1. Post Traumatic Stress Disorder
David A. Brady, D.O.
Midlothian, Virginia

2. Anxiety
Anxiety is a normal reaction to stress. It helps us deal with stressful situations, makes us more aware, increases focus and concentration.
Anxiety becomes a problem when it becomes an excessive, irrational dread of a situation, event, or object.

3. Anxiety Disorders
There are five major types of anxiety disorders. Each has different symptoms but all symptoms cluster around excessive, irrational fear, and dread.
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder
Posttraumatic Stress Disorder
Social Phobia (Social Anxiety Disorder)

4. Relevance
Lifetime prevalence of PTSD is 1% - 15% in the U.S. population.
[In high-risk groups, such as combat veterans and victims of violent crimes, prevalence ranges from 3% to 58%.]

5. Relevance
PTSD is more prevalent among war veterans than among any other group.
The National Vietnam Veterans Readjustment Survey reports that approximately 25% of U.S. veterans, men and women, were suffering from PTSD in the early 1990s.

6. Traumatic Events War Mugging Rape Torture Kidnapping Held captive
Child abuse
Accidents (work related, MVA)
Acts of terror
Train wrecks
Ship wrecks
Air plane crashes
Bombings
Natural disasters
Medical Procedures (Surgeries, ICU / CCU Stays, Chemotherapy, Burn Treatments)

7. Posttraumatic Stress Disorder
“The complex somatic, cognitive, affective and behavioral effects of psychological trauma.”
It is characterized by intrusive thoughts, nightmares and flashbacks of past traumatic events, avoidance of reminders, hypervigilance, and sleep disturbance, which lead to social, occupational and interpersonal dysfunction.

8. Posttraumatic Stress Disorder
“Neurobiological research has helped us to understand that PTSD is not an “emotional” or “psychological” disorder, but a physiological condition that effects the entire body, including cardiovascular functioning, hormone system balance, and immune functioning.”
Hoge

9. Posttraumatic Stress Disorder
Many people exposed to trauma will experience distress with similar symptoms associated with PTSD.
PTSD is a subset of people who are significantly impaired of a period of time greater than 1 month.

10. Epidemiology Lifetime prevalence 6.8-12.3 percent
Estimated 11 to 17 percent of US veterans returning from active duty in Afghanistan and Iraq
Onset at any age
Females > males (4X more likely to develop sx)
Susceptibility may run in families
Associated with drug and alcohol abuse and/or dependence
Look for one or more of the other anxiety disorders
PTSD is associated with increased median annual health care costs (38 to 104%)

11. Epidemiology Risk factors
Lack of social support = dissociation associated with the trauma
Extent of injury is strongly correlated with PTSD (those in combat)
Lower socioeconomic status
Parental neglect
Family or personal history of psychiatric illness
Initial severity of reaction to traumatic event
Previous exposure to trauma

12. Pathophysiology Unclear pathophysiology
MRI studies have shown decreased hippocampal volume in patients with PTSD.
Increased central norepinephrine levels with down-regulated central adrenergic receptors, chronically decreased glucocorticoid levels with up regulation of receptors.
Hemispheric lateralization
Abnormalities in amygdala
exaggerated response of the amygdala, resulting in impaired regulation by the medial prefrontal cortex
patients with PTSD have diminished activation of the medial prefrontal cortex during the processing of fear
Insufficient cognitive resources to engage appropriate cognitive strategies

13. Clinical Presentation
Marked cognitive, affective, and behavior responses to stimuli, leading to flashbacks, severe anxiety and fleeing or combative behavior.
Individuals compensate by avoiding triggers and generally shutting down.
Emotional numbing and diminished interest in everyday activities with detachment from others.
Sense of a foreshortened future
Psychiatric comorbidity is high:
Depression, anxiety, substance abuse, and somatization disorders

14. Anger / Irritability
“Anger is an emotion, an immediate internal reaction to a situation.”
“A problem in our society, and in the approach to anger “management”, is that anger - the emotion - is often confused with other responses.”
“It is not the anger that needs managing, but the various behaviors that can arise from it.”
Hoge

15. Flashbacks
Flashbacks consist of images, sounds, smells, or feelings triggered by ordinary events (Examples: car backfires, door slams).

