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Posttraumatic stress disorder (PTSD) is a condition marked by the development of symptoms after exposure to traumatic life events. The person reacts to this experience with fear and helplessness and tries to avoid being reminded of the events. Children who are behaviorally inhibited may be especially susceptible to anxiety or PTSD after threatening events.
To make the diagnosis the symptoms must last for more than a month after the event and must significantly affect important areas of life, such as family and work. DSM-IV-TR defines a disorder that is similar to PTSD called acute stress disorder, which occurs earlier than PTSD (within 4 weeks of the event) and remits within 2 days to 4 weeks. If symptoms persist then PTSD is warranted.
They can arise from experiences in war, torture, natural catastrophes, assault, rape, and serious accidents, for example, in cars and in burning buildings. Persons re-experience the traumatic event in their dreams and their daily thoughts. to evade anything that would bring the event to mind, they undergo a numbing of responsiveness along with a state of hyperarousal. Other symptoms: depression, anxiety, and cognitive difficulties, such as poor concentration.
History Soldier’s heart• was the name given during the US Civil War to a syndrome similar to PTSD. Jacob DaCostas 1871 paper, Irritable Heart, described soldiers with the syndrome. In the 1900s, the influence of psychoanalysis was strong, particularly in the United States, and clinicians applied the diagnosis of traumatic neurosis to the condition.
In World War I, the syndrome was called shell shock and was hypothesized to result from brain trauma caused by exploding shells. Psychiatric morbidity associated with Vietnam War finally brought the concept of PTSD.
Epidemiology The lifetime incidence about 9 to 15 percent, the lifetime prevalence about 8 percent , subclinical forms of the disorder 5 to 15 percent. it is most prevalent in young adults, because they tend be more exposed to precipitating situations. Men and women differ in the types of traumas to which they are exposed and their liability to develop PTSD.
Mens trauma was usually combat experience, and womens trauma was most commonly assault or rape. The disorder is most likely to occur in those who are single, divorced, widowed, socially withdrawn, or of low socioeconomic level. The most important risk factors, however, for this disorder are the severity, duration, and proximity of a persons exposure to the actual trauma.
Comorbidity Comorbidity rates are high among patients with PTSD with about two thirds having at least two other disorders. Common comorbid conditions include depressive disorders, substance-related disorders, other anxiety disorders, and bipolar disorders. Comorbid disorders make persons more vulnerable to developing PTSD.
Stressor prime causative factor in the development of PTSD. The response to the traumatic event must involve intense fear or horror. Clinicians must also consider individual preexisting biological and psychosocial factors and events that happened before and after the trauma. For example, a member of a group who lived through a disaster can sometimes deal with trauma because others shared the experience.
Psychodynamic Factors Trauma has reactivated a previously quiescent, yet unresolved psychological conflict. According to Freud, a splitting of consciousness occurs in patients who reported a history of childhood sexual trauma. A preexisting conflict might be symbolically reawakened by the new traumatic event.
Cognitive-Behavioral Factors The cognitive model of PTSD posits that affected persons cannot process or rationalize the trauma that precipitated the disorder. They attempt to avoid experiencing it by avoidance techniques. Persons experience alternating periods of acknowledging and blocking the event. The behavioral model of PTSD emphasizes two phases in its development.1) The trauma (the unconditioned stimulus) produces a fear response is paired, through classic conditioning, with a conditioned stimulus.2) through instrumental learning, the conditioned stimuli elicit the fear response independent of the original unconditioned stimulus, and persons develop a pattern of avoiding both the conditioned stimulus and the unconditioned stimulus. Some persons also receive secondary gains from the external world, commonly monetary compensation, increased attention or sympathy, and the satisfaction of dependency needs. These gains reinforce the disorder and its persistence.
Biological Factors Preclinical models in animals have led to theories about norepinephrine, dopamine, endogenous opioids, and benzodiazepine receptors and the hypothalamic-pituitary-adrenal (HPA) axis. In clinical populations, data have supported hypotheses that the noradrenergic and endogenous opiate systems, as well as the HPA axis, are hyperactive in at least some patients with PTSD. Other major biological findings are increased activity and responsiveness of the autonomic nervous system.
