Post traumatic stress disorder

Post Traumatic Stress Disorder
Presenter – Dr. Utkarsh Modi

• Introduction
• Historical aspect
• Evolution of concept
• Epidemiology
• Indian scenario
• Pathophysiology
• Diagnosis
• Differential Diagnoses
• Assessment
• Course and Prognosis
• Treatment
• Controversies
• Recent advances
OVERVIEW

INTRODUCTION
• Post traumatic stress disorder (PTSD) has been
described as "the complex somatic, cognitive,
affective, and behavioural effects of psychological
trauma“
• Severe anxiety disorder that can develop after
exposure to any event that results in psychological
trauma overwhelming the individual's ability to cope.
van der Kolk BA, Pelcovitz D, Roth S, et al.
Dissociation, somatization, and affect
dysregulation: the complexity of adaptation
of trauma. Am J Psychiatry 1996; 153:83.

• PTSD is characterized by :
– Intrusive thoughts
– Nightmares and flashbacks of past traumatic
events
– Avoidance of reminders of trauma
– Hyper vigilance
– Sleep disturbance
– All of which lead to considerable social,
occupational, and interpersonal dysfunction.
Posttraumatic stress disorder in adults:
Epidemiology, pathophysiology, clinical
manifestations, course, and diagnosis
Author - Paul Ciechanowski, MD

Common events
• Military combat
• Violent personal assault
• Natural and man-made disasters
• Severe motor vehicle accidents
• Rape
• Incest
• Childhood sexual abuse
• Diagnosis of a life-threatening illness
• Severe physical injury
• Hospitalization in an intensive care unit (ICU)

• Describing trauma
– One of the central issues for this field has been
defining and observing a traumatic event.
– ICD 10 : stressful event or situation (either short
lived or long lasting) of an exceptionally
threatening or catastrophic nature which is likely
to cause pervasive distress in almost everybody.
– DSM IV definition acknowledges the possibility of
a personal subjective response to a significantly
greater degree.
APP Textbook of Anxiety Disorders

HISTORICAL ASPECT
• The symptoms of PTSD have been described since
the inception of war.
• Epic of Gilgamesh.
• Homer’s Iliad and Ciceros’s Letters to his friends.
• Several accurate descriptions in Shakespeare’s
work as well.
PCNA 1994, The phenomenology of PTSD,
Dr. David A Tomb

Epic of Gilgamesh Homer’s Iliad

• Railway Spine –
 19th century
 Jon Eric Erichsen, British surgeon
 Avoided stigma of mental illness.
http://moftasa.net/ngram-ptsd

• Post American Civil War, soldiers developed
weakness, heart palpitations and chest pain –
soldier’s heart, irritable heart, effort syndrome,
DaCosta’s syndrome.
• First World War produced fatigue, exhaustion and
anxiety – Shell shock, Battle fatigue, Combat neurosis
Dr. David A Tomb

Evolution of concept
• Kardiner’s work post World War II – Physioneurosis
• DSM I – Gross Stress Reaction
• DSM II – Transient Situational Disturbance
• DSM III (1980)– Borrowed from work of Horowitz
and others to create the term “Post Traumatic Stress
Disorder” under anxiety disorders.
Dr. David A Tomb

• Vietnam War (1 November 1955 – 30 April 1975)
– Post Vietnam syndrome - combat related
nightmares, anxiety, anger, depression, alcohol
and/or drug dependence, and poor
responsiveness.
– Females in the military, especially nurses, were
exposed to highly traumatic events suffered from
PTSD.
– Policy for reimbursement flawed.
http://historyofptsd.umwblogs.org/vietna
m/

EPIDEMIOLOGY
• The lifetime prevalence - 6.8 to 12.3 % United States
(US)
• One-year prevalence rates of 3.5 to 6 %
• Overall, women are four times more likely to develop
PTSD than men, after adjusting for exposure to traumatic
events.
• The rates of PTSD are similar among men and women
after events such as accidents (6.3 versus 8.8 percent),
natural disasters (3.7 versus 5.4 %), or sudden death of a
loved one (12.6 versus 16.2 %)

• The rate of PTSD is lower in men than in women after
events such as molestation (12.2 versus 26.5 %) and
physical assault (1.8 versus 21.3 %).

