal
RE-EXPERIENCING
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Distressing recollections
Distressing dreams
Flashbacks – psychotic reenactments
Sense of reliving the event
Exposure to mimetic stimuli
– Intense psychological distress
– Physiological reactivity
AVOIDANCE
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Conversation
Activities, locations, people
Inability to recall important aspect of trauma
Markedly diminished interest or participation in
significant activities
• Feeling detached or estranged from others
• Restricted range of affect
• Sense of foreshortened future
INCREASED AROUSAL
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Sleep disturbance
Irritability or anger outbursts
Difficulty concentrating
Hypervigilance
Exaggerated startle response
• Full symptom picture must be present for
more than 1 month
• The disturbance must cause clinically
significant distress or impairment in social,
occupational or other important areas of
functioning.
Specifications
• Acute: symptoms last less than 3 months
• Chronic: symptoms last 3 months or more
• Delayed onset: onset of symptoms is at
least 6 months after the stressor
Prevalence Rates
• Exposure to trauma in America:
– Men 8.1%
– Women 20.4%
• PTSD:
– Men 5%
– Women 10.4%
Sexual Assault
• Women have greater chance of exposure
to interpersonal trauma
– Rape
– Sexual molestation
• Rape prevalence: men .7%; women 9.2%
• PTSD from rape: men 65%; women 45.9%
Combat/Terrorism
• Exposure to military combat
• Witnessing someone being critically
injured or killed
• Current VA: being exposed to an
environment in which one fears for their
safety
• Military combat PTSD increasing among
women
IN THE EYE OF THE BEHOLDER
• Event occurs
• Person “makes sense” of event through
cognitive and emotional processes
• Appraisal occurs
• Adjustment occurs
• Functionality occurs
• Mental health/illness occurs
Common Precursors
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Learning disabilities
Physical abuse
Sexual abuse
Existence of a mental disorder
Substance Abuse/Dependence
Unstable childhood
Custodial parent with PTSD
Impacts
• Duration of the traumatic event
• Traumatic event inflicted by a person
• Violence associated with the trauma
• Previous traumatic event(s)
Comorbidity
• National Comorbidity Study: 88.3% men
and 79% women diagnosed with PTSD
have at least one comorbid psychiatric
disorder.
– Depression
– Substance Abuse/Dependence
– Anxiety Disorder
Post-PTSD
• Depression
– Men 6.9 times
– Women 4.1 times
• Mania
– Men 10.4 times
– Women 4.5 times
Substance Abuse
• Estimated that about 35% of men with
PTSD have or develop substance abuse
problems
• Estimate for women is about 27%
Substance Abuse
• Intoxication is hypothesized to dull the
sense of fear and inability to cope
• Fear response does not extinguish
• Fear response continues
SUICIDE
• U.S. suicide rate higher in men than
women
– 23.19 per 100k v. 5.65 per 100k
• Rate of attempted suicide is 20% for
people diagnosed with PTSD
• 90% of suicides are by people diagnosed
with a mental illness
FEAR RESPONSE
• Normal fear response: immediate
sympathetic discharge activates “fight or
flight” reaction.
• Limbic system: Amygdala and
hippocampus
• Catecholamines and cortisol increase
relative to the severity of the stressor.
• Cortisol acts in a negative feedback loop
to suppress sympathetic activation and
cause further release of cortisol.
Memory Circuits
• Amygdala – limbic structure involved in
emotion, learning and memory. Processes
“reflexive” emotions like fear and anxiety.
• Hippocampus – plays a significant role in
the formation of long-term memories.
PHARMACOLOGIC TREATMENT
• SSRI’S are the mainstay of pharmacologic
treatment of PTSD.
– Zoloft (sertraline) and Paxil (paroxetine) only
FDA-approved medications for treatment of
PTSD
Mood Stabilizers
•divalproex (Depakote and Depakote ER)
•carbamazepine (Carbatrol, Equetro,
Tegretol)
•lamotrigine (Lamictal)
•topiramate (Topamax)
Medications for PTSD/SA
• Sertraline: improves early PTSD and
ETOH
• Disulfiram: improves ETOH and PTSD
• Naltrexone: decreases ETOH relapse, no
effect on PTSD
• Risperidone: combined with SSRI effective
in PTSD, combined with Naltrexone
effective for ETOH
• Valproate: no effect on PTSD, effective in
ETOH detox
OPIOIDS/BENZODIAZEPINES
• Create tolerance and dependence
• Analgesic effect for deep pain (e.g., back
and neck pain) is dampened
• Opioid-induced hyperalgesia: minimal
pain triggers a full pain effect (usually
occurs through suboptimal dosing)
• Use is contraindicated if there is
substance abuse
• No evidence they are useful in PTSD
treatment
Atypical Antipsychotics
• 10% of patients with PTSD receive
antipsychotic medication to treat the PTSD
symptoms
– Symptoms tend to be more intrusive and
severe
– Used to augment SSRI’s
– Risperidone effective for flashbacks
(psychotic re-experiencing) and nightmares
– Olanzapine and quetiapine
EVIDENCE-BASED
TREATMENTS
• Cognitive-behavioral therapies
• Avoidance is necessary component of
development and prolongation of PTSD
• Based on hypothesis of inability to tell the
difference between the traumatic event
and safety in the current environment
• Develop anxiety-management skills
Prolonged Exposure Therapy
• Edna Foa, Ph.D., University of Pittsburgh
• Uses sustained exposure to reduce fear
response to trauma-related stimuli
• Imaginal exposure
• In-vivo exposure
Cognitive Restructuring
• Correcting the distorted appraisal process
• Reduces perception of danger in neutral
and innocuous situations
Seeking Safety
• Lisa Najavits, Ph.D., Harvard Medical
School
• Group therapy for PTSD with comorbid
substance abuse
• Psychoeducation
• Exposure
• Cognitive processing
Acceptance and Commitment
Therapy
• Robyn Walser and Darrah Westrup
• Focus on concept of “mindfulness”
• Emphasizes acceptance of internal
phenomena and on valued living
• Helps client to see that reactions are
internal phenomena
• Goal is to experience internal phenomena
and learn to view them differently
Resistance to PTSD
• High-stress careers (fire, police, EMT, ER)
attract people more normally resistant to
traumatization
• Effects of preparedness training
FUTURE
• Trauma response can be passed down
through the generations, (children of
holocaust survivors)
• Children who witness parental violence
can have PTSD even if they are not the
targets of the violence.
• DSM-V, due in May of 2012, will reflect the
latest research on PTSD.