Post Traumatic Stress Disorder

1. Post Traumatic Stress Disorder Acute Stress Disorder Dr. A. Hadjebi

2. History • U. S. civil war : Soldier's heart syndrome • 1900 s : Traumatic neurosis due to the influence of psychoanalysis • World war I : shell shock • World war II : combat neurosis or operational fatigue • Vietnam war : post traumatic stress disorder

3. History • PTSD: DSM-III (1980) • ASD; DSM-IV (1994) • PTSD in DSM-III: reexperience(1),psychic numbing(2), other items(1), no duration criteria • PTSD in DSM-III-R is similar to DSM-IV-TR • In ICD-10 PTSD & ASD are stress related disoders

4. Epidemiology • Life time prevalence (8%) • 30% of Vietnam veterans • 25 % subclinical form of disorder • In women : life time prevalence 10- 12% • In men : life time prevalence 5- 6% • PTSD is most prevalent in young adults • Men's trauma : combat experience • Women's trauma : assault or rape

5. Epidemiology • PTSD most likely to occur in single , divorced , widowed , socially withdrawn , low socioeconomic level • First degree biological relatives of persons with a history of depression have an increased risk for developing PTSD following a traumatic event

6. Comorbidity • About 2/3 having at least tow other disorders • Common comorbid conditions include : depressive disorders , substance related disorders , other anxiety disorders and bipolar disorders

7. Etiology • Stressor • Risk factors • Psychodynamic factors • Cognitive – behavioral factors • Biological factors Noradrenergic system Opioid system Corticotropin – releasing factor and the HPA axis

8. Psychological aspects of PTSD • Emotional response to trauma reminder • Base line physiological activity • Exaggerated startle reflex.

9. Diagnostic criteria for PTSD • Exposure to a traumatic event • The traumatic event is persistently reexperienced • Persistent avoidance of stimuli associated with the trauma • Persistent symptoms of increased arousal • Duration of the disturbance is more than 1 month

10. Diagnostic criteria for PTSD • Significant distress or impairment in social, occupational or … • Specify if : acute : < 3 months chronic : > or = 3 months • With delayed onset

11. Diagnostic criteria for ASD The disturbance last for a min. of 2 days and a max. of 4 weeks and occurs within 4 weeks of the traumatic events

12. PTSD in children and adolescents • Child risk factors include : - demographic factors ( age, socioeconomic status ) - life events - psychiatric comorbidity - parental psychopathology - parental marital status

13. Gulf war syndrome • Health problems • Irritability • Chronic fatigue • Shortness of breath • Muscle and joint pain • Migraine headaches • Digestive disturbances • Rash • Hair loss • Forgetfulness • Difficulty concentrating

14. Differential diagnosisorganic; head trauma, epilepsy, alcohol use disorder • Pain disorder • Substance abuse • Other anxiety disorders • Mood disorders • Borderline disorders • Dissociative disorders • malingering

15. Course and prognosis 30 % recover completely 40 % mild symptoms 20 % moderate symptoms 10 % remain unchanged • Good prognosis is predicted by : - rapid onset of the symptoms - short duration of the symptoms - good premorbi functioning - strong social supports - absence of other psychiatric, medical or substance – related disorders

16. Course and prognosis • The very young and very old have more difficulty with traumatic events than do these in midlife • PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and difficult to treat • Social support influence the development, severity and duration of PTSD

17. Treatment • Psychotherapy • Pharmacotherapy

18. Psychotherapy • Psychodynamic psychotherapy • Cognitive – behavior therapy • Group therapy • Family therapy

19. pharmacotherapy • SSRIs : Sertraline and Paroxetine • Buspirone • TCA: Impramine, Amitriptyline • Some studies indicate that pharmacotherapy is more effective in treating the depression, anxiety and hyperarousal than in treating the avoidance and emotional numbing • Other drugs ; MAOIs ( Phenelzine ), Trazodone, Anticonvalsants, (carbamazapine, valpoarate ), clonidine, propranolol

20. Recommendation • Strongly recommend selective serotonin reuptake inhibitors (SSRIs) as first line agents for the treatment of PTSD. • Recommend tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as second-line treatments for PTSD. • Consider an antidepressant therapeutic trial of at least 12 weeks before changing therapeutic regimen.

21. Recommendation • Consider prazosin to augment the management of nightmares and other symptoms of PTSD. • Recommend medication compliance assessment at each visit. • Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely; however it is recommended that maintenance treatment should be periodically reassessed

25. Special considerations on sep. 11. 2001 • 3500 deaths and injuries • 45% of adults reported symptoms of stress , such as distressing recollections of the event, insomnia, nightmare,… • 90% reported minor degrees of symptoms • Susceptibility to symptoms was associated with : female, nonwhite, having previous psychological illness, being close to disaster site

26. Special considerations on sep. 11. 2001 • Over 80 % of parents reported that their children had one or more symptoms • Survey of Manhattan residents conducted 5 to 8 weeks after the world trade center collapsed: - 9.8% (90000 ) people had PTSD or clinical depression - 3.7% ( 34000 ) people met the criteria for both diagnosis