POST TRAUMATIC STRESS      DISORDER PRESENTED BY:DR.A.GODSON,MD
INTRODUCTION• Disorder driven by pathogenic memories of  past danger.• Symptoms must last for more than a month• Acute str...
EPONYMS OF PTSD• Civil War-Irritable heart• World War I-shell shock  /Effort syndrome• World war II – combat stress  syndr...
Common feature shared by all             syndromes• Fatigue, fainting• Shortness of breath,• Palpitations,• Headache, dizz...
EPIDEMIOLGY• Lifetime prevalence -8 percent in general  population• 5 to 15 percent -subclinical forms of the  disorder.• ...
• Sexual assault-higher impact• Sudden unexpected death  of a loved one and road  traffic accidents• Men -more traumatic  ...
COMORBIDITY•   Depressive disorders•   Substance-related disorders•   Anxiety disorders•   Bipolar disorders
ETIOLOGY
Stressor• Prime causative factor• Stressors of human design-rape and violent  assault, are usually more pathogenic• Sudden...
Risk factors for being exposed to                  trauma• Less than a college education• Being male• History of childhood...
Risk factors for PTSD Among those            exposed to trauma• Female, neuroticism• Lower social support• Lower IQ• Pre-e...
PREDICTORS• Previous exposure to trauma• Peritraumatic responses• Negative interpretations of ones acute  responses• Borde...
GENETICS• 1/3rd of variance in  symptoms is genetic• Trauma exposure-little or  no effect on measures of  IQ &neurocogniti...
Psychodynamic Factors• Trauma has reactivated a previously quiescent, yet  unresolved psychological conflict• The subjecti...
COGNITIVE FACTORS• Affected persons cannot process or rationalize  the trauma that precipitated the disorder.• They contin...
Emotional Stroop paradigm• Delayed naming  of the words  colour• Heightened  stroop  interference for  trauma words in  PTSD
Fear conditioning    Mowrers two-factor conditioning theory    Traumatic stimuli (UCS)         fear&arousal    UCS+CS     ...
Noradrenergic System• Nervousness, increased blood  pressure and heart rate,  palpitations, sweating,  flushing, and tremo...
• Increased urine  catecholamine  concentrations in sexually  abused girls• Platelet alpha2- and  lymphocyte beta 2  adren...
• Flashbacks after  yohimbine  administration
HPA Axis• Low plasma and urinary  free cortisol• CRF challenge yields a  blunted ACTH response• DMST- enhanced  suppressio...
Structural changes• Lower average volume  in the hippocampal  region• Structural changes in  the amygdale
Exaggerated Startle Responses• Larger EMG eye blink  responses to a sudden  auditory stimulus• Increased HR
NEUROIMAGING• PET Studies-less anterior cingulate activation  during the emotional Stroop task• fMRI experiment- attenuate...
DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder
The person has been exposed to a traumatic event  in which both of the following were present:• The person experienced, wi...
The traumatic event is persistently re-experienced in        one (or more) of the following ways:   Recurrent and intrusi...
 Acting or feeling as if the traumatic event were  recurring (includes a sense of reliving the experience,  illusions, ha...
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the  ...
Persistent symptoms of increased arousal (not present  before the trauma), as indicated by two (or more)     Difficulty f...
• Duration of the disturbance (symptoms in Criteria  B, C, and D) is more than 1 month.• The disturbance causes clinically...
DSM-IV                  ICD-10 research diagnostic                                         criteria.• Avoidance/numbing cl...
PTSDs in Children and Adolescents• High rates –war related  trauma, kidnapping,  severe illness or burns,  bone marrow  tr...
Reenactment and Reexperiencing• Reexperience the traumatic  event in the form of  distressing, intrusive thoughts  or memo...
• Older children may  incorporate aspects of the  trauma into their lives in  a process termed  reenactment.• Impulsive ac...
Gulf War Syndrome• Began in 1990 and ended  in 1991• Irritability, chronic  fatigue, shortness of  breath, muscle and join...
11/9/01• Terrorist activity  destroyed the world trade  center in new york city  and damaged the  pentagon in washington.•...
Tsunami• December 26, 2004.• Many survivors continue  to live in fear and show  signs of PTSD• Fishermen fear venturing  o...
Hurricane• In August 2005, a  category 5 hurricane,  Hurricane Katrina,  ravaged the Gulf of  Mexico, the Bahamas,  South ...
Earthquake• On October 8, 2005, a 7.6  magnitude earthquake hit  South Asia, affecting  Pakistan, Afghanistan and  Norther...
Torture• Defined as any deliberate  infliction of severe mental pain or  suffering, usually through cruel,  inhuman, or de...
BRAIN WASH• Combine physical and  psychological aspects is  brainwashing.• Prevalence rates of  PTSD among survivors  of t...