• Risk factors include –
– gender (overall, women are four times more likely to
develop PTSD than men)
– age at trauma
– race
– education
– lower socioeconomic status
– previous trauma
– general childhood adversity
– personal and family psychiatric history
– reported childhood abuse
– poor social support
– initial severity of reaction to the traumatic event
Meta-analysis of risk factors for
posttraumatic stress disorder in trauma-
exposed adults. Brewin CR1, Andrews B,
Valentine JD.

• Personality factors:
– Negative emotionality
– Neuroticism
– harm avoidance
– novelty-seeking
– trait hostility/anger
– trait anxiety.
• Negatively associated
with:
• Extraversion
• Conscientiousness
• self-directedness
• high positive and low
negative
emotionality
• optimism
Nenad Jakšić 1 , Lovorka Brajković 1 , Ena
Ivezić 2 , Radmila Topić 1 & Miro Jakovljević

• Sexual assault : 32% of women with PTSD had
been raped and 31% had experienced sexual assault
other than rape.
• Mass conflict and displacement : A meta
analysis of 145 studies of 64,332 refugees and other
conflict affected individuals internationally found a
mean PTSD prevalence rate of 30.6%

• Combat :
– Strongly correlated with the extent of injury and with the
occurrence and severity of traumatic brain injury
– The prevalence of PTSD was 4.2% at 1 month and 12.2% by
4 months.
– Experiencing traumatic brain injury during military
deployment was a strong predictor of subsequent PTSD
symptoms.

• ICU hospitalization :
– A 2008 systematic analysis of 15 studies found the
prevalence of PTSD in patients who survived intensive
care unit (ICU) hospitalization to be approximately
20%
– Risk factors for PTSD symptoms were benzodiazepine
use, early memories of frightening ICU experiences,
and pre ICU comorbid psychopathology. Neither the
severity of critical illness nor length of ICU stay were
predictors of PTSD.

• Trauma exposure and PTSD have also been
associated with physical illness.
– PTSD was associated with increased risks for
• angina,
• heart failure,
• bronchitis,
• asthma,
• liver, and
• peripheral artery disease after adjusting for socio-
demographic factors, smoking, body mass index, blood
pressure, depression, and alcohol use disorders.

• Co-morbidity
– 16 % have one coexisting psychiatric disorder, 17 % have
two psychiatric disorders, and 50 % have three or more.
– Somatization disorder is as much as 90 times more likely in
patients with PTSD.
– Depressive disorders, anxiety disorders, and substance
abuse are 2 - 4 times more prevalent in patients with PTSD
– substance abuse is often due to the patient's attempts to
self-medicate symptoms

Indian scenario
• Recent Trends in the Socio-demographic, Clinical
Profile and Psychiatric Comorbidity Associated
with Posttraumatic Stress Disorder: A Study from
Kashmir, India
– Of the total 3400 subjects (age≥18 years), the
prevalence of PTSD among general population was
found to be 3.76%
– Death of near one comprised the major traumatic
event.
– Acute onset PTSD was the commonest type, previous
history of psychiatric illness was found in 12 % of
patients and drug abuse was present in 22.6%.
Shoib S, Mushtaq R, Jeelani S, Ahmad J, Dar MM, Shah T.

