Associate Professor, Departments of Psychiatry and Pharmacology Anxiety Disorders Anita S. Kablinger MD Associate Professor, Departments of Psychiatry and Pharmacology LSUHSC-Shreveport

DSM-IV Anxiety Disorders Specific phobias Panic disorder Agoraphobia Generalized anxiety disorder Social phobia Obsessive-compulsive disorder PTSD

PTSD: Presentation Outline Introduction/History Clinical Presentation/DSM-IV Criteria Differential Diagnosis Etiology/Risk Factors Treatment Issues Prevention

Introduction/History First appeared in DSM-III (1980) Recognized by Shakespeare in Henry IV Civil War descriptions WWI- shell shock and soldier’s heart WWII- operational fatigue and combat neurosis Organic origin vs psychogenic derivation

Diagnostic Criteria for PTSD A. Exposed to traumatic event The person experienced, witnessed, or was confronted with an event involving actual or threatened death, serious injury or a threat to physical integrity of self or others The person’s response involved intense fear, helplessness or horror

Diagnostic Criteria for PTSD B. The traumatic event is reexperienced in one or more of the following ways Recurrent images, thoughts or perceptions Recurrent distressing dreams of the event Acting or feeling as if the event was recurring Intense psychological distress OR physiologic reactivity at exposure to cues that symbolize or resemble an aspect of the event

Diagnostic Criteria for PTSD C. Persistent avoidance of stimuli associated with trauma and numbing as indicated by 3 or more: Avoiding thoughts, feelings, or discussion, activities, places or people that bring back recollections; sense of foreshortened future Inability to recall; restricted affect Diminished interest or participation Feeling detached or estranged

Diagnostic Criteria for PTSD D. Persistent symptoms of increased arousal by 2 or more: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response E. Duration for more than 1 month

Diagnostic Criteria for PTSD F. Clinically significant impairment in functioning Acute: Less than 3 months Chronic: Greater than or equal to 3 months With delayed onset: Onset at least 6 months after the stressor

Diagnostic Criteria for Acute Stress Disorder A: Exposed to traumatic event B. Experiences three or more of: Subjective sense of numbing, detachment Reduction in awareness of surroundings Derealization Depersonalization Dissociative amnesia C. Persistent reexperiencing of the event

Diagnostic Criteria for Acute Stress Disorder D. Marked avoidance of stimuli that arouse recollections of the trauma E. Marked symptoms of anxiety or increased arousal F. Causes significant impairment G. Lasts 2 days to 4 weeks and occurs within 4 weeks of the trauma

Epidemiology Prevalence of PTSD: 1-14% community, 3-58% in at-risk populations 25-30% lifetime prevalence in Vietnam veterans 85% in concentration camp survivors May be modulated by cultural differences All ages; individuals or groups; F>M

Differential Diagnosis Mental disorder secondary to GMC (ex. head injury) Substance-induced disorder Dissociative disorders Major depressive episode Borderline personality disorder Malingering

Etiological Factors Magnitude of the stress exposure Cognitive appraisal factors Intense fear or helplessness predictive Sympathetic hyperactivity Psychological factors psychodynamic cognitive behavioral

Examples of Traumatic Events Complicated or unexpected bereavements Accidents Captivity Violent crime Sexual trauma Chronic physical abuse Military combat Natural disasters Manufactured disasters

Risk Factors Lack of social support Family psychiatric history, esp. anxiety Previous psychiatric history Certain personality traits Early separation of parents Parental poverty Abuse in childhood Childhood behavioral problems Limited education Adverse life-events prior to trauma Female

Six Strongest Predictors of Trauma Exposure Male Absence of college education Extroversion Neuroticism Early misconduct Family psychiatric illness

Six Strongest Predictors for Risk of PTSD Female Neuroticism Early separation from parents Prior anxiety or depression Familial anxiety Familial antisocial personality disorder

Associated Symptoms Important for Treatment Survival and behavioral guilt Somatic distress Paranoia Interpersonal alienation Vegetative changes of depression Hopelessness Impulsivity

Course and Prognosis 30% recover completely 40% continue with mild symptoms 20% moderate symptoms 10% unchanged or worsen Startle, nightmares, irritability and depression often worsen with age Comorbidity is high (MDD, OCD, Panic, substance abuse)

Treatment: ASD Talking about the trauma allowing: confrontation acceptance process integration Individual or group therapy, hypnosis Followed by support and superficiality

Treatment: PTSD Requires multiple modalities Initial education, support and referrals important to establish trust Pharmacotherapy Psychotherapy Relaxation Training

Treatment: PTSD-Pharmacotherapy Duration of at least 8-12 weeks Adequate dosages Maintenance treatment for at least 1 year Antidepressants Mood stabilizers Propranolol, clonidine Atypical antipsychotics

Drug Treatment of PTSD Amitriptyline Fluoxetine Sertraline* Paroxetine* Propranolol Clonidine Valproic Acid Carbamazepine 50-300 mg/day 20-60 50-200 20-50 40-160 0.2-0.6 750-1,750 200-1,200

Drug Treatment of PTSD Lithium Quetiapine Risperidone Olanzapine 300-1,500 mg/day 25-700 0.5-6 2.5-20

Treatment: PTSD- Individual Psychotherapy Crisis Intervention establish rapport, promote acceptance educate, attend to general health Trauma-focused psychotherapy Implosive therapy Systematic desensitization Hospitalization may be necessary at times

Points to Remember If a patient has multiple complaints, think PTSD or personality disorder up front Under-detected because we don’t ask the right questions One of the few DSM disorders defined by it’s cause!

DREAMS Detachment Re-experiencing the event Emotional effects Avoidance Month in Duration Sympathetic hyperactivity or hypervigilance

PTSD Questionnaire

DSM-IV Anxiety Disorders Specific phobias Panic disorder Agoraphobia Generalized anxiety disorder Social phobia Obsessive-compulsive disorder PTSD