PTSD

PTSDPost- traumatic

Stress

Disorder

Post-traumatic stress disorder (PTSD) Post traumatic stress disorder is a mental disorder in which an individual's normal response to fear is

changed. When a person without this disorder is faced with a frightening situation, a “fight-or-flight” response normally occurs in the body. This response causes the reactions that many associate with being afraid or stressed including an increased heart rate and a hyper-awareness of one's surroundings. This response occurs so that one would be able to fight or run away from the stimulus that originally caused this response. However, when individuals have post-traumatic stress disorder, this fight or flight response happens even when the individuals are not actually in danger (Post-Traumatic Stress Disorder (PTSD)). It as if the switch that “turns on” this response is broken, turning on the stress response even when it is not needed.

Mental Health After Traumatic Events and Violence; UCMUN 2014 World Health Organization

It is a problem in which the human brain continues to react with nervousness after the horrific trauma even though the original trauma is over. Brain can react by staying in "overdrive" and being hyperalert in preparation for the next possible trauma. Sometimes the brain continues to "remember" the trauma by having "flashbacks" about the event or nightmares even though the trauma was in the past.

As an effect of psychological trauma, PTSD is less frequent but more enduring than the more commonly seen acute stress response. Post-traumatic Stress Disorder (PTSD) is a persistent and sometimes crippling condition and develops in a significant proportion of individuals exposed to trauma, and untreated, can continue for years. Its symptoms can affect every life domain – physiological, psychological, occupational, and social

Post-traumatic stress disorder (PTSD) is a severe and complex disorder precipitated by exposure to a psychologically distressing event.

• It is an Anxiety disorder characterized by aversive anxiety-related experiences, behaviors, and physiological responses that develop after exposure to a psychologically traumatic event (sometimes months after).

• Its features persist for longer than 30 days, which distinguishes it from the briefer acute stress disorder. • These persisting posttraumatic stress symptoms cause significant disruptions in one or more important areas of

life function.

It has three sub-forms: – Acute: onset of symptoms < 1 month after the traumatic event– Chronic: onset of symptoms < 1-3 months after the traumatic event– Delayed-onset: onset of symptoms < more than 3 months after the traumatic event

Triggered by trauma • Any traumatic event i.e. such as “mugging, rape, torture, being kidnapped or held captive, child abuse, car

accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes” can trigger the disease (Post-Traumatic Stress Disorder (PTSD)).

• Chance of developing PTSD after trauma : 8%• No direct experience of the event necessary

Mental Health After Traumatic Events and Violence; UCMUN 2014 World Health Organization

Post-traumatic stress disorder (PTSD)

First introduced into the diagnostic and statistical manual of mental disorders (DSM) in 1980

One of the few DSM diagnoses to have a recognizable etiologic agent, in that it must develop in direct response to a severe (sudden, terrifying, or shocking) life event (American Psychiatric Association 2000)

Since the introduction of PTSD into DSM-III (American Psychiatric Association 1980), the disorder has been documented in children exposed to traumas such as domestic violence, natural disasters, medical trauma (such as hospitalization or medical procedures performed on children), war, terrorism, and community violence

DSM-IV-TR Criteria for PTSD

DSM-IV-TR Criteria for PTSD

• A:The person has been exposed to a traumatic event in which both of the following were present:– (1) 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.

– (2) 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:– (3) 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.

– (4) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

– (5) 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 on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

– (6) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

– (7) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

DSM-IV-TR Criteria for PTSD• C:Persistent avoidance of stimuli associated with the trauma and numbing of

general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

– (8) Efforts to avoid thoughts, feelings, or conversations associated with the trauma– (9) Efforts to avoid activities, places, or people that arouse recollections of the trauma– (10) Inability to recall an important aspect of the trauma– (11) Markedly diminished interest or participation in significant activities– (12) Feeling of detachment or estrangement from others– (13) Restricted range of affect (e.g., unable to have loving feelings)– (14) Sense of a foreshortened future (e.g., does not expect to have a career, marriage,

children, or a normal lifespan)

• D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (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

• Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

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

• Acute: if duration of symptoms is less than 3 months• Chronic: if duration of symptoms is 3 months or more• Specify if: • With Delayed Onset: if onset of symptoms is at least 6 months

after the stressor.