• Lessons from the 2004 Asian tsunami:
Epidemiological and nosological debates in the
diagnosis of PTSD in non-Western post-disaster
communities.
– The prevalence of PTSS was 15.1% (95% CI 12.3%-
17.9%).
– PTSS was significantly associated with traumatic grief,
female gender, physical injury, death of children and
financial losses.
Rajkumar AP, Mohan TS, Tharyan P

• Intimate Partner Violence and Sexual Coercion
among Pregnant Women in India: Relationship with
Depression and Post-Traumatic Stress Disorder
– Self-reported physical violence in the last year was
reported by 14% of women, psychological abuse by 15%,
and sexual coercion by 9%.
– Depression, somatic, and PTSD symptoms were higher in
those with a history of abuse or sexual coercion
– Alcohol abuse in the spouse was a predictor of the
presence and severity of abuse.
– Interestingly, the majority of women had sub-threshold
PTSD scores. Such PTSD symptoms are not only prevalent
but frequently disabling (Stein et al., 1997)
Varma D, Chandra PS, Thomas T, Carey MP. Intimate Partner Violence and
Sexual Coercion among Pregnant Women in India: Relationship with Depression
and Post-Traumatic Stress Disorder. Journal of affective disorders. 2007;102(1-
3):227-235. doi:10.1016/j.jad.2006.09.026.

• Measures in the Indian Armed Forces to deal with combat
stress.
• Liberalized leave.
• Increased provision of free warrants to home town.
• Government family accommodation in peace areas
• Enhanced officer–soldier interaction.
• Establishment of Rest and Recoup Centers in operational areas.
• Improved financial condition following last pay revision.
• Significant enhancement of hardship related allowances.
• Establishment of educational institutions for the wards of the soldier.
• Establishment of placement cells for better post retirement prospects.
• Modification of pay distribution method by direct collaboration with banks.
• Effective and faster grievance redressal.
• Creation of pool of trained counsellors at unit level by ongoing training
programs for RT JCOs and NCOs at psychiatric centers.

ETIOLOGY
• PTSD is defined in terms of etiology as much as
phenomenology.
• The relative severity of the traumatic event, predisposing
factors, and peri-traumatic environmental factors must
be considered.
• A consistent relationship occurred between magnitude of
stress exposure and risk of developing PTSD.
American Psychiatric Publication Text book
of Anxiety Disorders

Etiology : Neurobiological
• Increased central norepinephrine levels with down-
regulated central adrenergic receptors.
• A meta-analytic review found a positive association
between the diagnosis of PTSD and basal
cardiovascular activity
1. Yehuda et al. 1998
2. Buckley et al. 2001

• The HPA axis has been the most extensively studied
neuroendocrine system in PTSD.
• In a large sample of Vietnam veterans, combat-
exposed veterans with current PTSD had lower cortisol
compared to noncombat-exposed veterans without
PTSD or combat-exposed veterans with lifetime PTSD
but without current PTSD 1
• Administration of yohimbine, an alpha- 2-adrenergic
antagonist, provoked symptoms of PTSD in combat
veterans who had PTSD, as did the serotoninergic
challenge with m-chlorophenylpiperazine.
1. Boscarino 1996
2. Tasmann Psychiatry

Etiology : Imaging
• MRI scans : decreased volume of the hippocampus,
left amygdala, and anterior cingulate cortex in
patients with PTSD
• F-MRI and PET : increased reactivity of the amygdala
and anterior paralimbic region to trauma-related
stimuli
1. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology,
clinical manifestations, course, and diagnosis
2. Lieberzon et al. 1999

• In response to trauma- related stimuli, there is
decreased reactivity of the anterior cingulate and
orbitofrontal areas.
• Hemispheric lateralization in which there is a relative
failure of left hemispheric function (possibly
accounting for confusion related to time sequence of
traumatic events).
1. Shin et al. 1999
2. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology,
clinical manifestations, course, and diagnosis

Etiology : Genetic
• Researchers suspect that genetics may contribute to
an individual's susceptibility to PTSD through an
interaction with environmental factors.
• Presence of one of four polymorphisms at the stress
related gene FKBP5, increased risk for PTSD in
patients with a history of child abuse

