PTSD
Not Just in the Military
However……
History of PTSD
• “Since the earliest of times there have been warriors returning to
civilian life only to find that they have developed a behavior that is
unacceptable in their old communities. After the Civil War in the US,
the condition was called “soldier’s heart”; experiences in WWI
produced “Shell Shock”; and that was carried over to the WWII era;
and warriors in the Pacific called it “going Asian”. It was after the
Vietnam War that it came to be known as “PTSD”, post traumatic
stress disorder.
www.gowarriorsproject.org
Diagnosis of PTSD
• Diagnosis of PTSD was controversial because of the role of outside
stressors as the cause of the disorder.
• Psychiatry generally emphasized the internal weaknesses or
deficiencies of the person as the source of the mental disorders.
• Prior to the 70’s, trauma survivors were blamed for their symptoms
and regards as cowards, moral weaklings, or masochists.
• The high rate of psychiatric casualties among Vietnam vets led to
studies conducted by the VA. These studies helped establish PTSD
as a legitimate diagnostic entity with a complex set of causes. It
was in the 1980’s that PTSD was added to the DSM list of diagnoses.
• In PTSD patients, researchers found changes in the amygdala and
the hippocampus – the parts of the brain that form links between
fear and memory.
• PET scans suggest that trauma affects the parts of the brain that
govern speech and language.
• Societies that are highly authoritarian, glorify violence or sexualize
violence have high rates of PTSD even among civilians.
• Occupations with work that expose workers to traumatic events or
who treat trauma survivors may develop secondary PTSD (also
known as compassion fatigue or burnout). Risk of PTSD is related to
three factors, the amount and intensity of exposure to suffering,
worker’s degree of empathy and sensitivity and unresolved issues
from the worker’s personal history.
Causes of PTSD
• War
• Terrorist attacks
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Trauma - Physical or Emotional
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Rape
Kidnapping
Assault
Sexual or physical abuse
Elder abuse
Childhood neglect
Car or plane crashes
Sudden death of a loved one
Natural disasters
• Hurricanes, tornados, floods, fires
Classification of PTSD
•
•Acute Stress < 1 month
•Acute PTSD 1-3 months
•Chronic PTSD > 3 months
PTSD – Cycle of Symptoms
High anxiety
& stress +
Loss of sleep
Increased
cognitive
Impairment
Reduced
ability to
cope
Symptoms
•Re-experiencing – flashbacks, pounding heart, rapid
breathing, nausea
•Avoidance and numbing – selective amnesia, withdrawal,
detachment, loss of interest
•Increased arousal – hypervigilance, decreased sleep,
irritability, anger, startle reflex, loss of ability to concentrate
•Other symptoms – substance abuse, suicidal thoughts and
feelings
A Few Statistics
• 65% of rape is associated with burglary
• 73% of attacks occur in victim’s homes
• 300,000 elder abuse cases in 1 year
• 9,000 were sexual assault
• There is a 13% incidence of PTSD in the elderly compared to 10% in
the general population. This does NOT include the military.
• Higher rates of PTSD have been found to occur in African
Americans, Hispanics and Native Americans compared to
Caucasians.
Onset in the Elderly
• Onset in the elderly
• a. Neurological illness/depression
• b. Bereavement – loss of friends, family, spouse particularly if
suddenly
• c. LOSS – Late Onset Stress Symptomatology – retired with more
time to think about war, decreased physical condition, bad news of
TV brings back memories, use of alcohol in past to cope and now
have quit, normal to look back over your life as you age and reexperience it.
Don’t dismiss excessive worrying out of hand
• Sally had mid-stage Alzheimer’s disease and was
living along in her own home, near her daughter
June, who looked in 0n her and helped with
groceries, cooking, transportation, etc. Sally wanted
to remain in her own home and was able to manage
well.
• Sally start complaining that the house next door had
been invaded by aliens. Odd lights and noises
disturbed her sleep and filled her with a feeling of
dread.
Case Study
•Rebecca’s mother screamed frantically when
the aides in the nursing home tried to give her
a shower. Regardless of how kind, gentle or
persuasive the caregiver was, she began
yelling and sobbing hysterically when brought
to the bright, white shower room, where the
aide attempted to remove her clothes.
Case Study
• A 90-year-old woman has been a patient of BA Care Center for
several years. Chronic conditions are pernicious anemia,
osteoarthritis and urinary incontinency. She is fully functional and
fully independent. She provides care for her homebound husband
who has severe COPD. They live in a row home specifically close to
the hospital to ensure access to house calls for her husband.
