Post-Traumatic Stress Disorder

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder

Prevalence 3.6-8.0% of U.S. adults

May occur at any age; triggered by trauma

Women more likely affected

Minority groups have much higher rates of PTSD than do non-Hispanic white persons

30% of the men and women who have spent time in the war zones

Pathophysiology

Reduced hippocampal volume among those exposed to combat trauma, sexual assault, or MVA's

Increased regional cerebral blood flow to limbic and paralimbic areas esp. right amygdala, decreased blood flow to Broca's area in the left temporal lobe

Sympathetic nervous system activation

Autonomic hyperresponsiveness to both neutral and trauma-related stimuli

Elevated urinary catecholamine levels

Downregulation of beta- and alpha-2 adrenergic receptors

Increased reactivity to the alpha-2 antagonist, yohimbine

Hypothalamic-Pituitary-Adrenocortical mobilization

Lower urinary cortisol levels

Elevated lymphocyte glucocorticoid receptor levels

Dexamethasone supersuppression

Other theories of causation

Acoustic startle-response

Shorter latency and increased amplitude of the acoustic-startle-eyeblink reflex

Significant loss of the normal inhibitory modulation of the startle reflex

Resistance to habituation of the startle response

Fear conditioning

Appraisal

DSM-IV-TR

The person experienced or witnessed an event that involved death or serious injury, or the threat of death or serious injury; response to the event involved intense fear, horror, or a sense of helplessness

Relived experiences of the event, such as having distressing images and memories, upsetting dreams, flashbacks, or physical reactions

DSM-IV-TR Cont'd

Persistent avoidance of situations or things that remind the person of the traumatic event or feeling of emotional numbness

Feeling as if constantly on guard or alert for signs of danger, which may cause difficulty sleeping or concentrating

Symptoms last longer than one month

Acute: duration less than 3 months

Chronic: duration 3 months or more

Delayed: onset of symptoms is at least 6 months after stress

Course of PTSD

Signs and symptoms typically begin within three months of a traumatic event

May be delayed for more than six months or even years later

Severity and duration varies

Symptoms may come and go...may have more symptoms during times of higher stress

Some people recover within six months, others may not do so for much longer

Longitudinal Course

PTSD can persist for decades

Symptoms may worsen rather than improve over time

Approximately 40% of patients with lifetime PTSD are unlikely to recover whether or not they have ever received treatment

Series of remissions and relapses

Some people able to lead productive and fulfilling lives; others may develop a persistent incapacitating mental illness

Prognosis of PTSD

Best prognosis depends on how soon the symptoms develop after the trauma, and on early diagnosis and treatment

Some individuals who do not receive care recover over a period of years

More than 1/3 of patients never fully recover

Rarely, individuals may have worsening symptoms and kill themselves

Consequences of PTSD

Physiological outcomes

Physical complaints

Depression

Other anxiety disorders

Conduct disorders

Dissociation

Eating disorders

Consequences of PTSD Cont'd

Social outcomes

Interpersonal problems

Low self-esteem

Alcohol and substance use

Employment problems

Homelessness

Trouble with the law

Consequences of PTSD Cont'd

Self-destructive behaviors

Substance abuse

Suicidal attempts

Risky sexual behaviors leading to unplanned pregnancy or STD's, including HIV

Reckless driving

Self-injury

Treatment

Three major approaches

Cognitive-behavioral therapy

Pharmacotherapy

Individual and group dynamic psychotherapy

Cognitive-behavioral therapy

The most successful treatment for PTSD