Definition“Posttraumatic StressDisorder is a type ofanxiety disorder thatoccurs after one seesor experiences atraumatic event thatinvolves the threat ofinjury, death or otherphysical integrity.”Involved in/with eventWitness eventLearning or hearing about eventPerson responds with intensefear, horror, helplessness,disorganized or agitatedbehavior.Symptoms must be present formore than 1 monthDisturbance causes clinicallysignificant distress or impairmentin important areas offunctioning.
SpecifiersAcuteSymptoms last less than 3monthsChronicSymptoms last more than3 monthsDelayed OnsetAt least 6 months havepassed between traumaticevent and onset ofsymptoms
Differential DiagnosisAdjustment DisorderStressor can be of any severity.Situation in which symptoms occur are not extreme (e.g. beingfired, spouse leaving).Acute Stress DisorderSymptoms are similar to PTSD, but occur within 4 weeks andresolve within the same 4 week period.Obsessive-Compulsive DisorderRecurrent intrusive thoughts not related to traumatic event.Thoughts are experienced as inappropriate.
Causes• Natural disasters• Mass murder• Combat Exposure• Rape/Sexual Molestation• Childhood Neglect• Physical abuse/attack• Other traumatic events
Risk Factors• Female Middle-aged (40 to 60 years old)• No experience coping with traumatic events• Ethnic minority• Lower socioeconomic status• Children• Spouse or partner with PTSD• Pre existing psychiatric condition• Primary exposure to the trauma• Living in traumatized community
Symptoms• Sleep problems• Irritability,• Difficulty concentrating,• Jumpiness,• Feeling constantly “onguard”are associated with angerandhostility (hyper alertness)• Hostility• Fear and anxiety
Symptoms contd• Nightmares and flashbacks• Sight, sound, and smell recollection• Avoidance of recall situations• Anger and irritability• Guilt• Depression• Increased substance abuse• Negative world view• Decreased sexual activity
Screening for PTSD• Posttraumatic Stress Disorder Checklist• the only screening tool for PTSD• 17-item checklist• tested in primary care settings.• Sensitivity is low (11)• SPAN(Startle, Physiological arousal, Anger,Numbness).• only screens for four symptoms• correlates with more extensive measures of PTSD
Screening for Trauma(non-PTSD) Michigan Critical Events Perception Scale five-item questionnaire positive scores are 3X more likely to develop PTSD Acute Stress Disorder Scale 19-item self report psychometric properties(reliability, validity), not tested in trauma or primary care setting. Suicide evaluation Very important for any trauma victim
PCL: PTSD ChecklistExamples• Have you been jumpy or easilystartled lately?• Have you been irritable or hadoutbursts of anger?• Have you found yourself tryingto avoid situations that remindyou of it?• Have you had nightmares aboutit or thought about it when youdid not want to?The PCL is self administeredResponses range from 1 beingthe lowest to 5 being the highestThe higher the score, the moresymptoms a patient may have.Used for military personnel.
SPANSpan is administered by clinicianAnswers are evaluated by verbalanswer and body language.If client answers “NO” to 2 ormore questions, PTSD is veryunlikely“In your life have you ever had anyexperience that was sofrightening, horrible, or upsettingthat in the past month you: “Startle: “Have you had nightmaresor thought about it when you didnot want to”Physiological arousal: “Tried hardto avoid it or not think about it?”Anger: where constantly on guardor easily startled?Numbness: “felt numb ordetached?”
TreatmentTrauma-focused cognitive-behavioral therapy. Cognitive-behavioral therapy for PTSD and trauma involves carefullyand gradually “exposing” yourself to thoughts, feelings, and situations that remind you of the trauma. Therapy alsoinvolves identifying upsetting thoughts about the traumatic event–particularly thoughts that are distorted andirrational—and replacing them with more balanced picture.Family therapy. Since PTSD affects both you and those close to you, family therapy can be especially productive.Family therapy can help your loved ones understand what you’re going through. It can also help everyone in thefamily communicate better and work through relationship problems.Medication. Medication is sometimes prescribed to people with PTSD to relieve secondary symptoms of depression oranxiety. Antidepressants such as Prozac and Zoloft are the medications most commonly used for PTSD. Whileantidepressants may help you feel less sad, worried, or on edge, they do not treat the causes of PTSD.EMDR (Eye Movement Desensitization and Reprocessing). EMDR incorporates elements of cognitive-behavioraltherapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. Eyemovements and other bilateral forms of stimulation are thought to work by “unfreezing” the brain’s informationprocessing system, which is interrupted in times of extreme stress, leaving only frozen emotional fragments whichretain their original intensity. Once EMDR frees these fragments of the trauma, they can be integrated into acohesive memory and processed.