• The evidence suggests that psychiatric history,
both personal or in family members, increases
the likelihood of being exposed to a trauma
and developing PTSD once exposed .
Hidalgo and Davidson, True and Lyons 1999

Psychological Factors
• Behavioral Models - Conditioning theory has been
helpful in explaining the process through which
stimuli that are associated with a traumatic event
can alone elicit intense emotional responses in
individuals who have PTSD
Guthrie and Bryant, 2006

• Cognitive Models - The assumption of these
cognitive theories is that exposure to trauma
disrupts previously held beliefs about the world and
that maladaptive belief changes may contribute to
distress and functional impairment among trauma
survivors
(Boeschen et al. 2001)

Others
• Social/Environmental Factors
• Sleep pattern
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DIAGNOSIS : ICD 10
• A. Exposure to a stressful event or situation (either short or long lasting) of
exceptionally threatening or catastrophic nature, which is likely to cause
pervasive distress in almost anyone.
• B. Persistent remembering or "reliving" the stressor by intrusive flash backs,
vivid memories, recurring dreams, or by experiencing distress when exposed to
circumstances resembling or associated with the stressor.
• C. Actual or preferred avoidance of circumstances resembling or associated
with the stressor (not present before exposure to the stressor).
• D. Either (1) or (2):
– (1) Inability to recall, either partially or completely, some important aspects of the period of
exposure to the stressor
– (2) Persistent symptoms of increased psychological sensitivity and arousal (not present
before exposure to the stressor) shown by any two of the following:
• a) difficulty in falling or staying asleep;
• b) irritability or outbursts of anger;
• c) difficulty in concentrating;
• d) hyper-vigilance;
• e) exaggerated startle response
• E. Criteria B, C (For some purposes, onset delayed more than six months may
be included but this should be clearly specified separately.)

Diagnosis : DSM V
A. Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family
member or close friend. In cases of actual or threatened death of a
family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of
the traumatic event(s) (e.g., first responders collecting human
remains; police officers repeatedly exposed to details of child
abuse).
Note: Criterion A4 does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s). Note: In children older than six years, repetitive play may occur in
which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s). Note: In children, there may be
frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as
if the traumatic event(s) were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being a complete loss of
awareness of present surroundings.) Note: In children, trauma specific re-
enactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the
traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of the
following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that
arouse distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as
head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world, for example:
• "I am bad''
• "No one can be trusted''
• "The world is completely dangerous"
• "My whole nervous system is permanently ruined"
3. Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself or
others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity
associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Irritable behaviour and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behaviour.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep
or restless sleep).

F. Duration of the disturbance (Criteria B, C, D,
and E) is more than one month.
G. The disturbance causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
H. The disturbance is not attributable to the
physiological effects of a substance (e.g.,
medication, alcohol) or another medical
condition.

• With dissociative symptoms — The individual's
symptoms meet the criteria for posttraumatic stress
disorder, and in addition, in response to the stressor,
the individual experiences persistent or recurrent
symptoms of either of the following:
– 1. Depersonalization
– 2. Derealisation
• With delayed expression — If the full diagnostic criteria
are not met until at least six months after the event
(although the onset and expression of some symptoms
may be immediate).

Revision from DSM IV to DSM V
• Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in
DSM-5 on Trauma- and Stressor-Related Disorders. This is a move from DSM-
IV, which addressed PTSD as an anxiety disorder.
• The stressor criterion (Criterion A) in DSM5 requires being explicit as to
whether the traumatic events were experienced directly, witnessed, or
experienced indirectly.
• The criterion regarding the patient’s subjective reaction to the traumatic
event (Criterion A2) in DSM-IV was eliminated in DSM-5
• The categories of presenting symptoms were revised to intrusion, negative
alterations in mood and cognitions, avoidance, and arousal
• Two new symptoms were added to criteria E (marked alterations in arousal
and reactivity associated with traumatic event(s) including irritable behaviour
and angry outbursts and reckless or self destructive behaviour.