• In September 2000, the husband dies due to respiratory arrest. Her
only relative is a nephew who talks with her about once a month. In
October 2002, her home is broken into and the patient is raped and
robbed. She is taken to a local hospital specializing in rape. Here,
she is distressed, delusional, and is reported to be very emotionally
distraught.
• www.hopkinsmedicine.org/gec/studies/ptsd.html
Who and Why PTSD?
Risk factors include:
Previous traumatic experience
Family history of PTSD or depression
History of physical or sexual abuse
History of substance abuse
History of depression, anxiety or other mental illness
High level of stress in everyday life
Lack of support after the trauma
Lack of coping skills
Who is less apt to have PTSD?
Resilience factors include:
Strong support system
Counseling
Feeling good about one’s actions
Coping strategies
Being able to act and respond effectively despite fear
Treatments
• Cognitive Therapy
• Relive the experience and reframe it
• Processing emotions and sensations will help restore a sense of
control and reduce the hold that the memory has on your life
• Work through feelings of guilt, self blame and mistrust
• Exposure Therapy
• Virtual Reality
• EMDR – Eye Movement Desensitization & Reprocessing
• “unfreeze” the brain’s information processing system which is
interrupted in times of extreme stress
Medications and Therapy
Generalized Anxiety
Disorder
Benzodiazepines,
buspirone, and tricyclics.
Cognitive behavioral
therapy, stress
management and
biofeedback.
Panic Attacks
SSRIs; benzos, tricyclics,
MAO inhibitors.
Cognitive behavioral
therapy
Phobias
Benzos, beta-blockers,
SSRIs.
Cognitive behavioral
therapy (desensitization
therapy, hypnosis.
OCD
SSRIs first; clomipramine (
a tricyclic); MAO inhibitors
if non responsive to other
drugs
Cognitive behavioral
therapy (exposure and
response prevention)
PTSD
Antidepressants
Cognitive behavioral
particularly SSRIs, clonidine therapy
Alternative therapies
• Spiritual/religious counseling
• Yoga and various forms of bodywork
• Martial arts training
• Art therapy, journaling, dance therapy, and creative writing groups
can offer safe outlets for the strong emotions that follow trauma.
Barriers to Treatment
a. Non recognition of disease – denial by the provider that patient’s
symptoms are PTSD
b. Denial – by the patient that what they are feeling matches the
symptoms of PTSD
c. Medication Intolerance – inability to control anxiety and
depression with usual meds. Takes many trials of meds to control
symptoms
Prognosis
• CISD (critical incident stress debriefing) immediately after the event
shows the best prognosis.
• Full-Blown PTSD can be treated with a combination of peer-groups
meetings and individual psychotherapy and often be effective. May
take several years with relapses experienced.
• PTSD can become a chronic mental disorder that can persist for
decades, or the remainder of the patient’s life. These patients often
have a cyclical history of symptom remissions and relapses. These
have the poorest prognosis and some do not respond to any of the
currently available treatments for PTSD.
New treatments?
Stellate Ganglion Blocks
Stellate Ganglion Blocks
• A stellate ganglion block is an injection of local anesthetic into the
sympathetic nerve tissues of the neck. They are found in front of
the fifth and sixth cervical vertebrae
• A stellate ganglion block is typically done to:
• Diagnose the cause of pain in the face and head, arms and chest
• Manage pain in the head, neck, chest or arm caused by nerve
injuries, the effects of an attack of shingles (herpes zoster) or
angina that doesn't go away
• Reduce sweating in the face, head, arms and hands
• Treat reflex sympathetic dystrophy, sympathetic maintained pain or
complex regional pain syndrome
References
• www.gowarriorsproject.org
• http://www.bioportfolio.com/resources/pmarticle/35449/Ptsd-InOlder-Bereaved-People.html
• Source: National Center for PTSD
• http://www.helpguide.org/mental/post_traumatic_stress_disorder_
symptoms_treatment.htm
• http://www.ptsd.va.gov/public/pages/ptsd-older-vets.asp
• http://www.helpguide.org/mental/post_traumatic_stress_disorder_
symptoms_treatment.htm
• http://www.aplaceformom.com/senior-careresources/articles/elderly-anxiety-disorders
• http://health.nytimes.com/health/guides/disease/post-traumaticstress-disorder.html
• http://www.minddisorders.com/Ob-Ps/Post-traumatic-stressdisorder.html
References (cont)
• http://www.army.mil/article/86211/Virtual_reality_therapy_may_hel
p_PTSD_patients_recover.html
• http://www.hopkinsmedicine.org
• http://www.emdr.com/general-information/what-is-emdr.html
• http://www.cedars-sinai.edu/Patients/Programs-and-Services/PainCenter/Head-and-Neck-Pain/Stellate-Ganglion-Blocks.aspx