DIFFERENTIAL DIAGNOSIS• Organic considerations -epilepsy, alcohol-use  disorders, and other substance-related disorders, A...
Course and Prognosis• Symptoms can fluctuate ,most intense during  periods of stress.• Untreated, about 30 percent of pati...
Good prognostic factors         Poor prognostic factors• Rapid onset of the            • The very young  symptoms         ...
TREATMENT
Some principles for management• Comorbid depression – treat PTSD first.• Substance dependence should be addressed  first b...
Pharmacotherapy• SSRI’S-sertraline and paroxetine are  considered first-line treatments for PTSD• TCA’S-Imipramine and ami...
• MAOI’S -phenelzine ,trazodone are effective in  reducing re experiencing symptoms and  insomnia.,• Anticonvulsants :carb...
CBTEducation• about the symptoms of PTSD , treatment  rationales, Common reactions to trauma  ,giving up behaviours that m...
Exposure• Imaginal exposure.• In vivo exposure - going  to the site of the  traumatic event, driving  again after a road t...
Cognitive therapy• For anxiety disorder focus on identification and  modification of misinterpretations that lead to  over...
Eye-movement desensitization              reprocessing• New and controversial treatment.• Patient is instructed to focus o...
Psychodynamic therapy• The goal of the treatment is to work through and  resolve an unconscious conflict which the  trauma...
• Avoidance is one of  the main symptoms of  PTSD, and it can thus  take years for the  patient to seek help for  this con...
PTSD-NOT ALL WOUNDS ARE VISIBLE                 THANK YOU
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Post traumatic stress disorder-ppt

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Post traumatic stress disorder-ppt

  1. 1. POST TRAUMATIC STRESS DISORDER PRESENTED BY:DR.A.GODSON,MD
  2. 2. INTRODUCTION• Disorder driven by pathogenic memories of past danger.• Symptoms must last for more than a month• Acute stress disorder, which occurs earlier than PTSD
  3. 3. EPONYMS OF PTSD• Civil War-Irritable heart• World War I-shell shock /Effort syndrome• World war II – combat stress syndrome• Vietnam War- brought the concept of PTSD.• Gulf war syndrome• PTSD entered the DSM-III in 1980
  4. 4. Common feature shared by all syndromes• Fatigue, fainting• Shortness of breath,• Palpitations,• Headache, dizziness,• Excessive sweating,• Disturbed sleep,• Difficulty in concentration• Forgetfulness
  5. 5. EPIDEMIOLGY• Lifetime prevalence -8 percent in general population• 5 to 15 percent -subclinical forms of the disorder.• Among high-risk groups -5 to 75 percent.• 10 to 12 percent among women• 5 to 6 percent among men.• Higher in women, single, divorced, widowed, socially withdrawn, of low socioeconomic level
  6. 6. • Sexual assault-higher impact• Sudden unexpected death of a loved one and road traffic accidents• Men -more traumatic events• Women - higher impact events.
  7. 7. COMORBIDITY• Depressive disorders• Substance-related disorders• Anxiety disorders• Bipolar disorders
  8. 8. ETIOLOGY
  9. 9. Stressor• Prime causative factor• Stressors of human design-rape and violent assault, are usually more pathogenic• Sudden, unexpected, and life-threatening events• Disasters related
  10. 10. Risk factors for being exposed to trauma• Less than a college education• Being male• History of childhood conduct problems• Family history of psychiatric illness• Extroverted• More neurotic
  11. 11. Risk factors for PTSD Among those exposed to trauma• Female, neuroticism• Lower social support• Lower IQ• Pre-existing psychiatric illness• Family history of mood, anxiety, or substance abuse disorders• Neurological soft signs
  12. 12. PREDICTORS• Previous exposure to trauma• Peritraumatic responses• Negative interpretations of ones acute responses• Borderline, paranoid, dependent, or antisocial personality disorder traits• Presence of childhood trauma• Inadequate family or peer support system• Recent stressful life changes• Recent excess alcohol intake
  13. 13. GENETICS• 1/3rd of variance in symptoms is genetic• Trauma exposure-little or no effect on measures of IQ &neurocognitive functioning• Similarity in the test scores between co-twins implies genetic influence on cognitive performance• Above average cognitive ability -protect
  14. 14. Psychodynamic Factors• Trauma has reactivated a previously quiescent, yet unresolved psychological conflict• The subjective meaning of a stressor may determine its traumatogenicity.• Traumatic events can resonate with childhood traumas.• Inability to regulate affect can result from trauma.• Somatization and alexithymia may be among the after effects of trauma.• Common defenses -denial, minimization, splitting, projective , dissociation, and guilt• Mode of object relatedness involves projection and introjection
  15. 15. COGNITIVE FACTORS• Affected persons cannot process or rationalize the trauma that precipitated the disorder.• They continue to experience the stress and attempt to avoid experiencing it by avoidance techniques.• Less decline in vividness, emotional intensity, and accuracy of traumatic memories.• Exhibit difficulty retrieving specific memories• Difficulties of attentional control
  16. 16. Emotional Stroop paradigm• Delayed naming of the words colour• Heightened stroop interference for trauma words in PTSD
  17. 17. Fear conditioning Mowrers two-factor conditioning theory Traumatic stimuli (UCS) fear&arousal UCS+CS fear response stimulus generalization variety of stimuli become triggers avoidance of CS negative reinforcement by operant conditioning prevents extinction of conditioned fear responses maintains the problem.•