• Differentiating acute stress disorder —
– Presenting symptoms of posttraumatic stress and
functional impairment after a highly traumatic
event
– diagnosed as having acute stress disorder (ASD)
for the first 30 days following the event.
– Most people recover completely within this
period.
– For those who remain symptomatic (at the
threshold established by DSM5 criteria) after 30
days, their diagnosis is then reclassified as PTSD.

DIFFERENTIAL DIAGNOSES
• Adjustment disorder
• Specific phobias
• Generalized anxiety disorder
• Obsessive–compulsive disorder (OCD)
• Panic attack
• Depression
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ASSESSMENT
• In screening patients for PTSD, e.g., primary
care patients, returning veterans, or
individuals experiencing domestic violence,
particular attention should be paid to
individuals presenting with new anxiety, fear,
or insomnia
Posttraumatic stress disorder in adults: Epidemiology,
pathophysiology, clinical manifestations, course, and diagnosis

PTSD Checklist for veterans
• Helpful in screening
patients for PTSD and
monitoring the progress
of treatment over time.
• The sensitivity of the PCL
ranges from 69 to 94 and
the specificity is from 83
to 99.
• A score of 50 out of a
maximum score of 85 is
associated with a
diagnosis of PTSD.
• Self administered by
patients.

Adult PTSD Interviews
# of
items
Time to
Admin.
(in min.)
Allows
Multiple
Trauma
Correspond
s to DSM-IV
Criteria
Clinician-Administered PTSD Scale
(CAPS)
30 40-60 Up to 3 Yes
PTSD Symptom Scale-Interview
Version (PSS-I)
17 20-30 No Yes
Structured Clinical Interview for DSM-
IV PTSD Module (SCID)
21 20-30 No Yes
Structured Interview for PTSD (SI-
PTSD)
27 20-30 No Yes
http://www.ptsd.va.gov/professional/asses
sment/adult-int/chart-adult-interviews.asp

• Self-report measures –
– Posttraumatic Stress Diagnostic Scale (PDS)
– Davidson Trauma Scale (DTS)
– Mississippi Scale for Combat-Related PTSD (Mississippi
Scale)
• Child measures –
– Child Posttraumatic Stress Reaction Index (CPTS-RI)
– The Child PTSD Symptom Scale (CPSS)
– Children's Impact of Traumatic Events Scale-Revised
(CITES-2)
– Parent Report of Child's Reaction to Stress
– Trauma Symptom Checklist for Children (TSCC)
– Trauma Symptom Checklist for Young Children (TSCYC)
http://www.ptsd.va.gov/professional/asses
sment/child/index.asp

COURSE AND PROGNSIS
• Approximately 25 % experience a delayed onset after
six months or more.
• Only 1/3 of patients recovering at one year follow up
• 1/3 still symptomatic ten years after the exposure to
the trauma.
• PTSD may increase the risk for attempted suicide

• Higher rates of problems in intimate relationships,
including marital difficulties, compared to people
without PTSD.
• Individual psychotherapy has been found to improve
overall psychosocial functioning

TREATMENT
• Posttraumatic stress disorder (PTSD) is a
heterogeneous and complex disorder that may
require a multifaceted treatment approach.
• General principles of treating PTSD involve
explanation and de-stigmatization.
• Regaining self- esteem and attaining greater control
over impulses and affect are also desired in many
instances.
Tasmanns Psychiatry

Approach
• Traumatized individuals are often more comfortable
seeking assistance from their primary care provider.
• Reflection of reality to point out early that recovery may
be a slow process and that some symptoms (e.g., phobic
avoidance and startle response) may persist.
• Providers need to pay attention to secondary
traumatization issues.
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• It is helpful to engage the spouse or significant family
member in treatment because of the difficulties and
stresses to which they may be subjected
• Specific treatment approaches include the use of
– pharmacotherapy
– psychotherapy
– anxiety management
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Pharmacotherapy
• Casualties from the American Civil War were
observed more than 100 years ago by Weir Mitchell.
He commented on the use of bromides, opium,
chloral, and brandy.
• Two main categories of PTSD symptoms respond to
medication: core symptoms and secondary
symptoms
Davidson 1997

