Post Traumatic Stress Disorder Acute Stress Disorder Dr. A. Hadjebi

History  U. S. civil war : Soldier's heart syndrome  1900 s : Traumatic neurosis due to the influence of psychoanalysis  World war I : shell shock  World war II : combat neurosis or operational fatigue  Vietnam war : post traumatic stress disorder

History  PTSD: DSM-III (1980)  ASD; DSM-IV (1994)  PTSD in DSM-III: reexperience(1),psychic numbing(2), other items(1), no duration criteria  PTSD in DSM-III-R is similar to DSM-IV-TR  In ICD-10 PTSD & ASD are stress related disoders

Epidemiology  Life time prevalence (8%)  30% of Vietnam veterans  25 % subclinical form of disorder  In women : life time prevalence %  In men : life time prevalence 5- 6%  PTSD is most prevalent in young adults  Men's trauma : combat experience  Women's trauma : assault or rape

Epidemiology  PTSD most likely to occur in single, divorced, widowed, socially withdrawn, low socioeconomic level  First degree biological relatives of persons with a history of depression have an increased risk for developing PTSD following a traumatic event

Comorbidity  About 2/3 having at least tow other disorders  Common comorbid conditions include : depressive disorders, substance related disorders, other anxiety disorders and bipolar disorders

Etiology  Stressor  Risk factors  Psychodynamic factors  Cognitive – behavioral factors  Biological factors Noradrenergic system Opioid system Corticotropin – releasing factor and the HPA axis

Psychological aspects of PTSD  Emotional response to trauma reminder  Base line physiological activity  Exaggerated startle reflex.

Diagnostic criteria for PTSD  Exposure to a traumatic event  The traumatic event is persistently reexperienced  Persistent avoidance of stimuli associated with the trauma  Persistent symptoms of increased arousal  Duration of the disturbance is more than 1 month

Diagnostic criteria for PTSD  Significant distress or impairment in social, occupational or …  Specify if : acute : < 3 months chronic : > or = 3 months  With delayed onset

Diagnostic criteria for ASD The disturbance last for a min. of 2 days and a max. of 4 weeks and occurs within 4 weeks of the traumatic events

PTSD in children and adolescents  Child risk factors include : - demographic factors ( age, socioeconomic status ) - life events - psychiatric comorbidity - parental psychopathology - parental marital status

Gulf war syndrome  Health problems - Irritability - Chronic fatigue - Shortness of breath - Muscle and joint pain - Migraine headaches - Digestive disturbances - Rash - Hair loss - Forgetfulness - Difficulty concentrating

Differential diagnosis organic; head trauma, epilepsy, alcohol use disorder  Pain disorder  Substance abuse  Other anxiety disorders  Mood disorders  Borderline disorders  Dissociative disorders  malingering

Course and prognosis 30 % recover completely 40 % mild symptoms 20 % moderate symptoms 10 % remain unchanged  Good prognosis is predicted by : - rapid onset of the symptoms - short duration of the symptoms - good premorbi functioning - strong social supports - absence of other psychiatric, medical or substance – related disorders

Course and prognosis  The very young and very old have more difficulty with traumatic events than do these in midlife  PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and difficult to treat  Social support influence the development, severity and duration of PTSD

Treatment  Psychotherapy  Pharmacotherapy

Psychotherapy  Psychodynamic psychotherapy  Cognitive – behavior therapy  Group therapy  Family therapy

pharmacotherapy  SSRIs : Sertraline and Paroxetine  Buspirone  TCA: Impramine, Amitriptyline  Some studies indicate that pharmacotherapy is more effective in treating the depression, anxiety and hyperarousal than in treating the avoidance and emotional numbing  Other drugs ; MAOIs ( Phenelzine ), Trazodone, Anticonvalsants, (carbamazapine, valpoarate ), clonidine, propranolol

Recommendation  Strongly recommend selective serotonin reuptake inhibitors (SSRIs) as first line agents for the treatment of PTSD.  Recommend tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as second-line treatments for PTSD.  Consider an antidepressant therapeutic trial of at least 12 weeks before changing therapeutic regimen.

Recommendation  Consider prazosin to augment the management of nightmares and other symptoms of PTSD.  Recommend medication compliance assessment at each visit.  Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely; however it is recommended that maintenance treatment should be periodically reassessed

GroupNameGlobal imp. Reexp.Avoid.Hypera rousal SSRI Fluoxe tine **** Sertrali ne *** Paroxe tine **** TCAs** MAOIs***

GroupNameGlobal imp. Reexp.Avoid.Hypera rousal Sympa tholytic ** Prazosi n * Propran olol Novel Antidep. Trazod. *** Nefaz.***

GroupNameGlobal imp. Reexp.Avoid.Hypera rousal Antico nvul. CBZ** Valpro.* BDZ** Atyp.a ntipsy. **

Special considerations on sep  3500 deaths and injuries  45% of adults reported symptoms of stress, such as distressing recollections of the event, insomnia, nightmare,…  90% reported minor degrees of symptoms  Susceptibility to symptoms was associated with : female, nonwhite, having previous psychological illness, being close to disaster site

Special considerations on sep  Over 80 % of parents reported that their children had one or more symptoms  Survey of Manhattan residents conducted 5 to 8 weeks after the world trade center collapsed: - 9.8% (90000 ) people had PTSD or clinical depression - 3.7% ( ) people met the criteria for both diagnosis