Posttraumatic Stress Disorder

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Posttraumatic Stress Disorder
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Historical Overview of Traumatic Reactions late
19th century

• Terms used in combat veterans populations
• Cardiovascular
• Soldiers heart
• Da Costas Syndrome
• Neurocirculatory asthenia
• Psychiatric
• Nostalgia
• Shell shock
• Combat fatigue
• War neurosis
• Terms used in civilian populations
• Railway Spine

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Later Descriptions of Traumatic Reactions
(1940s-1980s)

• Later descriptions of post-traumatic responses
  were labeled according to the type of trauma
• Rape trauma syndrome
• Survivor syndrome
• War neurosis
• Shell shock

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PTSD DSM-III (1980)

• PTSD becomes an established diagnosis
• Traumatic event defined as a recognizable
  stressor that would evoke significant symptoms of
  distress in almost anyone.
• Three symptom clusters (based on clinical
  experience) reexperiencing, numbing and
  detachment, and changes in personality

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PTSD DSM-III-R (1987)

• Definition of trauma was narrowed
• An event outside the range of usual human
  experience and that would be markedly distressing
  to almost anyone
• Avoidance symptoms were added to numbing cluster
• Symptoms expanded from 12 to 17
• Duration and onset criteria added
• Impairment in functioning and/or distress added.
• Issues with definition
• Definition proved too restrictive as traumas more
  common than originally believed
• Did not allow for individual differences

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PTSD DSM-IV (1994)

• Exposure to a traumatic event in which the
  person
• experienced, witnessed, or was confronted by
  death or serious injury to self or others AND
• responded with intense fear, helplessness, or
  horror
• Symptoms
• appear in 3 symptom clusters reexperiencing,
  avoidance/numbing, and hyperarousal
• last for gt 1 month
• cause clinically significant distress or
  impairment in functioning

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Acute Stress Disorder DSM-IV (1994)

• Exposure to a traumatic event in which the
  person
• experienced, witnessed, or was confronted by
  death or serious injury to self or others AND
• responded with intense fear, helplessness, or
  horror
• gt 3 dissociative symptoms
• gt1 reexperiencing symptoms
• gt1 anxiety/arousal symptoms
• Onset 2 days to 4 weeks
• Clinically significant distress or impairment in
  functioning

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Criterion A Exposure Criteria

• Experienced or Witnessed an Event that involved
  actual or threatened death or serious injury or a
  threat to physical integrity
• Persons response involved fear, helplessness, or
  horror or in children agitated behavior

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Criterion B Re-experiencing Criteria

• Recurrent and Intrusive distressing recollections
  of the event (images, thoughts, or repetitions)
• Recurrent distressing dreams of the event
• Acting or feeling as if the traumatic event were
  recurring

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Criterion B continued

• Intense Psychological Distress at exposure to
  internal or external cues that symbolize or
  resemble an aspect of the traumatic event
• Physiological Reactivity on exposure to internal
  or external cues that symbolize or resemble an
  aspect of the traumatic event

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Criterion C1 Persistent Avoidance Criteria

• 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

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Criterion C2 Numbing of Gen. Responsiveness
Criteria

• Markedly diminished interest or participation in
  significant activities
• Feeling of detachment or estrangement from others
• Restricted range of affect
• Sense of foreshortened future

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Criterion D Increased Arousal Criteria

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

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Criterion E

• Symptoms in criteria B, C, and D are more than 1
  month

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Criterion F

• The disturbance causes significant distress or
  impairment in social, occupational, or other
  important areas of functioning

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Specifications

• Acute if duration of symptoms is less than 3
  months
• Chronic if duration of symptoms is 3 months or
  more
• With delayed onset if onset of symptoms is at
  least 6 months after the stressor

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Acute Stress Disorder
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Criterion A Exposure Criteria

• Experienced or Witnessed an Event that involved
  actual or threatened death or serious injury or a
  threat to physical integrity
• Persons response involved fear, helplessness, or
  horror or in children agitated behavior

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Criterion B Dissociative Criteria

• Subjective sense of numbing, detachment, or
  absence of emotional responsiveness
• Reduction in awareness of ones surroundings
  (e.g., being in a daze)
• Derealization
• Depersonalization
• Dissociative amnesia

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Criterion C Re-experiencing Criteria

• Recurrent images
• Thoughts, dreams, illusions
• Flashback episodes, or a sense of reliving the
  experience
• Distress on exposure to reminders of the
  traumatic event

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Criterion D Avoidance Criterion

• Marked avoidance of stimuli that arouse
  recollections of the trauma (e.g., thoughts,
  feelings, conversations, activities, places,
  people)

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Criterion E Physiological Criteria

• Marked symptoms of anxiety or increased arousal
  (e.g., difficulty sleeping, irritability, poor
  concentration, hypervigilance, exaggerated
  startle response, motor restlessness)

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Criterion F Psychosocial Criteria

• Clinically significant distress or impairment in
  social, occupational, or other important areas of
  functioning
• Impaired ability to pursue some necessary task,
  such as obtaining personal assistance or
  mobilizing personal resources

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Criterion G Time Criteria

• Minimum of 2 days
• Maximum of 4 weeks
• Occurs within 4 weeks of the traumatic event

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Inter-relationship between ASD and PTSD
Event
ASD
PTSD
4 weeks and on
2 days 4 weeks
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How does someone develop PTSD?
Classical Conditioning
Unconditioned Stimulus
Unconditioned Response
CR
CS
Thoughts Feelings Behaviors
Car Jacking
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Validity is Well Established

• PTSD has proven to be a useful and valid
  diagnosis after 25 years of clinical use
• Although there have been minor revisions to the
  diagnostic criteria the core concept has
  withstood the test of time

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PTSD Prevalence in US Adults

• National Comorbidity Survey (1995)
  NCS-Replication (2005)
• Large national probability samples (Ns gt 5000)
• Benchmark for prevalence of mental disorders in
  US
• Lifetime PTSD prevalence 6.8 (NCS-R)
• 9.7 women
• 3.6 men
• Current PTSD prevalence 3.6 (NCS-R)
• 5.2 women
• 1.8 men

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The Burden of PTSD

• Individuals with PTSD have
• Elevated risk of mood, other anxiety, and
  substance abuse disorders
• Elevated risk of suicide attempts
• Greater functional impairment
• Reduced quality of life
• PTSD had the greatest impact of all anxiety
  disorders on economic burden to society
  (Greenberg et al., 1999)

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PTSD and Functioning in the NCS

• In NCS, PTSD associated with
• 40 elevated odds of academic failure
• 30 elevated odds of teenage parenthood
• 60 elevated odds of marital problems
• 150 elevated odds of current unemployment