  18. 18. Noradrenergic System• Nervousness, increased blood pressure and heart rate, palpitations, sweating, flushing, and tremors - symptoms of adrenergic drugs.• Increased 24-hour urine epinephrine concentrations in veterans
  19. 19. • Increased urine catecholamine concentrations in sexually abused girls• Platelet alpha2- and lymphocyte beta 2 adrenergic receptors are downregulated
  20. 20. • Flashbacks after yohimbine administration
  21. 21. HPA Axis• Low plasma and urinary free cortisol• CRF challenge yields a blunted ACTH response• DMST- enhanced suppression of cortisol• Indicates hyper- regulation of HPA axis
  22. 22. Structural changes• Lower average volume in the hippocampal region• Structural changes in the amygdale
  23. 23. Exaggerated Startle Responses• Larger EMG eye blink responses to a sudden auditory stimulus• Increased HR
  24. 24. NEUROIMAGING• PET Studies-less anterior cingulate activation during the emotional Stroop task• fMRI experiment- attenuated rostral anterior cingulate activation when exposed to war- related words• Dysfunction in the medial prefrontal cortex and amygdala• Hypoactive medial PFC loss of inhibition on amygdala hyper-responsive amygdala
  25. 25. DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder
  26. 26. 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 persons response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior
  27. 27. The traumatic event is persistently re-experienced in one (or more) of the following ways:  Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.  Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content.
  28. 28.  Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in young children, trauma- specific reenactment may occur. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  29. 29. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:  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  Markedly diminished interest or participation in significant activities  Feeling of detachment or estrangement from others  Restricted range of affect (e.g., unable to have loving feelings)  Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span
  30. 30. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more)  Difficulty falling or staying asleep  Irritability or outbursts of anger  Difficulty concentrating  Hypervigilance  Exaggerated startle response
  31. 31. • Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.• Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more Specify if: With delayed onset: if onset of symptoms is at least 6 months after the stressor
  32. 32. DSM-IV ICD-10 research diagnostic criteria.• Avoidance/numbing cluster • Not included of symptoms - requiring a • Patient could be diagnosed minimum of three as having PTSD in the• Increased arousal is absence of hyperarousal necessary symptoms if amnesia is• Minimum symptom present duration of 1 month • Not included• Significant distress or • Not included impaired functioning
  33. 33. PTSDs in Children and Adolescents• High rates –war related trauma, kidnapping, severe illness or burns, bone marrow transplantation, natural and man-made disasters• Underestimated in children and adolescents.• Family factors• Parents responses to traumatic events
  34. 34. Reenactment and Reexperiencing• Reexperience the traumatic event in the form of distressing, intrusive thoughts or memories, flashbacks, and dreams• Nightmares, flashbacks also play a role• Traumatic play, a specific form of reexperiencing seen in young children, consists of repetitive acting out of the trauma or trauma-related themes in play•
  35. 35. • Older children may incorporate aspects of the trauma into their lives in a process termed reenactment.• Impulsive acting out secondary to anger, sexual acting out, substance use, and delinquency• Regressive behaviors, such as enuresis or fear of sleeping alone
  36. 36. Gulf War Syndrome• Began in 1990 and ended in 1991• Irritability, chronic fatigue, shortness of breath, muscle and joint pain, migraine headaches,• Digestive disturbances, rash, hair loss, forgetfulness, and difficulty concentrating .• Amyotrophic lateral sclerosis (ALS)
  37. 37. 11/9/01• Terrorist activity destroyed the world trade center in new york city and damaged the pentagon in washington.• Survey found a prevalence rate of 11.4 percent for PTSD and 9.7 percent for depression in US citizens 1 month after 11/9
  38. 38. Tsunami• December 26, 2004.• Many survivors continue to live in fear and show signs of PTSD• Fishermen fear venturing out to sea• Children fear playing at beaches they once enjoyed• Trouble sleeping in fear of another tsunami
  39. 39. Hurricane• In August 2005, a category 5 hurricane, Hurricane Katrina, ravaged the Gulf of Mexico, the Bahamas, South Florida, Louisiana, Mississippi, and Alabama
  40. 40. Earthquake• On October 8, 2005, a 7.6 magnitude earthquake hit South Asia, affecting Pakistan, Afghanistan and Northern India.• More than 85,000 casualties have occurred .• Up to 3 million people were left homeless.• Many cases of PTSD developed among those who experienced these disasters• Recently in japan
  41. 41. Torture• Defined as any deliberate infliction of severe mental pain or suffering, usually through cruel, inhuman, or degrading treatment or punishment.• Torture is distinct from most other types of trauma because it is human inflicted and intentional.• physical -beatings, burning of the skin, electric shock, or asphyxiation• Psychological -threats, humiliation, or being forced to watch others, often loved ones, being tortured.