DSM-IV-TR Criteria for PTSD

The age-standardised disability adjusted life-year (DALY) rates for PTSD

The United Nations' World Health Organization’s estimates of PTSD impact for each of its member states(2004): per 100,000 inhabitants, in 10 most ranking countries

The age-standardised disability adjusted life-year (DALY) rates for PTSD, per 100,000 inhabitants, in 10 most ranking countries

Incidence of psychiatric disorders after disasters in India

Psychiatric morbidity

PTSD Major depression

Generalised anxiety

Panic disorders

1 Latur earthquake (1) 74% 89% 42% 28%

2 Odissa supercyclone(8)

80.4% 44.3% 52.7% 57.5%

3 Tsunami(post tsunami)13

79.7% 1.25%* √√√ √√√

4 Tsunami A and N 3.7%* √√√ √√√ √√√

*Psychological symptoms get taken care of by the informal social mechanism and counselors working with non-governmental organizations (NGO) and that the specialist psychiatric services are required for a smaller proportion of populations D

International research: Factors leading to Vulnerability (1)

• Biological diathesis• Early childhood developmental experiences• Trauma severity.• Proximity to, duration of, and severity of the trauma• Interpersonal traumas • Genetic factors• Women develop PTSD at about twice the rate as men• Prior trauma history/multiple traumas• A premorbid psychiatric history• Fewer support• Limited inter-personal coping skills• Trauma intensity• Personal perception of event as life threatening • Hereditary

Amarendra Narayan Prasad (2012). Post Traumatic Stress Disorder – An Overview, Post Traumatic StressDisorders in a Global Context, Prof. Emilio Ovuga, Md, PhD (Ed.), ISBN: 978-953-307-825-0, InTech, Availablefrom: http://www.intechopen.com/books/post-traumatic-stress-disorders-in-a-global-context/post-traumaticstress-disorder-an-overview

• Demographic factors: – Females vs males,– older age

• Biological factors: – Moderate hereditary factors / though no single gene identified.

• Psychological factors and psychiatric symptoms: – certain personality traits , such as neuroticism and introversion,

• Post-trauma social resource factors: – inadequate social support – economic or marital issues – disruption of one’s daily life- relocation the death of an intimate partner, or other

significant loss problems

Frank Huang-Chih Chou and Chao-Yueh Su (2012). Risk Factors and Hypothesis for Posttraumatic Stress Disorder (PTSD) in Post Disaster Survivors, Post Traumatic Stress Disorders in a Global Context, Prof. Emilio Ovuga, Md, PhD (Ed.), ISBN: 978-953-307-825-0, InTech, Available from: http://www.intechopen.com/books/post-traumatic-stress-disorders-in-a-global-context/risk-factors-andhypothesis-for-posttraumatic-stress-disorder-ptsd-in-post-disaster-survivors

International research: Factors leading to Vulnerability (2)

Pre trauma factors

Trauma and post trauma factors

Trauma severity

Lack of social support

Additional life stress

Psychiatric illness (PTSD)

Hypothesis for PTSDHobfoll’s conservation of resources (COR) model

deprivation of internal or external

resources

According to Hobfoll’s conservation of resources theory, resource loss is an important determinant of individual stress and physical and mental health, including PTSD.

When faced with stress, frustration (e.g., life events), or traumatic events (e.g., brain damage or deprivation of internal or external resources) individuals, either suddenly or gradually, become more vulnerable to psychiatric impairment and diseases such as PTSD .An individual might reach a sub-threshold of PTSD and then develop the illness due to a decreased availability of resources, an accumulation of risk factors (personality traits, poor social interactions, etc.) or a major stressful event. Furthermore, unresolved, subclinical psychiatric symptoms caused by a disaster may increase a survivor’s sensitivity to future stresses.

Frank Huang-Chih Chou and Chao-Yueh Su (2012). Risk Factors and Hypothesis for Posttraumatic Stress Disorder (PTSD) in Post Disaster Survivors, Post Traumatic Stress Disorders in a Global Context, Prof. Emilio Ovuga, Md, PhD (Ed.), ISBN: 978-953-307-825-0, InTech, Available from: http://www.intechopen.com/books/post-traumatic-stress-disorders-in-a-global-context/risk-factors-andhypothesis-for-posttraumatic-stress-disorder-ptsd-in-post-disaster-survivors

WHO: factors for PTSD

Negative factors• History of mental illness• Become physical harmed • See others physically harmed• Experience ongoing stress

after the traumatic event.

