POST TRAUMATIC STRESS DISORDER: Lest We Forget

1. McMaster Mini Med School March 24, 2009 Jon Davine, MD, CCFP, FRCP(C) Associate Professor, McMaster University POST TRAUMATIC STRESS DISORDER: Lest We Forget

4. PTSD • “Invented” 1980 in DSM • Started with Vietnam war vets • Quintesential environmental disease, as must have environmental stress

5. POST TRAUMATIC STRESS DISORDER (PTSD) • The person has been exposed to a traumatic event in which both of the following were present: • the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • the person’s response involved intense fear, helplessness, or horror.

6. POST TRAUMATICSTRESS DISORDER – RE-EXPERIENCING • The traumatic event is persistently reexperienced in one or more of the following ways: • recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions (recurring thoughts). • recurrent distressing dreams of the event (nightmares). • acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions (flashbacks).

7. POST TRAUMATICSTRESS DISORDER - TRIGGERS • Intense psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event. • Physiological reactivity on exposure to cues that symbolize or resemble as aspect of the traumatic event. • Can become a panic attack. • e.g., very upset if hears the squeal of brakes.

8. POST TRAUMATICSTRESS DISORDER - AVOIDANCE • Persistent avoidance of stimuli associated with the trauma: • Efforts to avoid thoughts, feelings or conversations associated with the trauma • Efforts to avoid activities, places or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • e.g., avoid driving

9. POST TRAUMATIC STRESS DISORDER - AROUSAL • Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: • difficulty falling or staying asleep • irritability or outbursts of anger • difficulty concentrating • hypervigilance • exaggerated startle response

10. POST TRAUMATICSTRESS DISORDER • duration of the disturbance is more than one month • the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

11. TRAUMATIC EVENT RE-EXPERIENCE AVOIDANCE/NUMBING UNABLE TO FUNCTION MONTH AROUSAL (HYPERAROUSAL)

12. POST TRAUMATICSTRESS DISORDER • Specify if: • Acute: if duration of symptoms is less than three months • Chronic: if duration of symptoms is three months or more • Specify if: • with delayed onset: if onset of symptoms is at least six months after the stressor. • Can happen with sexual abuse.

13. Chronic PTSD (> 3 months) PTSD: Subtype Specifiers PTSD Symptoms Acute Stress Disorder Acute PTSD (< 3 months) Delayed Onset PTSD 1 3 6 Time from Trauma (months)

14. SCREENING QUESTIONS Thus, in screening for PTSD, ask: • Do you keep re-experiencing the event? Nightmares Flashbacks (“daymares”) • Can be like hallucinations Can’t stop thinking about it. • Can look like obsession • Do things that remind you of the event bring out a huge response? • Can look like panic attacks

15. SCREENING QUESTIONS • Do you avoid things that remind you of the event? • Are you personally more anxious since the event? • ?decreased sleep, concentration • more irritable • startle easily • Has it gotten in the way of your life?

16. Psychiatric Comorbidity (lifetime) Panic9.9% Alcohol Abuse / Dependence39.9% Major Depression48.2% PTSD GAD15.9% Social Phobia29.9% Agoraphobia19.25% Kessler et al, Arch Gen Psychiatry 1995

17. LIFETIME PREVALENCE OF PTSD APPROXIMATELY 10% • Breslan et al ‘91 • 9.2% • National Comorbidity Survey ‘91 (NCS) • 8.7% • 5-6% males • 10-14% females • Detroit Area Survey of Trauma ‘96 • 14% • 10% males • 18% females

18. EXPOSURE TO TRAUMATIC EVENTS • Lifetime exposure to traumatic events • 40-69%. Only 10% get PTSD • Higher in males/females 1.2 : 1

19. EXPOSURE TO TRAUMA • Trauma type NCS Male Female Rape 0.7 9.2 Sexual Assault 2.8 12.3 Combat 6.4 0.0 Witnessing Violence 35.6 14.5 Accidents 25.0 13.8 Car Accidents 32.8 23.5 Threatened with a weapon 19.0 6.8 Physical attack 11.1 6.9 Natural Disaster 18.9 15.2 Learning about trauma to others 63.1 61.8 Sudden unexpected death 61.1 59.0

