Post-traumatic stress disorder

1. Post-traumatic stress disorder Symptoms, prevalence rate, assignments.

2. Youtube – The deer hunter. (more suggestions of films to see at the end of the presentation).

3. Symptoms of PTSD (DSM IV) A: The person has been exposed to a traumatic event involving death or serious injury, and their reponse involved intenese fear, helplessness or horror.

4. B: The traumatic event is re-experienced in ways that might inclue intrusive distressing thoughts, and dreams of the event, feeling that the traumatic event is recurring and showing intense psychological distress when exposed to anything that resembles or sumbolises the tramatic event.

5. C: Persistent avoidance of stimuli associated with the trauma, e.g. Avoiding anything that might arouse recolletions of the trauma, and feeling detached from others.

6. D: Persistent symptoms, of increased arousal, including sleeping difficulties, outburst of anger and concentration difficulties.

7. Criterion E distinguishes PTSD from acute stress reactions to trauma (hence the word post in ”post traumatic stress disorder E: These symptoms last for a period of more than 1 month

8. Criterion F acknowledges that PTSD is a diagnosable disorder. This is important as it means that somegroups (war veterans for example) canreceivecompensation) F: The disturbancecausesclinciallysignificantdistress of impairment in social, occupational, or otherimportant areas of functioning.

9. Symptoms related to levels of analysis: • Affective: adhedonia; emotional numbing • Behavioural: hypervigilance; passitivity, nightmares; flashbacks; exaggerated startle respose • Cognitive: intrusive memories, inability to concentrate, hyperarousal • Somatic lower back pain, headaches, stomach ache and digestion problems, insomnia, regression in some children.

10. Complication in diagnosis: PTSD frequently occurs together with related disorders such as depression, substance abuse, problems of memory and cognition and other problems of physical and mental health. (two last parts of ”the gorund truth”)

11. Historical approach Not a new phenomenon. WWI ”Shell shock”, and was seen as nothing more than cowardice or personal weaknessess. After WWI – the conclusion was that it was of physical origin (injury to the nerves) – but as not all who suffered these symtoms actually had been near the fights – this suggested psychological nature instead. The anticipation of the horrors – a significant determinant of mental health problems. (Hoge (2004), found that among US combat infantry units, over 9% developed mental health problems juch as major depression or PTSD prior to deployment in Iraq)

12. Cont. Historical approach WW II – psychiatrists were deployed to fighting units. A realization that the bloodier the combants and closer to fights the soldiers were – the greater the likelyhood of PTSD. Post – Vietnam syndrom  PTSD First in DSM IV (revised 2000) that the other than war related traumas were included. First, the trauma had to be ”outside the range of usual human experience” and rape – unfortunately being common – was not seen to be. New version describe the traumatic event as ”one in which the person experienced a threat of death or serious injury and responded with intense fear”

13. Prevalence rates today: Prevalence rate = the measure of the total number of cases of the disorder in a given population. Lifetime prevalence = the percentage of the population that will experience the disorder at some time in their life. .

14. US prevalence rate = 1-3 per cent and estimated lifetime prevalence 5 per cent in men and 10 per cent in women. Davidson et al (2007) estimate that PTSD affects 15-24 per cent of individuals who are exposed to traumatic events (see etiology for a discussion why some are affected and some not). In communities that have experienced traumatic events, average prevalence increases to 9 per cent (eg. September 11).

15. DSM IV criticism: • PTSD may not be a mental disorder because it is a reaction to an even that would be disstressing for almost anyone. • PTSD should be separated from anxiety disorders and placed in an etiologically based category along with other disorders that follow traumatic events (McNally). That is also how it is classified in ICD. • The core symtoms are both anxiety (anxiety, intrusive images…) related but also dissociative (amnesia, multible personality, flashbacks) • Future versions of DSM should address these. • True prevalence is difficult to judge – especially when some traumatic events affect a large number of people simulataneously (hurricane, flooding) – 60 % of all men and 51 % of women reported at least one traumatic event at some time during their lives (Kessler, 1999). • Unclearities of why more women experience PTSD than men. Rape might be one reason, more psychological than physical trauma.

16. Type of trauma is a key factor: 3 % of those who experience a personal attack, 20 % of wounded veterans and 50% of rape victims develop PTSD. Above all – loss of a loved one (in a trauma) – 1/3 of the total of all cases.

17. Watch a movie of your choice: • Taxi Driver (1976) • Coming Home (1978) • Apocalypse Now (1979) • The Deer Hunter (1979) • Return of the Soldier (1982) • Birdy (1984) • Born on the Fourth of July (1989) • Heaven and Earth (1993) • These movies unleash the inner mindset of combat veterans trying their best to cope with the trauma of war.

18. To do with the film For the ambitious – at home: ”Using the criteria listen in box 1 (in article) – what aspects of the main character’s behaviour in each of these films would lead you to diagnose PTSD?” In class: • Research evidence – using the internet, read more abou thte hoge it al. (2004) and Iversen et al. (2009). These can be found at: http//content.nejm.org/cgi/content/full/351/1/13 (Hoge et al.) and at www.biomedcenter.com/1471-244X/9/68 (Iversen at al.). • What were the main methods used in each study? • What were the main conclusions drawn about the relationship between combat stress and the development of psychiatric illness Homework: Read about Jocelyn’s case. Underline 10 sentences (paragraphs) that you reacted against, or felt was especially important when reading the case. Thursday will be spent covering the case and etiology. If you are not prepared, you will not participate in the seminar.