• Core symptoms :
– Intrusive re-experiencing
– Hyper arousal
– Numbing, estrangement and anhedonia
– Avoidance
• Secondary symptoms :
– impaired function
– poor resilience to stress
– comorbid conditions
• The end point of pharmacological therapy for PTSD is
the same regardless of the conceptual model: to
reduce symptom distress, strengthen resilience, and
then restore function.

• The selective serotonin reuptake inhibitors (SSRIs)
and serotonin–norepinephrine reuptake inhibitors
(SNRI) are now first-line agents.
• Several placebo-controlled trials have shown positive
effects for the SSRI medications, specifically
fluoxetine2 , sertraline3 , and paroxetine4
1. Tasmanns Psychiatry
2. Connor et al. 1999, Martenyi et al.
2002 , 2003 , van der Kolk et al. 1994
3. Brady et al. 2000 , Davidson et al. 2001
4. Marshall et al. 1998, Tucker et al. 2001
SSRI and SNRI

Pharmacotherapy for posttraumatic stress disorder in adults
Author Murray B Stein, MD, MPH
Section Editor, Peter P Roy-Byrne, MD, Deputy Editor Richard
Hermann, MD

• Amitriptyline and imipramine in combat veterans
with PTSD. In both studies, the medication was
effective on intrusive PTSD symptoms and, to a
weaker extent, on avoidant symptoms.
Davidson et al. 1990, Frank et al. 1988
Tricyclic antidepressants

MAOI
• Phenelzine has been found to be effective in
symptom reduction.
• Rarely used.
• The side effects of phenelzine limit its use to a third-
or fourth-line drug.
Kosten et al. (1991)

Atypical antipsychotics
• The overall evidence from clinical trials does not
support the use of atypical antipsychotics to
augment SSRIs or SNRIs in the treatment of PTSD in
military veterans.
• Adjunctive use of an atypical antipsychotic for PTSD
symptoms resistant to SSRIs/SNRIs.
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Alpha-adrenergic receptor blockers
• Prazosin has been shown to reduce nightmares and
improve sleep.
• Prazosin is typically started at 1 mg at bedtime and is
gradually increased to 3 to 10 mg as tolerated.
• Sudden discontinuation of prazosin must be avoided
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Benzodiazepines
• Rarely studied in PTSD
• Frequently used to treat symptoms of anxiety and
hyperarousal.
• High prevalence of comorbid substance abuse in
patients with PTSD, benzodiazepines should be
avoided in patients with a history of substance use
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Early intervention
• A meta-analysis concluded that
– There is moderate quality evidence for the efficacy of
hydrocortisone for the prevention of PTSD development in
adults.
– The study found no evidence to support the efficacy of
propranolol, escitalopram, temazepam and gabapentin in
preventing PTSD onset.
– The findings, however, are based on a few small studies
with multiple limitations.
Pharmacological interventions for
preventing post-traumatic stress disorder
(PTSD). Amos T1, Stein DJ, Ipser JC.

