Post Traumatic Stress Disorder

1. Post Traumatic Stress Disorder Dr Linda McCarthy Senior Specialist Psychiatrist Director, PTSD Program RGH Daw Park

2. History of PTSD • Symptoms of traumatic syndromes date back over centuries • Ancient Rome • Soldiers Heart • Shell Shock • PTSD

3. History of PTSD • Consistent description of features, but a lack of effective treatments for traumatic syndromes • Battle fatigue after WW2 • Battle shock • Implications about relationship to mental disorders (compensation)

4. History of PTSD • PTSD first described as such in DSM III in 1980 • Prototype for environmentally induced disorder triggered by an external event • Involved emotional deregulation and memory disturbance • Concept essentially the same, empirically validated, consensus achieved • Born from Vietnam war

5. Diagnostic criteria for PTSD DSM - 5 • Criterion A: stressor • Person exposed death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) • Direct exposure • Witnessing, in person. • Indirectly, learning that close relative or friend exposed to trauma. Must have been violent or accidental.

6. Diagnostic criteria for PTSD DSM - 5 • Criterion A: stressor • Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). • Does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

7. Diagnostic criteria for PTSD DSM - 5 • Criterion B: • Traumatic event persistently re-experienced in the following way(s): (one required) • Recurrent, involuntary, and intrusive memories • Traumatic nightmares • Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness • Intense or prolonged distress after exposure to traumatic reminders • Marked physiologic reactivity after exposure to trauma-related stimuli.

8. Diagnostic criteria for PTSD DSM - 5 • Criterion C: Avoidance symptoms • Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) • Trauma-related thoughts or feelings. • Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

9. Diagnostic criteria for PTSD DSM - 5 • Criteria D: Negative alterations, cognition and mood: • Inability to recall key features of the traumatic event (dissociative amnesia). • Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). • Persistent distorted blame of self or others for causing the traumatic event or resulting consequences

10. Diagnostic criteria for PTSD DSM - 5 Criteria D: (cont.) • Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). • Markedly diminished interest in (pre-traumatic) significant activities. • Feeling alienated from others (e.g., detachment or estrangement). • Constricted affect: persistent inability to experience positive emotions.

11. Diagnostic criteria for PTSD DSM - 5 • Criterion E: alterations in arousal and reactivity (two required): • Irritable or aggressive behaviour (angry outbursts, little or no provocation) • Self-destructive or reckless behaviour • Hypervigilance • Exaggerated startle response • Problems in concentration • Sleep disturbance

12. Diagnostic criteria for PTSD DSM - 5 • Specify if: With dissociative symptoms. • Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream) • Derealization: experience of unreality, distance, or distortion (e.g., "things are not real"). • Specify if: With delayed expression • Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

13. Diagnostic criteria for PTSD DSM - 5 • Criterion F: duration • Persistence of symptoms for more than one month • Criterion G: functional significance • Clinically significant functional impairment (e.g., social, occupational, other). • Criterion H: exclusion • Disturbance not due to medication, substance use, or other illness

15. PTSD

16. Complex PTSD • Major causes: trauma in childhood – abuse, neglect • Sx of PTSD also accompanied by personality changes – c.f. borderline traits • Emptiness • Emotional dysregulation • Hostility • DSM has not been adequate so far…

17. Post-Traumatic Stress Disorder • Estimates suggests that up to 90% of people will be exposed to a significant traumatic event during their lifetime • 20% of ♀ and 8% ♂ will go on to PTSD • Lifetime prevalence 10% ♀ and 5% ♂ • Lifetime prevalence amongst Australian Vietnam veterans > 17%

18. Risk factors for PTSD • Male gender: • Assault • MVA • Combat • Female gender: • Sexual assault • Others – low socio-economic status, high risk occupations • Lower educational achievement, family dysfunction, family psychiatric hx

19. Biology of PTSD • Disturbance of key neurotransmission in the brain, and other hormonal axes: noradrenergic, thyroid, endogenous opioid, serotonin and HPA • Up-regulated catecholamines • Down-regulated adrenergic receptors • Typical fight or flight response • Reduced regulation of autonomic response to emotional arousal and external stressors • Disturbed appraisal, learning and memory

20. Comorbidities & PTSD • People with PTSD up to 80% more likely to satisfy diagnostic criteria for other psychiatric dx: • Alcohol use problems • Other substance misuse • Depression • Other anxiety disorders • Chronic pain • Medical issues (obesity, diabetes, CV disease, smoking-related illnesses) • TBI

21. PTSD treatment options • Psychological therapy (regarded as first line): • Psychoeducation • Cognitive behavioural therapy • Trauma focus therapy • Desensitisation • Little or no role for routine “debriefing” after a traumatic event • Drug therapy

22. PTSD programme goals • Manage anxiety • Anger • Nightmares, flashbacks • Reduce impact on QOL • Reduce impact on relationships and general functioning

23. PTSD programme elements • Psychoeducation • Anxiety management: • Physical • Controlled breathing strategies • Progressive muscle relaxation • Aerobic exercise •  stimulant intake (caffeine, nicotine) • Cognitive • Thought stopping • Distraction • Behavioural • To address avoidance and social withdrawal

