Epidemiology of PTSD

1. Epidemiology of PTSD • Incidence: proportion of the population that falls ill within a specified time period (e.g., annual incidence rate) • Prevalence: proportion of the population that has the disorder within a specified time period (e.g., annual prevalence rate, current prevalence, lifetime prevalence)

2. Epidemiologic Catchment Area (ECA) Survey • Helzer et al. (1987) • 2,493 adults in St. Louis area • Lifetime prevalence of PTSD: 1% • 3.5% in civilians exposed to physical attack • 20% in vets wounded in Vietnam

3. Epidemiologic Catchment Area (ECA) Survey • Davidson et al. (1991) • 2,985 adults in North Carolina • 1.3% lifetime prevalence • 0.44% current (past six months) prevalence • About half became chronic • Suicide attempt in PTSD vs. no disorder (19.8% vs. 0.8%)

4. These ECA studies suggested that PTSD was a relatively rare disorder in the general communiy • Based on DSM-III criteria

5. National Comorbidity Survey - Replication (2005) • Ron Kessler • Lifetime prevalence of DSM-IV PTSD in USA is 6.8% • 9.7% of women • 3.6% of men • Not attributable to differential trauma exposure • Current prevalence (during the past 12 months) • 3.5% in the NCS-R

6. Breslau’s Detroit-area studies • 90% of adults have been exposed to a DSM-IV trauma • But the vast majority of respondents did not develop PTSD • Conditional probability (% of trauma-exposed persons who met PTSD diagnostic criteria) • 13% of trauma-exposed women got PTSD • 6% of trauma-exposed men got PTSD

7. Breslau’s Detroit-area studies • Likelihood of PTSD depended on the type of event • 40% of the cases of lifetime PTSD were caused by assaultive violence • Combat, rape, physical violence • Almost 30% of the cases were caused by sudden, unexpected death of friend or relative

8. How long does PTSD last? • Kessler’s NCS (1995) DSM-III-R study • After one year, about two-thirds of the cases remit • Among those who fail to remit after one year, about 50% will eventually remit (regardless of treatment) • Breslau’s data • By one year, 50% of the male cases had remitted • By four years, 50% of the female cases had remitted

9. Prevalence in children and adolescents • Kilpatrick et al. (2003) • National survey12-17 year-olds • 3.7% males, 6.3% females • Breslau et al. (1991) • Large Midwestern sample of 16-24 year-olds • 10.4% female, 6% male • Breslau et al. (2004): more recent study • Large Eastern U.S. city • 7.9% females, 6.3% males • 15.1% for individuals exposed to interpersonal violence • Perkonigg et al. (2000): Munich, Germany • 7.8% lifetime PTSD (DSM-IV A1+A2) • 1% males, 2.2% females

10. Prevalence in children and adolescents • Youth in urban juvenile detention • 11.2% in past year (Abram et al., 2004) • Higher PTSD prevalence rates in studies with youth exposed to events affecting entire community • terrorism, hurricanes, earthquakes, fires, armed conflict) • sniper attack: 60.4% of school children 1-month later (Pynoos et al., 1987) • 9/11 attack: 10.6% of NYC school children 6-months later (Hoven et al., 2005) • Taiwanese earthquake: 21.7% of 12-14 year-olds 6 weeks after (Hsu et al., 2002) • Australian brush fire: 52.8% at 8 months, 57.2% at 26 months (McFarlane, 1987) • Lebanese and Palestinian children exposed to war: roughly one-third met criteria for PTSD (Saigh, 1988; Khamis, 2005)

11. Traumatic experiences versus PTSD in children and adolescents • Essau et al., 1999: Munich, Germany • Traumatic experience (22.5%) • 28.5% males, 18.4% females • 11.8% 12-13y, 27% 14-15y, 30.2% 16-17y • PTSD (1.6%) • 1.4% males, 1.8% females • 0.3% 12-13y, 2.3% 14-15y, 2.6% 16-17y

12. Problems of studying trauma and PTSD in very young children • Reactions often determined by parental reports • Research on posttraumatic stress symptoms involving very young children (< 9 years) has generally been rare • Notable exception: study of PTSD in young children following the Buffalo Creek dam collapse (Green et al., 1991) • group of 43 children between 4 and 9 years • results indicate fewer PTSD symptoms in the youngest age group (compared to two other older age groups)

13. Problems of studying trauma and PTSD in very young children • The prevalence of PTSD and PTSD symptoms in preschool-age children reported to be far lower than in older children (Scheeringa et al., 2003) • interpreted to suggest that young children generally more resilient (Garmezy & Rutter, 1985). • However, young children’s failure to report PTSD symptoms (such as intrusive thoughts) may also be the result of their limited ability to report on their cognitive symptoms (Scheeringa, Wright, Hunt & Zeanah, 2006)

14. Other Trauma Syndromes? • Acute Stress Disorder (David Spiegel) • No diagnosis for posttraumatic stress arising within one month • ASD should be recognized as a disorder because it predicts PTSD

15. Criterion A • Traumatic event • Criterion B (dissociative symptoms - 3) • Numbing, detachment, absence of emotional responsiveness • Reduction in awareness (being in a daze) • Derealization • Criterion B • Depersonalization • Dissociative amnesia • Criterion C (1) • Recurrent images, dreams, flashbacks • Distress on exposure to reminders

16. Criterion D • Marked avoidance • Criterion E • Anxiety or increased arousal (startle, sleep problems, hypervigilance, poor concentration) • Criterion F • Distress and impairment • Criterion G • Last for at least 2 days, maximum of 4 weeks

17. Other Trauma Syndromes? • Dissociative symptoms supposedly especially predictive • Richard Bryant • Between 72% and 83% of those diagnosed with ASD have PTSD 6 months post-trauma • But between 37% and 73% who develop PTSD first had ASD • Early PTSD predicts later PTSD? Critique • Are we medicalizing normal responses to terrible events? • Dissociative symptoms are not that predictive

18. Complex PTSD • Judith Herman • DESNOS (Disorders of Extreme Stress Not Otherwise Specified) • Believed to be a trauma syndrome arising from chronic trauma, especially that beginning in childhood

19. Complex PTSD • Multiplicity of symptoms • Anxiety • Chronic depression • Paranoia • Somatic complaints • Self-mutilation • Dissociation • Insomnia • Affect regulation problems

20. Complex PTSD • Characterological change • Disturbed interpersonal relationships • Destroy autonomy and identity (losing name) • Forced to betray or harm others • increased likelihood of getting in harm’s way

21. Complex PTSD • Critique • DSM-IV field indicated that individuals meeting criteria for complex PTSD also meet criteria for PTSD • Multiple co morbidities, including borderline personality disorder? • How plausibly can we trace the syndrome to early childhood trauma?

22. Secondary posttraumatic stress • in emergency personal (Andrews et al., 2006) 485 emergency service personnel, who had experienced an occupational trauma • Same posttraumatic stress symptoms • Intrusions • Avoidance • Numbing • E.g. „Have you felt that your ability to experience the whole range of emotions is impaired?“ • Arousal • +general PTSD factor

23. Same posttraumatic stress reaction in emergency personnel • Intrusions • Avoidance • Numbing • E.g. „Have you felt that your ability to experience the whole range of emotions is impaired?“ • Arousal • +general PTSD factor Data from 485 emergency service personnel, who had experienced an occupational trauma (see Andrews et al., 2006)