Psychotherapy
• Exposure-based treatments
• Cognitive approaches
• EMDR
• Adding components
• Other approaches
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Prolonged Exposure
• Depends on the fact that anxiety will be extinguished
in the absence of real threat, given a sufficient
duration of exposure in vivo or in imagination to
traumatic stimuli.
• Imaginal exposure
• There are patients who will be reluctant to confront
traumatic reminders due to transient increased
anxiety.
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Eye movement desensitization and
reprocessing (EMDR)
• EMDR facilitates the accessing and processing of
traumatic memories to bring closure and resolution.
• Patients are asked to bring to mind the disturbing
image, sensations, and the negative cognition while
tracking the clinician’s moving finger back and forth in
front of their visual field.
• Although EMDR has been empirically supported in the
literature, there is some controversy about the “active
ingredient” in EMDR and the restricted access to this
treatment protocol through a proprietary company.
Shapiro 2001
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• A meta-analysis confirmed that
EMDR therapy significantly reduces the
symptoms of PTSD, depression, anxiety, and
subjective distress in PTSD patients.
Efficacy of eye-movement desensitization and reprocessing for patients with posttraumatic-stress disorder: a meta-analysis
of randomized controlled trials. Chen YR1, Hung KW2, Tsai JC3, Chu H4, Chung MH1, Chen SR5, Liao YM1, Ou KL6, Chang YC7,
Chou KR8

Anxiety management
• Designed to reduce anxiety by providing patients
with better skills for controlling worry and fear.
– muscle relaxation
– self-distraction (thought stopping)
– control of breathing and diaphragmatic breathing
– guided self-dialogue
– stress inoculation training
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Cognitive therapy
• Focuses on challenging dysfunctional, automatic
thoughts that may develop following trauma
exposure. 1
• In a comparison of cognitive therapy to imaginal
exposure in the treatment of chronic PTSD, both
treatments were associated with positive
improvements at post-treatment and follow-up, with
no differences in outcome between treatments 2
2. Tarrier et al. 1999

• As no single treatment for PTSD has been shown to
be curative, patient characteristics, characterization
of the nature and range of stress responses of
trauma victims 2, partial response 3, treatment
combinations, sequencing of treatment approaches,
and further well-controlled investigations of current
approaches are all important empirical topics to be
addressed.
2. McFarlane and Yehuda 2000
3. Taylor et al. 2001

Psychodynamic approach
• Emphasize the interpretation of the traumatic event
as being a critical determinant of symptoms.
• Treatment is geared to alter attributions.
• Reinterpret the experience in a more realistic and
adaptive fashion.
• Support needs to be provided throughout, and
sometimes other treatment approaches are used
adjunctively. Tasmanns Psychiatry

• Horowitz ( 1973 ) developed a trauma-focused, time-
limited, psychotherapeutic approach.
• Overwhelmingly intrusive symptoms are
counteracted by means of structuring, and avoidance
and numbing are met with procedures to minimize
such behavior.
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Factors affecting treatment
• Psychiatric Comorbidity
• General Medical Comorbidity
• Demographic Factors
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Summary of treatment
• Goals are common to all and can be summarized as follows:
1. reduce intrusive symptoms
2. reduce avoidance symptoms
3. reduce numbing and withdrawal
4. dampen hyperarousal
5. reduce psychotic symptoms when present
6. improve impulse control when this is a problem.
• The three major treatment approaches, pharmacotherapeutic, cognitive–
behavioral, and psychodynamic, all emphasize different aspects of the problem.
• Pharmacotherapy targets the underlying neurobiological alterations found in PTSD
and attempts to control symptoms
• Cognitive–behavioral treatments emphasize confronting traumatic memories
through exposure as well as identifying and challenging dysfunctional beliefs about
the trauma
• The psychodynamic approach emphasizes the associations that arise from the
trauma experience and that lead to unconscious and conscious representations
Tasmanns Psychiatry

CONTROVERSIES
• As disability awards for PTSD have grown
nearly fivefold over the last 13 years, so have
concerns that many veterans might be
exaggerating or lying to win benefits.