24. PTSD programme elements • Exposure treatments • Imaginal exposure (CBT technique) • Cognitive restructuring • Management of comorbid conditions • Alcohol • Depression

25. PTSD – Psychological interventions • Strongest evidence for exposure therapy (Foa & Rothbaum) • Imaginal exposure • Trauma emotionally processed or digested • Cognitive processing therapy • Exposure by writing

26. PTSD drug treatment options • Antidepressants • Antipsychotics • Hypnosedatives • Mood stabilisers such as anticonvulsants • Adjuvant therapies

27. PTSD drug treatment options • Many drug treatment options have been examined, no treatment universally effective • Many patients need sequential trials of drug treatment • Many require combinations of drugs, also combined with psychological approach

28. PTSD drug treatment options • Many drugs are known to work for PTSD • Methodological difficulties with research, many studies short duration with high drop-out rates • Many drugs not examined thoroughly because of patent limitations

29. Antidepressants for PTSD • Almost all antidepressant drugs are known to work for PTSD • First research with TCAs and MAOIs • Greatest evidence now for SSRIs, some with FDA and TGA approval • Anxiolytic effect may be independent of antidepressant effects

30. Antidepressants for PTSD • SSRIs • Mirtazapine • Venlafaxine • TCAs • MAOIs • Other agents may also be effective

31. Antipsychotics for PTSD • Relative lack of controlled research • Clinical use in situations where there is severe agitation, anger or requirement for sedation • Not approved indication, no PBS subsidy but may attract RPBS subsidy • Generally reserved for time limited course of treatment or prn therapy

32. Hypnosedatives & PTSD • BZDs play multiple roles: • Sedation • Anxiolytic • Substance withdrawal management • Care required in view of high potential for dependence and known association of PTSD and substance use disorders

33. Hypnosedatives & PTSD • Avoid very short acting drugs (alprazolam) and favour longer acting drugs (e.g. diazepam) • May interact with SSRIs • Can potentiate sedation seen with other prescribed drugs, will also interact with alcohol

34. Mood stabilisers & PTSD • Not regarded as first line therapy • Valproate and carbamazepine most often used • Regarded as helpful for severe anger/impulse control issues • Many serious adverse effects, not safe in overdose or pregnancy

35. Adjuvant therapies for PTSD • Prazosin • Propranolol • Baclofen • Clonazepam • Buspirone • Others under investigation • Topiramate

36. Alcohol & PTSD • Use of treatments to decrease EtOH use: • Naltrexone • Acamprosate • Disulfiram (last choice) • Topiramate (strong evidence evolving) • May enhance the effectiveness of other interventions

37. Why use yoga for ptsd? Yoga used for thousands of years to calm both mind and body, reduces autonomic sympathetic activation, muscle tension, & BP Normalises neuroendocrine & hormonal activity, decreases physical symptoms and emotional distress, ultimately increasing quality of life Yoga shows promise for cognitive, emotional, and physiological symptoms of PTSD (Emerson et al., 2009) • Yoga is known to increase vagal tone • increases GABA tone in the brain (main inhibitory neurotransmitter) • increases oxytocin and prolactin release → positive emotions like safety, bonding • Greater heart rate variability→ Well balanced ANS, equates to wellbeing

38. PTSD Neurology (Van der Kolk) Recent research neurobiological and neuro-imaging suggests that those with PTSD have changes in blood flow: • Decreased in (L) PFC • Decreased in Broca’s area – speech • Increased in (R) limbic area (Amygdalia) • Increased in visual cortex (Brodmann’s area 19) Potential consequences include • Diminished working memory • Diminished problem solving – executive functioning • Diminished attention and verbal communication • Intenseemotions and stress response • Flashbacks

39. PTSD Three Brain Systems (Van der Kolk) The Watchtower – the medial prefrontal cortex • Interoception • Meditative practices • Mindfulness • Yoga • Body work The Cook – thalamus – dysfunctional, integrates sensations • Disintegration - flashbacks EMDR The Smoke Detector Primitive brain – amygdala – hyperactive Fear/Fight/Flight/Freeze

40. Yoga and PTSD • Yoga is body-based & breath-based & exerts influence on autonomic nervous system that cannot be achieved through verbally based treatments or pharmacological manipulation • Body/breath-based approaches facilitate re-connection of brain functions allowing recognition of sensory input & disruption of pathological feedback loops that perpetuate symptoms (alarm/danger/threat) • The results of RGH research accord with those emerging from other research, mainly from the USA, in large part funded by the Department of Defence

41. Yoga and PTSD • Ironically, this also accords with ancient wisdom that has long been held in non-Western cultures but which has been up until recently not well understood in Western medicine • Neuroplasticity may well underpin the effects of yoga by allowing the brain to change and adapt in a positive way under the influence of techniques that facilitate the re-establishment of functional neural pathways and the down-regulation of other maladaptive connections.

42. In conclusion… • Relatively common, especially amongst specific groups • Unique amongst almost all Dx in DSM5 • Extreme variability in presentation, course, severity and outcome despite consistent core symptoms