20. TRAUMA • Extended from war, earthquakes, assaults • MVA’s; grief; workplace incidents • Legitimate cause for disability

21. CONDITIONAL RISK OF PTSD • 9% all trauma • Females > males 2:1 (adjusted for trauma type)

22. CONDITIONAL RISK FOR PTSD Trauma Type %PTSD Assaultive violence 20.9 Raped 49.0 Shot or stabbed 15.4 Badly beaten up 31.9 Serious car accident 6.1 Learning about trauma to others 0.2 Sudden unexpected death of a close friend or relative 14.3 Any trauma 9.2

23. CONDITIONAL RISK FOR PTSD Females Males Molestation 26.5 vs 12.2 Threatened with a weapon 32.6 vs 1.9 Assaultive Violence 35.7 vs 6.0

24. Risk Factors for PTSD Development Peri- Trauma Pre- Trauma Post- Trauma PTSD

25. Pre-Trauma Risk Factors • Female gender • Previous trauma / younger age at time of trauma • Childhood abuse • Trait neuroticism / poor coping style Brewin et al, J Consult Clin Psychol 2000

26. Peri-Traumatic Risk Factors Influencing PTSD • Nature of trauma (personal assault) • Severity of trauma / chronicity of trauma Brewin et al, J Consult Clin Psychol 2000

27. Post-Trauma Risk Factors • Lack of social support • Lack of appropriate early treatment or access to services Yehuda et al, Biol Psychiatry1998

28. LONGITUDINAL COURSE • 53% recovered at three months. • 58% recovered at nine months. • 15-25% unrecovered after years. I often see this with people from war zones.

29. Longitudinal Course of PTSD Symptoms 6% recovered 53% recovered 58% recovered 15-25% UNRECOVERED Weeks 3 months 9 months YEARS Shalev & Yehuda, Psychological Trauma 1998

30. NEUROBIOLOGY • Studies have shown decreased size of the hippocampus in brain studies. • “Seat of Memory” • Different pathways • “Sabretooth Tiger” example re evolutionary advantage, but now…..

31. Psychosocial CBT (exposure) Anxiety management Psychoeducation EMDR (controversial) Pharmacological SSRIs NSRI PTSD Treatment Options

32. CONTROVERSY • must you re-explore the trauma --NO • when is the most appropriate timing--WHEN THE PATIENT IS READY

33. CBT - Psychoeducation/Supportive Counselling • Normal to be upset and have symptoms • PTSD symptoms does not mean “going crazy” • provide client with corrective information (psychoeducation) • It’s very common (10%) • Treatment can help

34. CBT-Imaginal Exposure, a Behavioural Treatment • This is healing. It gets rid of the power of the event • Literally, talking about the very thing you’d rather not talk about • This is the hallmark of therapy

35. CBT- In-Vivo Exposure Therapy • Behavioural homeworks involve exposure to avoided activities • Usually done as hierarchy • Can pair it with muscle relaxation • Must stay in the activity until calm. Don’t stop activity while still anxious • E.g. driving a car after an accident

36. COGNITIVE THERAPY • Challenge automatic thoughts with evidence for and against • Re-formulate to more realistic ones • e.g. all men will assault me • e.g. I will always have an accident

37. CAUTION!! • I tell people talking about the difficult event is healing…..as long as they feel ready to do it • If they feel it’s too much, I say “wait until you feel ready, and then we’ll do it”

38. ANXIETY MANAGEMENT TRAINING Give client skills to handle anxiety: • e.g. relaxation training, deep muscle • breathing retraining

39. Recommendation for Pharmacotherapy for PTSD First-line Fluoxetine, paroxetine, sertraline, venlafaxine XR, (SSRI’s, NSRI) Second-line Fluoxamine, mirtazapine, moclobemide, phenelzine Adjunctive: resperidone, olanzapine

40. EXAMPLE: SEXUAL ABUSE • ask regarding nightmares, flashbacks, avoidance, triggers, mood • “not your fault”, “metaphorically bound and gagged” • “if there’s anything I ask you that you would rather not answer, you don’t ...” • support. Validate feelings e.g. anger, hatred • normalize issue of self esteem, trust, intimacy, sexuality • pressure cooker analogy