• PTSD has been de-contextualized, its original
meaning and links rendered invisible, its
criteria loosened as it was moved to the
civilian sector
• It pathologizes individuals, equates the
problems of perpetrators of crimes (e.g..
Soldiers killing people) with the suffering of
victims of trauma.
• It medicalizes personal distress, assumes
biological causation, and argues for medical
solutions
Diagnostic and statistical manual-5: position paper of the Indian
psychiatric society K. s. Jacob, r. a. Kallivayalil, a. K. Mallik, N. Gupta,
j. K. trivedi, b. N. Gangadhar, K. praveenlal, V. Vahia, t. s.
sathyanarayana Rao

RECENT ADVANCES
• A meta-analysis shows that active rTMS applied to the
DLPFC seems to be effective and acceptable for
treating PTSD.
• A RCT examines the effectiveness of "Family of
Heroes," an online avatar-based post-deployment
stress and resiliency training simulation concluded that
results strongly suggest that it is an effective tool to
engage families in taking an active role in motivating
their veterans who exhibit signs of post-
deployment stress to seek help at the VA.
1) http://www.ncbi.nlm.nih.gov/pubmed/25565694

• The effectiveness of yoga in treating PTSD is unclear.
Two RCTs found opposite effects in two dissimilar
patient populations, while one systematic review
concluded that yoga may be effective as a
monotherapy or in combination with medication for
treating patients with PTSD.
• The effectiveness of mindfulness in treating PTSD is
unclear. Three RCTs found opposite effects in
veterans with PTSD.
Yoga for the Treatment of Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Depression, and Substance
Abuse: A Review of the Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and
Technologies in Health; 2015 Jun.
Mindfulness Interventions for the Treatment of Post-Traumatic Stress Disorder, Generalized Anxiety Disorder,
Depression, and Substance Use Disorders: A Review of the Clinical Effectiveness and Guidelines [Internet].
Source
Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2015 Jun.

• Sudarshan Kriya yoga - Reductions in startle
correlated with reductions in hyperarousal symptoms
immediately postintervention (r = .93, p < .001) and
at 1-year follow-up (r = .77, p = .025). This
longitudinal intervention study suggests there may
be clinical utility for Sudarshan Kriya yoga for PTSD.
Breathing-based meditation decreases posttraumatic stress disorder
symptoms in U.S. military veterans: a randomized controlled longitudinal
study. Seppälä EM1, Nitschke JB, Tudorascu DL, Hayes A, Goldstein MR,
Nguyen DT, Perlman D, Davidson RJ.

SUMMARY
• Posttraumatic stress disorder
(PTSD) has been described as
"the complex somatic, cognitive,
affective, and behavioral effects
of psychological trauma“
• Clinical features – Intrusive
thoughts, nightmares, flashbacks,
avoidance, hypervigilance, sleep
disturbance.
• Described since inception war
and came into focus after the
world wars and Vietnam war.
• Term first introduced in DSM III.
• Lifetime prevalence - 6.8 to 12.3
% US, 1 year prevalence 3.5 – 6%
• Associated with increased risk of
physical illnesses.
• Pathophysiology-
• Neurobiological : ↑ central
NE levels, ↓ cortisol levels,
HPA axis dysfunction
• Imaging : MRI, PET changes in
amygdala and ant. Para-
limbic region.
• Genetic : FKBP5 gene related
with risk of PTSD in children,
interaction with
environmental factors.
• Psychosocial factors, Sleep
pattern
• ICD 10 and DSM V diagnostic
criteria.
• Differential diagnoses – other
anxiety spectrum disorders,
depression, dissociation.

• Assessment – Commonly used
scales are CAPS, PTSD checklist.
• Course – Chronic condition, 1/3
pts symptomatic 10 years after
exposure.
• Treatment – Pharmacological:
SSRIs/SNRI → add
TCA/α1AA/BZD → switch to
TCA/MAOI
• Psychotherapy : Exposure
based, CBT, EMDR, anxiety
management, psychodynamic
approach.
• Controversies
– Loosening of criteria
– Malingering for compensation.
– Converting personal distress
into a pathology.
Tasmanns Psychiatry
- Difficult to define
trauma
- Absence of diagnosis
post civilian disasters in
Indian context.
• Recent advances
• rTMS
• Avatar based therapy
• Yoga
• Mindfulness
interventions.

Post traumatic stress disorder

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