Noradrenergic System Soldiers with PTSD-like symptoms exhibit nervousness, increased blood pressure and heart rate, palpitations, sweating, flushing, and tremor- -symptoms associated with adrenergic drugs. Studies found increased 24-hour urine epinephrine concentrations in veterans with PTSD and increased urine catecholamine concentrations in sexually abused girls.
Opioid System Abnormality in the opioid system is suggested by low plasma B-endorphin concentrations in PTSD. Combat veterans with PTSD demonstrate a naloxone (Narcan)-reversible analgesic response to combat- related stimuli, raising the possibility of opioid system hyperregulation similar to that in the HPA axis.
Corticotropin-Releasing Factor andthe HPA Axis Studies have demonstrated low plasma and urinary free cortisol concentrations in PTSD. More glucocorticoid receptors are found on lymphocytes, and challenge with exogenous corticotropin-releasing factor (CRF) yields a blunted ACTH response. Some studies have revealed cortisol hypersuppression in trauma-exposed patients who develop PTSD, compared with patients exposed to trauma who do not develop PTSD, indicating that it might be specifically associated with PTSD and not just trauma.
Diagnosis The DSM-IV-TR diagnostic criteria for PTSD specify that the symptoms of experiencing, avoidance, and hyperarousal must have lasted more than 1 month. symptoms present for less than 1 month - acute stress disorder. Acute - If symptoms of PTSD have lasted less than 3 months Chronic - if the symptoms have lasted 3 months or more..
Table 16.5-5 DSM-IV-TR DiagnosticCriteria for Acute Stress Disorder
Clinical Features The principal clinical features of PTSD are painful reexperiencing of the event, a pattern of avoidance and emotional numbing, and fairly constant hyperarousal. Mental status examination reveals feelings of guilt, rejection, and humiliation. Patients may describe dissociative states and panic attacks, and illusions and hallucinations may be present. Associated symptoms : aggression, violence, poor impulse control, depression, and substance-related disorders. Cognitive testing may reveal that patients have impaired memory and attention.
PTSDs in Children and Adolescents Symptoms such as repetitive dreams of the event, nightmares of monsters, and the development of physical symptoms such as stomachaches and headaches. High rates of PTSD have been documented in children exposed to such life-threatening events as combat and other war-related trauma, kidnapping, severe illness or burns, bone marrow transplantation, and a number of natural and man- made disasters.
StressorStressors in childrenmay be sudden, single-incident trauma orongoing or chronictrauma, such as physicalor sexual abuse. Children also suffer asthe result of indirectexposure that is, theunwitnessed death orinjury of a loved one, asin situations of disaster,war, or communityviolence.
Reenactment and Reexperiencing “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. Older children may incorporate aspects of the trauma into their lives in a process termed reenactment. Related behaviors in child and adolescent victims of trauma include sexual acting out, substance use, and delinquency.
Gulf War Syndrome On the return of American soldiers from the Persian Gulf War, more than 100,000 US veterans reported a vast array of health problems, including irritability, chronic fatigue, shortness of breath, muscle and joint pain, migraine headaches, digestive disturbances, rash, hair loss, forgetfulness, and difficulty concentrating. Collectively, these symptoms were called the Gulf War syndrome. the soldiers may have been exposed to chemical weapons and disorder may have been precipitated by exposure to an unidentified toxin.
Physicians need to acknowledge that many Gulf War veterans are experiencing stress-related disorders and the physical consequences of stress. Thousands of Gulf War veterans developed PTSD . PTSD is caused by psychological stress and the Gulf War syndrome is presumed to be caused by environmental biological stressors. Signs and symptoms often overlap and both conditions may exist at the same time.
9/11/01 On September 11, 2001, terrorist activity destroyed the World Trade Center (Fig. 16.5-1) in New York City and damaged the Pentagon in Washington. More than 25,000 people continue to suffer symptoms of PTSD related to the 9/11 attacks beyond the 1 year mark.
Iraq and Afghanistan In October 2001, the United States, along with Australia, Canada, and the United Kingdom, began the invasion of Afghanistan in the wake of the September 11, 2001 attacks. Both wars are ongoing and PTSD is a rising problem with an estimated 17 percent of returning soldiers having PTSD.
