Posttraumatic Stress Disorder

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Posttraumatic Stress Disorder
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Epidemiology of PTSD

• Kessler et al. (1995) Posttraumatic Stress
  Disorder in the National Comorbidity Study
• Representative National Sample
• N 5877 AGE 15-54 Years old
• Lifetime prevalence of PTSD is 7.8
• More than 1/3 of people with an initial episode
  of PTSD fail to recover after 10 years

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Kessler National Comorbidity

• Women Most Common Experiences
• Rape
• Sexual Molestation
• 50 had experienced a trauma that met DSM-IV
  stressor criterion
• Men Most Common Experiences
• Combat
• Witnessing death or severe injury
• 60 had experienced an event that would meet
  DSM-IV stressor criterion

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Kilpatrick et al (1992)

• Nationally representative sample
• 4008 women
• 13 reported a completed rape
• Of those who were raped
• Lifetime PTSD 32
• Current PTSD 12

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Prevalence of PTSD

• 5th Most Common Psychiatric Condition
• Behind
• Major Depression
• Attention-deficit/hyperactivity disorder
• Specific phobia
• Social phobia

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Comorbidity

• PTSD/Depression Nearly 50 Comorbid
• Specific phobia, social phobia, and dysthymic
  disorder also prevalent
• Male PTSD/Alcohol Abuse (52)

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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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Greens Generic Dimensions to Stressors

• Threat to ones life
• Threat to bodily integrity
• Severe physical harm/injury
• Exposure to grotesque
• Witnessing/learning of violence or severe harm to
  others
• Learning of exposure to a noxious agent
• Causing death or severe harm to another

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Dohrenwend

• National Veterans Readjustment Study
• Congressional Mandate in 1983
• Representative sample of 1632 US Vietnam Theater
  Veterans and matched sample of 716 Vietnam era
  veterans and 668 civilian comparison
• NVVRS rates for Male VTV 30.9 lifetime
• And 15.2 current
• CDC rates reported 14.7 lifetime and 2.2
  current all 11 to 12 years after the Vietnam war
  ended

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Dohrenwend contd.

• National Veterans Readjustment Study
• Perplexing in these relatively high rates of PTSD
  was the relatively low rates of combat
• Used data from archival sources to develop a
  record based military historical measure for
  exposure
• Impairment wasnt formerly a part of the criteria
• Adjusted Rates for impairment and verification
  are
• 18.7 lifetime and 9.1 current
• Dose response relationship between combat and
  exposure

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Cultural Factors and PTSD

• Hispanic veterans report significantly higher
  rates of PTSD than AA or Caucasian veterans.
  Hypotheses include
• Greater exposure to war zone stressors
• Greater prewar vulnerability
• Culturally driven differences in reporting
  symptoms
• Different post war stressful events
• Greater experiences with racial/ethnic prejudice
  and discrimination

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Sample

• Subsample NVVRS
• 94 Majority White
• 70 African American
• 84 Hispanic (Mostly Mexican American (63),
  Puerto Rican (15), Latin American (6)
• War Zone stressor severity measured
• Peri- and Post-War Discrimination
• Vulnerability Factors Measured
• Younger age at entry to Vietnam
• Lower Armed Forces Qualification Tests
• Disciplinary Actions
• Pre-Vietnam educational level
• Pre war psychiatric disorder

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Results

• Both Blacks and Hispanics had higher rates of
  war-related first onsets of PTSD (current PTSD
  10-11 years after the war)
• PTSD course was more chronic for Hispanics than
  Blacks
• Hispanics experiences more war-zone stressors
  compared with Caucasians
• Controlling war zone exposure did not account for
  the greater rates of PTSD in Hispanics
• Prewar vulnerability factors emerged as
  important younger age, less education, lower
  AFQT scores

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9/11

• Explored stressor exposure and PTSD symptoms in
  11,037 adults who live south of Canal Street in
  NYC on 9/11 (lower Manhattan)
• PTSD Checklist Civilian Version
• Within disaster exposure, e.g., residential
  proximity, direct exposure intensity (caught in
  the dust cloud from the tower collapse, an
  occupant of the north or south tower, sustaining
  an injury, witnessed horror, seeing people fall
  or jump from the buildings)

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9/11 Results

• 43.6 reported reexperiencing, 20.4 reported
  avoidance, 38.6 reported hyperarousal
• Most common symptoms were hypervigilance, being
  upset by reminders, and insomnia
• Current PTSD prevalence 12.6

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9/11 Results Bivariate results

• Increased risk was reported for African
  Americans, Hispanics, and other nonAsian
  minorities (Asian race was protective)
• Increased risk for women
• Lower education and lower income was associated
  with increased risk
• Older age and female gender was assoc with
  increased risk
• Being divorced, separated or separated was
  associated with increased risk
• Within disaster risk factors were sustained
  injury, witnessed horror exposure to dust cloud,
  being in a building that was damaged or destroyed
  (except WTC towers), living less than 1000 feet
  from the towers
• Post disaster risk was associated with evacuation
  from ones home and involvement in
  rescue/recovery efforts.

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9/11 Results Multivariate results

• Risk for PTSD increased for all age groups
  relative to the younger groups (greatest risk for
  adults 45-64 years)
• Increased risk for women
• Risk for PTSD higher among Hispanics, African
  American, and other ethnicities
• Divorced, widowed or separated continued to
  increase risk
• Lower education and income was associated with
  increased risk
• Exposure intensity remained as a significant risk
  factor
• Evacuation and involvement in rescue recovery
  efforts remained

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Confluence of Factors

• Discuss findings in terms of the diathesis,
  personality, stress model

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Acute Stress Disorder
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(No Transcript)
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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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Classical Conditioning
Triple vulnerability
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Model for PTSD

• PTSD develops through the process of classical
  conditioning
• When cues are encountered, anxiety and other
  emotional reactions increase. Over time,
  habituation would occur.
• Avoidance maintains PTSD because habituation can
  never occur.
• Negative Reinforcement