Positive factors

• Social support system• Have a coping strategy to

deal with the after effects of the trauma

Topic B Mental health after traumatic events and violence UCMUN 2014 World Health Organization

Meta-analysis for strengths of risk factors for PTSD

Factors

1. Gender

2. Age at trauma

3. Socioeconomic status (SES)

4. Education

5. Intelligence

6. Race

7. Previous psychiatric history

8. Reported abuse in childhood

9. Reports of other previous traumatization

10. Reports of other adverse childhood factors (excluding abuse)

11. Family history of psychiatric disorder

12. Trauma severity,

13. Post-trauma life stress,

14. And post-trauma social support.

Chris Brewin, Bernice Andrews, John Valentine; Meta-analysis of risk factors for post traumatic stress disorders in trauma exposed adults; Journal of Consulting and clinical psychology 2000, vol. 68, no 5, 748-766

Research on factors affecting PTSD since 1980 were studied. After a rigorous selection based on design, sampling and measurement , 77 original research on PTSD were studied. Meta-analyses were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the moderating effects of various sample and study characteristics, including civilian/military status, were examined

Risk factor No. Of Studies Population Size Weighted Average

Gender (female) 25 11,261 0.13

Younger age 29 7,207 0.06

Low SES 18 5,957 0.14

Lack of education 29 11,047 0.1

Low intelligence 6 1,149 0.18

Race (minority status) 22 8,165 0.05

Psychiatric history 22 7,307 0.11

Childhood abuse 9 1,746 0.14

Other previous trauma 14 5,147 0.12

Other adverse childhood 14 6,969 0.19Family psychiatric history 11 4,792 0.13

Trauma severity 49 13,653 0.23

Lack of social support 11 3,276 0.4

Life stress 8 2,804 0.32

Meta-analysis for strengths of risk factors for PTSD: Summary of risk factors predicting PTSD

Trauma and post trauma events• Trauma severity• Social support• Subsequent life stress

Demographic variable• Female gender• Low SES• Less education• Lower Intelligence

Prior history variable • Positive psychiatric history• Reported history of abuse• Other trauma• Childhood adversity• Family psychiatric history

Younger age of trauma

Race(minority status)

Convey the strongest risk of PTSD, with effect sizes that are individually small to moderate

Individual effectsizes are generally regarded as small

Effect sizes are weaker still, but highly significant because of the large numbers involved.

Meta-analysis for strengths of risk factors for PTSD

Chris Brewin, Bernice Andrews, John Valentine; Meta-analysis of risk factors for post traumatic stress disorders in trauma exposed adults; Journal of Consulting and clinical psychology 2000, vol. 68, no 5, 748-766

• Gender , age , race : predict PTSD in some populations not others

• Education, previous trauma, general childhood adversity-predict PTSD more consistently but varyingly according to populations studied

• Psychiatric history, reported childhood abuse, family psychiatric history –more uniform predictive effects

• All the factors had only a modest effect but trauma and post trauma factors had stronger effects compared to pretrauma factors

Meta-analysis for strengths of risk factors for PTSD

Chris Brewin, Bernice Andrews, John Valentine; Meta-analysis of risk factors for post traumatic stress disorders in trauma exposed adults; Journal of Consulting and clinical psychology 2000, vol. 68, no 5, 748-766

Indian research on factors affecting PTSD(1)

• Trauma factors: Moderate increase in psychiatric morbidity was observed in medium term in the disaster affected group which for most part had subsided by the follow-up stage five years post-disaster.

• Socio-demographic factors: as measures of distress and recovery of the affected community.

• Early phase: importance of primary exposure variables in genesis of morbidity

• Late phases: while the secondary and mediating factors (life events and social support)

Indian Council of Medical Research: Centre for Advanced Research on health consequences of earthquake disaster with special reference to mental health at the Maharashtra Institute of Mental Health, Pune.