Medication• Selective serotonin reuptake inhibitors• Celexa, Lexapro, Paxil and Prozac• Reduce avoidance, numbing, hyper arousal, and intrusive thoughts.• Side effects are general nausea, restlessness, and loss of libido.• Heterocyclic antidepressants• Elavil, Tofranil, and Pamelor• Inhibit nerve cells ability to reuptake serotonin and norepinehrine• Reduce intrusive thoughts, hyper arousal, numbing, and insomnia• Side effects include weight gain, sedation, constipation, dry mouth,dizziness, blurred vision, EKG changes, Orthostasis. Can be harmful ifsuddenly stopped.
Alternative Prevention• Reach out to others for support• Avoid alcohol and drugs• Challenge your sense of helplessness• http://www.youtube.com/watch?v=eHmXYhS4HQIPositive ways of coping with PTSD:• Learn about trauma and PTSD.• Join a PTSD support group• Practice relaxation techniques• Confide in a person you trust• Spend time with positive people• Avoid alcohol and drugs
Complications• Early treatment is better.• PTSD symptoms can change family life.• PTSD can be related to other health problems.• Previous traumatic experiences, especially in early life.• Family history of PTSD or depression.• History of physical or sexual abuse.• History of substance abuse.• History of depression, anxiety, or another mental illness.• High level of stress in everyday life.• Lack of support after the trauma.• Lack of coping skills.
PTSD Self-TestAre you troubled by the following?Yes NoYou have experienced or witnessed a life-threatening event that caused intense fear, helplessness, or horror.Do you re-experience the event in at least one of the following ways?Yes NoRepeated, distressing memories, or dreamsYes NoActing or feeling as if the event were happening again (flashbacks or a sense of reliving it)Yes NoIntense physical and/or emotional distress when you are exposed to things that remind you of the eventDo reminders of the event affect you in at least three of the following ways?Yes NoAvoiding thoughts, feelings, or conversations about itYes NoReference:Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994.
ReferencesHathaway, L. M., Boals, A., & Banks, J. B. (2010). PTSD symptoms and dominantemotional response to a traumatic event: an examination of DSM-IV CriterionA2.Anxiety, Stress & Coping, 23(1), 119-126. doi:10.1080/10615800902818771Marshall, G. N., Schell, T. L., & Miles, J. V. (2010). All PTSD symptoms are highlyassociated with general distress: Ramifications for the dysphoria symptomcluster. Journal of Abnormal Psychology, 119(1), 126-135.doi:10.1037/a0018477Park, C. L., Mills, M., & Edmondson, D. (2010). Ptsd as meaning violation: Testing acognitive worldview perspective. Psychological Trauma: Theory, Research,Practice, and Policy, doi:10.1037/a0018792Postdeployment Anger and Aggressiveness in Veterans of Iraq and Afghanistan Wars.(2010). The American Journal of Psychiatry, (), . Retrieved fromhttp://www.psych.org/MainMenu/Newsroom/NewsReleases/2010-News-Releases/Anger-and-Aggressiveness-in-Veterans-.aspx
References contdDrug treatment for posttraumatic stress disorder retrieved thoughhttp://pier.axponline.org/physicians on February 5, 2011DHCC Clinicians Helpline. (2003). PCL Primer. Retrieved fromhttp://www.pdhealth.mil/guidelines/downloads/PCL_Primer.pdfhttp://www.adaa.org/living-with-anxiety/ask-and-learn/screenings/screening-posttraumatic-stress-disorder-ptsd