POST TRAUMATIC POST TRAUMATIC STRESS DISORDER: STRESS DISORDER:

Lest We ForgetLest We Forget

McMaster Mini Med SchoolMcMaster Mini Med School

March 24, 2009March 24, 2009

Jon Davine, MD, CCFP, FRCP(C)Jon Davine, MD, CCFP, FRCP(C)

Associate Professor, McMaster UniversityAssociate Professor, McMaster University

PTSDPTSD

• ““Invented” 1980 in DSMInvented” 1980 in DSM

• Started with Vietnam war vetsStarted with Vietnam war vets

• Quintesential environmental disease, as Quintesential environmental disease, as must have environmental stressmust have environmental stress

POST TRAUMATICPOST TRAUMATIC STRESS DISORDER (PTSD) STRESS DISORDER (PTSD)

• The person has been exposed to a The person has been exposed to a traumatic event in which both of the traumatic event in which both of the following were present:following were present:– the person experienced, witnessed or was the person experienced, witnessed or was

confronted with an event or events that involved confronted with an event or events that involved actual or threatened death or serious injury, or a actual or threatened death or serious injury, or a threat to the physical integrity of self or othersthreat to the physical integrity of self or others

– the person’s response involved intense fear, the person’s response involved intense fear, helplessness, or horror.helplessness, or horror.

POST TRAUMATICPOST TRAUMATICSTRESS DISORDER – STRESS DISORDER –

RE-EXPERIENCINGRE-EXPERIENCING• The traumatic event is persistently reexperienced in The traumatic event is persistently reexperienced in

one or more of the following ways:one or more of the following ways:– recurrent and intrusive distressing recollections of recurrent and intrusive distressing recollections of

the event, including images, thoughts or the event, including images, thoughts or perceptions perceptions (recurring thoughts).(recurring thoughts).

– recurrent distressing dreams of the event recurrent distressing dreams of the event (nightmares).(nightmares).

– acting or feeling as if the traumatic event were acting or feeling as if the traumatic event were recurring (includes a sense of reliving the recurring (includes a sense of reliving the experience, illusions experience, illusions (flashbacks).(flashbacks).

POST TRAUMATICPOST TRAUMATICSTRESS DISORDER - STRESS DISORDER - TRIGGERSTRIGGERS

– Intense psychological distress at exposure Intense psychological distress at exposure to cues that symbolize or resemble an to cues that symbolize or resemble an aspect of the traumatic event.aspect of the traumatic event.

– Physiological reactivity on exposure to Physiological reactivity on exposure to cues that symbolize or resemble as aspect cues that symbolize or resemble as aspect of the traumatic event.of the traumatic event.

– Can become a panic attack.Can become a panic attack.– e.g., very upset if hears the squeal of e.g., very upset if hears the squeal of

brakes.brakes.

POST TRAUMATICPOST TRAUMATICSTRESS DISORDER - STRESS DISORDER - AVOIDANCEAVOIDANCE

• Persistent avoidance of stimuli associated Persistent avoidance of stimuli associated with the trauma:with the trauma:– Efforts to avoid thoughts, feelings or Efforts to avoid thoughts, feelings or

conversations associated with the traumaconversations associated with the trauma– Efforts to avoid activities, places or people that Efforts to avoid activities, places or people that

arouse recollections of the traumaarouse recollections of the trauma– Inability to recall an important aspect of the Inability to recall an important aspect of the

trauma trauma – e.g., avoid drivinge.g., avoid driving

POST TRAUMATIC POST TRAUMATIC STRESS DISORDER - AROUSALSTRESS DISORDER - AROUSAL

• Persistent symptoms of increased arousal Persistent symptoms of increased arousal (not present before the trauma), as (not present before the trauma), as indicated by two (or more) of the following:indicated by two (or more) of the following:– difficulty falling or staying asleepdifficulty falling or staying asleep– irritability or outbursts of angerirritability or outbursts of anger– difficulty concentratingdifficulty concentrating– hypervigilancehypervigilance– exaggerated startle responseexaggerated startle response

POST TRAUMATICPOST TRAUMATICSTRESS DISORDERSTRESS DISORDER

• duration of the disturbance is more than duration of the disturbance is more than one monthone month