Indian research on factors affecting PTSD(2)

Negative factors • Women versus men: 6.35 times higher risk (when adjusted for other variables)• Residents of urban versus rural• Areas of maximum destruction• Effect of all the protective factors against PTSD was low for the residents of urban

area as compared to those in the rural area. • This reminds that disasters impact whole communities, not selected individuals.• Low SES had significant risk of PTSD• Death of a relative and injury to self or family members were significantly associated

with PTSD

Protective factors • Absence of fear of recurrence of tsunami• Counseling received more than three times• Satisfaction of services received

Risk factors of post-traumatic stress disorder in tsunami survivors of Kanyakumari District, Tamil Nadu, IndiaT. T. Pyari, Raman V. Kutty,1 and P. S. Sarma Indian J Psychiatry. 2012 Jan-Mar; 54(1): 48–53. doi:  10.4103/0019-5545.94645 ,PMCID: PMC3339219

Indian research on factors affecting PTSD (3)

Co morbidity was found in 39.0% of adolescents with a psychiatric diagnosis

• Middle socioeconomic status• Gender differences in the presentation of the symptoms• Prolonged periods of helplessness• Lack of adequate post-disaster psychological support• Severity of the disaster.

Research Open AccessPost-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: a study of Comorbidity Nilamadhab Kar*1 and Binaya Kumar Bastia2 Published: 26 July 2006 Clinical Practice and Epidemiology in Mental Health 2006, 2:17 doi:10.1186/1745-0179-2-17This article is available from: http://www.cpementalhealth.com/content/2/1/17

Risk of posttraumatic stress disorder and depression in survivors of the floods in Bihar, IndiaShirley Telles, Nilkamal Singh, Meesha Joshi Indian Journal of Medical Sciences Year : 2009  |  Volume : 63  |  Issue : 8  |  Page : 330--334

Risk of PTSD higher in people above the age of 60 years

Children and PTSD (Medscape)

Negative factors • Previous exposure to traumatic incidents • Repeated trauma -• Personal threat• Developmental state Older age more at risk • Type of trauma – abuse worse than disaster/accident • Relationship with Trauma perpetuator • Trauma caused by a person rather than resulting from an accident is more likely to lead to PTSD;

in particular, • Guilt• A preexisting psychiatric disorder • Symptoms at the time of the abuse • Physiologic response - Children who have an elevated heart rate in the period soon after the

trauma (eg, those seen in an emergency department [ED]) are more likely to develop PTSD

Positive factors • Parental support • Extra familial support • Resilience

Sex difference in pathways to PTSD

• Males and females differ in their expression of PTSD symptomatology- thus they may respond differently to treatment.

• Sex differences in the risk and protective factors associated with the development and maintenance of PTSD may still result in sex differences in treatment outcome.

• Finally, males and females may differ in how comfortable they feel in different treatment settings and with different treatment paradigms.

• It has been suggested that gender socialisation plays a role in the treatment of PTSD, and that males express less affect and are more cognitively oriented in therapy than females (Cason et al., 2002).

• It could be argued that such behaviour represents problem-focused coping and is consistent with activation of the fight-or-flight system. Based on the idea that different pathways lead to PTSD in males and females, and that different risk factors may thus be important for the development of PTSD in the two sexes as illustrated in Figure 1, it might be expected that females will benefit more from therapy, which aims to reduce levels of dissociation and increase levels of social support. In contrast,a therapeutic approach, which aims to reduce physiological arousal and dampen anxiety may be more beneficial to males

Sex difference in pathways to PTSD

Diagnosis and management algorithm for PTSD

Prevention and treatment

• Psychiatric ‘First Aid’ • Psychological First Aid

Treatment strategies

• Psychosocial treatment strategies– Prolonged Exposure (PE)– Cognitive Processing Therapy (CPT)– Stress Inoculation Training (SIT)– Eye Movement Desensitization and Reprocessing (EMDR)

• Pharmacotherapy of adult PTSD– Antidepressants: SSRIs (selective serotonin reuptake inhibitors), Atypical

Antidepressants

– Anticonvulsants– Mood stabilizers– Major tranquilizers and – Anti-psychotic medications– Beta blockers (Propranolol)

General treatment components in children

• Initial stages:– Establishing rapport with the child and caregiver(s)– Providing a rationale for treatment.

1st line: Trauma-focused cognitive-behavioral treatment (CBT) to resolve PTSD

• Teaching stress management techniques• Relaxation techniques• Cognitive coping techniques• Direct exploration/discussion of the traumatic experience• Exploring and correcting inaccuate attributions

Pharmacotherapy

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