  42. 42. BRAIN WASH• Combine physical and psychological aspects is brainwashing.• Prevalence rates of PTSD among survivors of torture are about 36 percent
  43. 43. DIFFERENTIAL DIAGNOSIS• Organic considerations -epilepsy, alcohol-use disorders, and other substance-related disorders, Acute intoxication or withdrawal from some substances• Panic disorder and generalized anxiety disorder: PTSD associated with re-experiencing and avoidance of a trauma• Borderline personality disorder, dissociative disorders, and factitious disorders.- do not usually have the degree of avoidance behavior, the autonomic hyperarousal, or the history of trauma• Obsessive-compulsive disorder (OCD) and generalized anxiety disorder.-PTSD concerns memory—the intrusion of past stressors into the present. In contrast, OCD concerns current and future threats
  44. 44. Course and Prognosis• Symptoms can fluctuate ,most intense during periods of stress.• Untreated, about 30 percent of patients recover completely,• 40 percent continue to have mild symptoms,• 20 percent continue to have moderate symptoms• 10 percent remain unchanged or become worse.• After 1 year, about 50 percent of patients will recover
  45. 45. Good prognostic factors Poor prognostic factors• Rapid onset of the • The very young symptoms • very old• Short duration <6 months • Pre-existing psychiatric• Good premorbid disability, whether a functioning personality disorder or a• Strong social supports more serious condition• Absence of other psychiatric, medical, or substance-related disorders
  46. 46. TREATMENT
  47. 47. Some principles for management• Comorbid depression – treat PTSD first.• Substance dependence should be addressed first before treating PTSD• Support, encouragement to discuss the event, and education about a variety of coping mechanisms• Sedatives and hypnotics can be helpful.
  48. 48. Pharmacotherapy• SSRI’S-sertraline and paroxetine are considered first-line treatments for PTSD• TCA’S-Imipramine and amitriptyline .Dosages same as those used to treat depressive disorders, trial should last at least 8 weeks. continue the pharmacotherapy for at least 1 year if respond well
  49. 49. • MAOI’S -phenelzine ,trazodone are effective in reducing re experiencing symptoms and insomnia.,• Anticonvulsants :carbamazepine , valproate• Benzodiazepines-Benzodiazepines do not appear to be effective although they may show some effects on insomnia, irritability, and general anxiety and arousal symptoms
  50. 50. CBTEducation• about the symptoms of PTSD , treatment rationales, Common reactions to trauma ,giving up behaviours that maintain the problem such as avoidance and safety behaviours.Self-monitoring of symptoms• self-monitoring may in itself be therapeutic
  51. 51. Exposure• Imaginal exposure.• In vivo exposure - going to the site of the traumatic event, driving again after a road traffic accident• Exposure is repeated until the patient no longer responds with high levels of distress.• Helps in correcting dysfunctional beliefs about danger
  52. 52. Cognitive therapy• For anxiety disorder focus on identification and modification of misinterpretations that lead to overestimation of threat and under estimation of their coping abilities• But in PTSD the perceived threat arise from the interpretation of trauma and its consequences.• The patient is encouraged to drop behaviour and cognitive strategies that leads to negative interpretation.
  53. 53. Eye-movement desensitization reprocessing• New and controversial treatment.• Patient is instructed to focus on a trauma-related image and its accompanying feelings, sensations, and thoughts, while visually tracking the therapists fingers as they move back and forth in front of the patients eyes.• After a set of approximately 24 eye movements, cognitive and emotional reactions are discussed with the therapist.• Once the distress to traumatic image is reduced coping statements are also introduced while the scene is being imagined.
  54. 54. Psychodynamic therapy• The goal of the treatment is to work through and resolve an unconscious conflict which the traumatic event is thought to have provoked.Hypnotherapy• The goal of this treatment is to enhance control over trauma-related emotional distress and hyperarousal symptoms and to facilitate the recollection of details of the traumatic event• The effect is below trauma focused CBT or EMDR
  55. 55. • Avoidance is one of the main symptoms of PTSD, and it can thus take years for the patient to seek help for this condition
  56. 56. PTSD-NOT ALL WOUNDS ARE VISIBLE THANK YOU
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