Natural DisastersTsunamiOn December 26,2004, a massivetsunami struck theshores of Indonesia,Sri Lanka, SouthIndia, and Thailandand caused seriousdamage.Those survivorscontinue to live infear and show signsof PTSD.
Torture The intentional physical and psychological torture of one human by another can have emotionally damaging effects. Torture is any deliberate infliction of severe mental pain or suffering, usually through cruel, inhuman, or degrading treatment or punishment. This broad definition includes various forms of interpersonal violence, from chronic domestic abuse to broad-scale genocide.
Torture is distinct from most other types of trauma because it is human inflicted and intentional. Methods can be physical (e.g., beatings, burning of the skin, electric shock, or asphyxiation) or psychological, through threats, humiliation, or being forced to watch others, often loved ones, being tortured. One distinct method of torture that may combine physical and psychological aspects is brainwashing. Treatment methods for survivors of torture are the same as those for other posttraumatic symptoms and disorders.
Differential Diagnosis head injury during the trauma Epilepsy alcohol-use disorders substance-related disorders Acute intoxication or withdrawal from some substances Symptoms of PTSD can be difficult to distinguish from both panic disorder and generalized anxiety disorder, because all three syndromes are associated with prominent anxiety and autonomic arousal.
Keys to correctly diagnosing PTSD involve a careful review of the time course relating the symptoms to a traumatic event. Major depression is also a frequent concomitant of PTSD. Borderline personality disorder can be difficult to distinguish from PTSD. The two disorders can coexist or even be causally related.
Course and Prognosis PTSD usually develops some time after the trauma. The delay can be as short as 1 week or as long as 30 years. If untreated : 30 % recover completely 40% with mild symptoms 20% with moderate symptoms 10% remained unchanged or become worst
In general, the very young and the very old have more difficulty with traumatic events than do those in midlife. PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and may be difficult to treat.
Treatment The major approaches are support, encouragement to discuss the event, and education about a variety of coping mechanisms (e.g., relaxation). The use of sedatives and hypnotics can also be helpful. When a patient experienced a traumatic event in the past and now has PTSD, the emphasis should be on education about the disorder and its treatment, both pharmacological and psychotherapeutic. Additional support for the patient and the family can be obtained through local and national support groups for patients with PTSD.
Pharmacotherapy first-line treatments for PTSDSelective serotonin reuptake inhibitors (SSRIs), such assertraline (Zoloft) and paroxetine (Paxil). Buspirone (BuSpar) is serotonergic and may also be of use. Other drugs : Monoamine oxidase inhibitors (MAOIs) phenelzine [Nardil]), trazodone (Desyrel), The anticonvulsants carbamazepine [Tegretol], valproate [Depakene].
Psychotherapy Reconstruction of the traumatic events with associated abreaction and catharsis may be therapeutic, but psychotherapy must be individualized because reexperiencing the trauma overwhelms some patients. Psychotherapeutic interventions for PTSD include behavior therapy, cognitive therapy, and hypnosis. The short-term nature of the psychotherapy minimizes the risk of dependence and chronicity, but issues of suspicion, paranoia, and trust often adversely affect compliance.
Patients should be encouraged to review and abreact emotional feelings associated with the traumatic event and to plan for future recovery. “Abreaction” -- experiencing the emotions associated with the event-- may be helpful for some patients. The amobarbital (Amytal) interview has been used to facilitate this process. When PTSD has developed, two major psychotherapeutic approaches can be taken.1) Exposure therapy2) Stress management
1) Exposure therapy : in which the patient reexperiences the traumatic event through imaging techniques or in vivo exposure. The result of this therapy lasts longer.2) Stress management : including relaxation techniques and cognitive approaches to coping with stress. This shows result more rapidly. eye movement desensitization and reprocessing (EMDR) : the patient focuses on the lateral movement of the clinicians finger while maintaining a mental image of the trauma experience. It is possibly more effective than other treatments for PTSD.
Group therapy include sharing of traumatic experiences and support from other group members. Group therapy has been particularly successful with Vietnam veterans and survivors of catastrophic disasters such as earthquakes. Family therapy often helps sustain a marriage through periods of exacerbated symptoms. Hospitalization may be necessary when symptoms are particularly severe or when a risk of suicide or other violence exists.