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

TTRAUMATIC EVENTRAUMATIC EVENT

RRE-EXPERIENCEE-EXPERIENCE

AAVOIDANCE/NUMBINGVOIDANCE/NUMBING

UUNABLE TO FUNCTIONNABLE TO FUNCTION

MMONTHONTH

AAROUSAL (HYPERAROUSAL)ROUSAL (HYPERAROUSAL)

POST TRAUMATICPOST TRAUMATICSTRESS DISORDERSTRESS DISORDER

• Specify if:Specify if:– Acute:Acute: if duration of symptoms is less than three if duration of symptoms is less than three

monthsmonths– ChronicChronic: if duration of symptoms is three months : if duration of symptoms is three months

or moreor more• Specify if:Specify if:

– with delayed onset: if onset of symptoms is at with delayed onset: if onset of symptoms is at least six months after the stressor.least six months after the stressor.

– Can happen with sexual abuse.Can happen with sexual abuse.

PTSD: Subtype SpecifiersPTSD: Subtype Specifiers

Time from Trauma (months)Time from Trauma (months)

11 33 66

PT

SD

P

TS

D S

ym

pto

ms

Sy

mp

tom

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AcuteAcuteStressStress

DisorderDisorder

AcuteAcutePTSD PTSD

(< 3 months)(< 3 months)

Chronic PTSD (> 3 months)Chronic PTSD (> 3 months)

DelayedDelayedOnsetOnsetPTSDPTSD

SCREENING QUESTIONSSCREENING QUESTIONS

Thus, in screening for PTSD, ask:Thus, in screening for PTSD, ask:• Do you keep re-experiencing the event? Do you keep re-experiencing the event?

NightmaresNightmares

Flashbacks (“daymares”)Flashbacks (“daymares”)– Can be like hallucinationsCan be like hallucinations

Can’t stop thinking about it.Can’t stop thinking about it.– Can look like obsessionCan look like obsession

• Do things that remind you of the event bring out a huge Do things that remind you of the event bring out a huge response?response?– Can look like panic attacksCan look like panic attacks

SCREENING QUESTIONSSCREENING QUESTIONS

• Do you avoid things that remind you of the event?Do you avoid things that remind you of the event?

• Are you personally more anxious since the event?Are you personally more anxious since the event?– ?decreased sleep, concentration?decreased sleep, concentration– more irritablemore irritable– startle easilystartle easily

• Has it gotten in the way of your life?Has it gotten in the way of your life?

Psychiatric Comorbidity Psychiatric Comorbidity (lifetime)(lifetime)

PTSDPTSD

Major DepressionMajor Depression48.2%48.2%

AgoraphobiaAgoraphobia19.25%19.25%

Social PhobiaSocial Phobia29.9%29.9%

Alcohol Alcohol Abuse / DependenceAbuse / Dependence

39.9%39.9%

PanicPanic9.9%9.9%

Kessler et al, Arch Gen Psychiatry 1995

GADGAD15.9%15.9%

• Breslan et al ‘91Breslan et al ‘91– 9.2%9.2%

• National Comorbidity Survey ‘91 (NCS)National Comorbidity Survey ‘91 (NCS)– 8.7%8.7%– 5-6% males5-6% males– 10-14% females10-14% females

• Detroit Area Survey of Trauma ‘96Detroit Area Survey of Trauma ‘96– 14%14%– 10% males10% males– 18% females18% females

LIFETIME PREVALENCE OF LIFETIME PREVALENCE OF PTSD APPROXIMATELY 10%PTSD APPROXIMATELY 10%

EXPOSURE TO TRAUMATIC EXPOSURE TO TRAUMATIC EVENTSEVENTS

• Lifetime exposure to traumatic eventsLifetime exposure to traumatic events– 40-69%. Only 10% get PTSD40-69%. Only 10% get PTSD