16. Nightmares

17. Problems With Authority

18. Loss of Faith

19. Bias and Hate

20. Symptoms
“Every “symptom” included in the definition can also reflect normal responses to life-threatening events or the normal way the body responses to extreme stress.”
Hoge

21. Symptoms
Symptoms are usually worse if the traumatic event was triggered by another person (examples: rape, terror, mugging, direct contact in war).

22. Mental Status Exam
General appearance may be affected (disheveled / poor personal hygiene).
Behavior may be altered. Agitated, extreme startle reaction.
Orientation is sometimes affected. The patient may not know the current place or time.
Patients may report forgetfulness, especially concerning the specific details of the traumatic event.
Concentration is poor.
Impulse control is poor.
Speech rate and flow may be altered.
Mood and affect may be changed. Patients may have feelings of depression, anxiety, guilt, and/or fear.
Patients may be more concerned with the content of hallucinations, delusions, suicidal ideation, phobias, and reliving the experience. Certain patients may become homicidal.

23. Diagnosis 6 categories:
Subjective and objective components of exposure to trauma
Reexperiencing of the trauma
Persistent avoidance of the trauma
Increased arousal
Duration > 1 month
Disturbance causes social and vocational impairment…

24. DSM IV criteria
The person has been exposed to a traumatic event in which both of the following have been 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. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. 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. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
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.

25. DSM IV Criteria
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following: 
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 
markedly diminished interest or participation in significant activities 
feeling of detachment or estrangement from others 
restricted range of affect (e.g., unable to have loving feelings) 
sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 or more of the following: 
(1) difficulty falling or staying asleep  (2) irritability or outbursts of anger  (3) difficulty concentrating  (4) hypervigilance  (5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

26. Imaging in PTSD
MRI studies of the brain suggest that the amount of hippocampal atrophy correlates with the intensity of PTSD symptoms, but MRI is still not a recommended diagnostic test. Some studies in monozygotic twins show that a small hippocampus may be a predisposing factor to the later development of PTSD in the face of a stressor.

27. Amygdala hyperactivity combined with hippocampal atrophy seems to be consistent with diagnosis of PTSD.
TBI that has destroyed amygdala function will prevent PTSD.

28. Screening PTSD checklist PCL-M or the PCL-C
Clinician Administered PTSD Scale (CAPS)
SPAN (Startle, Physiological Arousal, Anger, and Numbness)

29. Differential Diagnosis
Acute stress disorder
Traumatic Brain Injury
Adjustment disorder
Malingering (must be excluded)
Mood disorder with or without psychotic features
Psychotic disorders caused by a general medical condition
Substance induced disorders

30. Implications in Primary Care
The diagnosis of PTSD can be missed in a primary care setting, as patients frequently present with somatic complaints or depression and are often reluctant to discuss their traumatic experiences.

31. Treatment of PTSD

32. Treatment of PTSD
Treatment is often best accomplished with a combination of pharmacologic and nonpharmacologic therapies.
Medications may be required to control the physiological symptoms, which can enable the patient to tolerate and work through the highly emotional material in psychotherapy.
SSRI’s are first choice in medical management
Prazosin for nightmares
Atypical antipsychotics
If present, alcohol or substance abuse problems should be the initial focus of treatment
Hyperarousal symptoms can be treated with B-blockers

33. Treatment of PTSD Exposure Therapy Group Therapy Support Groups
Don’t insult the patient
Never tell the patient: Don’t talk about your trauma, talk about your feelings…
Virtual Reality
Sexual Issues (psychological and physiological)
Physical Issues

34. Treatment of PTSD
Don’t forget the forgotten (spouses, children, mothers, fathers, brothers, sisters, friends, neighbors, ministers, healthcare providers…)
Close medical follow-up
Exercise
Recreation
Routine (Sleep)
Vocational Rehabilitation
Education
Spiritual Issues

35. Prognosis
PTSD is a chronic condition with 1/3 of patients recovering at one year and 1/3 symptomatic at 10 years…

36. “I hold it to be a fundamental truth of human nature, that when someone withholds something traumatic it can cause great damage. When you share something with someone it helps to place it in perspective, but when you hold it inside, as one of my students once put it, “it eats you alive from the inside out.” Furthermore, there is great therapeutic valve in the catharsis that comes with lancing these emotional boils. The essence of counseling is that pain shared is pain divided…”
Grossman

37. The End