• Higher in males/femalesHigher in males/females

1.2 : 11.2 : 1

EXPOSURE TO TRAUMAEXPOSURE TO TRAUMA• Trauma typeTrauma type NCS NCS

Male FemaleMale Female

RapeRape 0.70.7 9.29.2

Sexual AssaultSexual Assault 2.82.8 12.312.3

CombatCombat 6.46.4 0.00.0

Witnessing ViolenceWitnessing Violence 35.635.6 14.514.5

AccidentsAccidents 25.025.0 13.813.8

Car AccidentsCar Accidents 32.832.8 23.523.5

Threatened with a weaponThreatened with a weapon 19.019.0 6.86.8

Physical attackPhysical attack 11.111.1 6.96.9

Natural DisasterNatural Disaster 18.918.9 15.215.2

Learning about trauma to othersLearning about trauma to others 63.163.1 61.861.8

Sudden unexpected deathSudden unexpected death 61.161.1 59.059.0

TRAUMATRAUMA

• Extended from war, earthquakes, Extended from war, earthquakes, assaultsassaults

• MVA’s; grief; workplace incidentsMVA’s; grief; workplace incidents

• Legitimate cause for disabilityLegitimate cause for disability

CONDITIONAL RISKCONDITIONAL RISK OF PTSD OF PTSD

• 9% all trauma9% all trauma

• Females > males 2:1 (adjusted for Females > males 2:1 (adjusted for trauma type)trauma type)

CONDITIONAL RISKCONDITIONAL RISK FOR PTSD FOR PTSD

Trauma TypeTrauma Type %PTSD%PTSD Assaultive violenceAssaultive violence 20.920.9RapedRaped 49.049.0Shot or stabbedShot or stabbed 15.415.4Badly beaten upBadly beaten up 31.931.9Serious car accidentSerious car accident 6.16.1Learning about traumaLearning about trauma to othersto others 0.20.2Sudden unexpected deathSudden unexpected death of a close friend or relative of a close friend or relative 14.314.3Any traumaAny trauma 9.29.2

CONDITIONAL RISKCONDITIONAL RISK FOR PTSD FOR PTSD

Females MalesFemales Males

MolestationMolestation 26.5 vs26.5 vs 12.212.2

Threatened withThreatened with

a weapona weapon 32.632.6 vs vs 1.91.9

Assaultive ViolenceAssaultive Violence 35.735.7 vs vs 6.06.0

Risk Factors for PTSD Risk Factors for PTSD DevelopmentDevelopment

Peri-Peri-TraumaTrauma

PTSD

Post-Post-TraumaTrauma

Pre-Pre-TraumaTrauma

Pre-Trauma Risk FactorsPre-Trauma Risk Factors

• Female genderFemale gender

• Previous trauma / younger age at time Previous trauma / younger age at time of traumaof trauma

• Childhood abuseChildhood abuse

• Trait neuroticism / poor coping styleTrait neuroticism / poor coping style

Brewin et al, J Consult Clin Psychol 2000

Peri-Traumatic Risk Factors Peri-Traumatic Risk Factors Influencing PTSDInfluencing PTSD

• Nature of trauma (personal assault)Nature of trauma (personal assault)

• Severity of trauma / chronicity of traumaSeverity of trauma / chronicity of trauma

Brewin et al, J Consult Clin Psychol 2000

Post-Trauma Risk FactorsPost-Trauma Risk Factors

• Lack of social support Lack of social support

• Lack of appropriate early treatment or Lack of appropriate early treatment or access access to servicesto services

Yehuda et al, Biol Psychiatry1998

LONGITUDINAL COURSELONGITUDINAL COURSE

• 53% recovered at three months.53% recovered at three months.

• 58% recovered at nine months.58% recovered at nine months.

• 15-25% unrecovered after years. I 15-25% unrecovered after years. I often see this with people from war often see this with people from war zones.zones.

Longitudinal Course of Longitudinal Course of PTSD SymptomsPTSD Symptoms

3 months3 months 9 months9 months

15-25%15-25%

58% recovered58% recovered

53% recovered53% recovered

WeeksWeeks

6% recovered6% recovered

YEARSYEARS

UNRECOVEREDUNRECOVERED

Shalev & Yehuda, Psychological Trauma 1998

NEUROBIOLOGYNEUROBIOLOGY

– Studies have shown decreased size of the Studies have shown decreased size of the hippocampus in brain studies.hippocampus in brain studies.

– ““Seat of Memory”Seat of Memory”– Different pathwaysDifferent pathways– ““Sabretooth Tiger” example re evolutionary Sabretooth Tiger” example re evolutionary

advantage, but now…..advantage, but now…..

PTSD Treatment Options PTSD Treatment Options

PharmacologicalPharmacological

SSRIsSSRIsNSRINSRI

PsychosocialPsychosocialCBT (exposure)CBT (exposure)

Anxiety managementAnxiety management

PsychoeducationPsychoeducation

EMDR EMDR (controversial)(controversial)

CONTROVERSYCONTROVERSY

• mustmust you re-explore the trauma --NO you re-explore the trauma --NO

• whenwhen is the most appropriate timing-- is the most appropriate timing--WHEN THE PATIENT IS READYWHEN THE PATIENT IS READY

– Normal to be upset and have symptomsNormal to be upset and have symptoms– PTSD symptoms does not mean “going PTSD symptoms does not mean “going

crazy”crazy”– provide client with corrective information provide client with corrective information

(psychoeducation)(psychoeducation)– It’s very common (10%)It’s very common (10%)– Treatment can helpTreatment can help

CBT - CBT - Psychoeducation/Supportive Psychoeducation/Supportive

CounsellingCounselling

• This is healing. It gets rid of the power of the This is healing. It gets rid of the power of the eventevent

• Literally, talking about the very thing you’d Literally, talking about the very thing you’d rather not talk aboutrather not talk about

• This is the hallmark of therapyThis is the hallmark of therapy

CBT-Imaginal Exposure, a CBT-Imaginal Exposure, a Behavioural TreatmentBehavioural Treatment

CBT- In-Vivo Exposure CBT- In-Vivo Exposure TherapyTherapy

• Behavioural homeworks involve Behavioural homeworks involve exposure to avoided activitiesexposure to avoided activities

• Usually done as hierarchyUsually done as hierarchy

• Can pair it with muscle relaxationCan pair it with muscle relaxation

• Must stay in the activity until calm. Don’t Must stay in the activity until calm. Don’t stop activity while still anxiousstop activity while still anxious

• E.g. driving a car after an accidentE.g. driving a car after an accident

COGNITIVE THERAPYCOGNITIVE THERAPY

• Challenge automatic thoughts with Challenge automatic thoughts with evidence for and againstevidence for and against

• Re-formulate to more realistic onesRe-formulate to more realistic ones

• e.g. all men will assault mee.g. all men will assault me

• e.g. I will always have an accidente.g. I will always have an accident

CAUTION!!CAUTION!!

• I tell people talking about the difficult I tell people talking about the difficult event is healing…..as long as they feel event is healing…..as long as they feel ready to do itready to do it

• If they feel it’s too much, I say “wait until If they feel it’s too much, I say “wait until you feel ready, and then we’ll do it”you feel ready, and then we’ll do it”

ANXIETY MANAGEMENT ANXIETY MANAGEMENT TRAININGTRAINING

Give client skills to handle anxiety:Give client skills to handle anxiety:

– e.g. relaxation training, deep muscle e.g. relaxation training, deep muscle

– breathing retrainingbreathing retraining

Recommendation for Recommendation for Pharmacotherapy Pharmacotherapy

for PTSDfor PTSDFirst-lineFirst-line

Fluoxetine, paroxetine, sertraline, venlafaxine Fluoxetine, paroxetine, sertraline, venlafaxine XR, (SSRI’s, NSRI)XR, (SSRI’s, NSRI)

Second-lineSecond-line

Fluoxamine, mirtazapine, moclobemide, Fluoxamine, mirtazapine, moclobemide, phenelzinephenelzine

Adjunctive: resperidone, olanzapineAdjunctive: resperidone, olanzapine

EXAMPLE: SEXUAL ABUSEEXAMPLE: SEXUAL ABUSE• ask regarding nightmares, flashbacks, avoidance, ask regarding nightmares, flashbacks, avoidance,

triggers, moodtriggers, mood• ““not your fault”, “metaphorically bound and gagged”not your fault”, “metaphorically bound and gagged”• ““if there’s anything I ask you that you would rather if there’s anything I ask you that you would rather

not answer, you don’t ...”not answer, you don’t ...”• support. Validate feelings e.g. anger, hatredsupport. Validate feelings e.g. anger, hatred• normalize issue of self esteem, trust, intimacy, normalize issue of self esteem, trust, intimacy,

sexualitysexuality• pressure cooker analogypressure cooker analogy