Posttraumatic stress disorder (PTSD) is caused by exposure to traumatic events that cause intense fear, horror, or helplessness. Symptoms include re-experiencing the event, avoidance of trauma reminders, and hyperarousal. To be diagnosed, symptoms must last over a month and impair functioning. Common causes include war, assault, accidents, and natural disasters. Treatment involves psychotherapy such as exposure therapy and medication like SSRIs. PTSD significantly impacts individuals and society.

2.  Posttraumatic stress disorder (PTSD) is a condition
marked by the development of symptoms after
exposure to traumatic life events.
 The person reacts to this experience with fear and
helplessness and tries to avoid being reminded of the
events.
 Children who are behaviorally inhibited may be
especially susceptible to anxiety or PTSD after
threatening events.

3.  To make the diagnosis
 the symptoms must last for more than a month after the
event and
 must significantly affect important areas of life, such as
family and work.
 DSM-IV-TR defines a disorder that is similar to PTSD
called acute stress disorder, which occurs earlier than
PTSD (within 4 weeks of the event) and remits within 2
days to 4 weeks.
 If symptoms persist then PTSD is warranted.

4.  They can arise from experiences in war, torture,
natural catastrophes, assault, rape, and serious
accidents, for example, in cars and in burning
buildings.
 Persons re-experience the traumatic event in their
dreams and their daily thoughts.
 to evade anything that would bring the event to mind,
they undergo a numbing of responsiveness along
with a state of hyperarousal.
 Other symptoms: depression, anxiety, and cognitive
difficulties, such as poor concentration.

6. History
 Soldier’s heart• was the name given during the US
Civil War to a syndrome similar to PTSD.
 Jacob DaCosta's 1871 paper, Irritable Heart, described
soldiers with the syndrome. In the 1900s, the influence
of psychoanalysis was strong, particularly in the
United States, and clinicians applied the diagnosis of
traumatic neurosis to the condition.

7.  In World War I, the syndrome was called shell shock
and was hypothesized to result from brain trauma
caused by exploding shells.
 Psychiatric morbidity associated with Vietnam War
finally brought the concept of PTSD.

9. Epidemiology
 The lifetime incidence about 9 to 15 percent,
 the lifetime prevalence about 8 percent ,
 subclinical forms of the disorder 5 to 15 percent.
 it is most prevalent in young adults, because they tend
be more exposed to precipitating situations.
 Men and women differ in the types of traumas to which
they are exposed and their liability to develop PTSD.

10.  Men's trauma was usually combat experience, and
women's trauma was most commonly assault or rape.
 The disorder is most likely to occur in those who are
single, divorced, widowed, socially withdrawn, or
of low socioeconomic level.
 The most important risk factors, however, for this
disorder are the severity, duration, and proximity of
a person's exposure to the actual trauma.

11. Comorbidity
 Comorbidity rates are high among patients with PTSD
with about two thirds having at least two other
disorders.
 Common comorbid conditions include depressive
disorders, substance-related disorders, other
anxiety disorders, and bipolar disorders.
 Comorbid disorders make persons more vulnerable to
developing PTSD.

12. Etiology
 Stressor
 Risk factors
 Psychodynamic factors
 Cognitive behavioral factors
 Biological factors
 Corticotropin-Releasing factor and HPA axis

13. Stressor
 prime causative factor in the development of PTSD.
 The response to the traumatic event must involve
intense fear or horror.
 Clinicians must also consider individual preexisting
biological and psychosocial factors and events that
happened before and after the trauma.
 For example, a member of a group who lived through a
disaster can sometimes deal with trauma because
others shared the experience.

14. Risk Factors

15. Psychodynamic Factors
 Trauma has reactivated a previously quiescent, yet
unresolved psychological conflict.
 According to Freud, a splitting of consciousness occurs
in patients who reported a history of childhood sexual
trauma.
 A preexisting conflict might be symbolically
reawakened by the new traumatic event.

16. Cognitive-Behavioral Factors
 The cognitive model of PTSD posits that affected persons cannot
process or rationalize the trauma that precipitated the disorder.
 They attempt to avoid experiencing it by avoidance techniques.
 Persons experience alternating periods of acknowledging and blocking
the event.
 The behavioral model of PTSD emphasizes two phases in its
development.
1) The trauma (the unconditioned stimulus)
 produces a fear response is paired, through classic conditioning, with a
conditioned stimulus.
2) through instrumental learning, the conditioned stimuli elicit the
fear response independent of the original unconditioned stimulus,
and persons develop a pattern of avoiding both the conditioned
stimulus and the unconditioned stimulus.
 Some persons also receive secondary gains from the external world,
commonly monetary compensation, increased attention or sympathy,
and the satisfaction of dependency needs. These gains reinforce the
disorder and its persistence.

17. Biological Factors
 Preclinical models in animals have led to theories
about norepinephrine, dopamine, endogenous
opioids, and benzodiazepine receptors and the
hypothalamic-pituitary-adrenal (HPA) axis.
 In clinical populations, data have supported
hypotheses that the noradrenergic and endogenous
opiate systems, as well as the HPA axis, are hyperactive
in at least some patients with PTSD.
 Other major biological findings are increased activity
and responsiveness of the autonomic nervous system.

18. Noradrenergic System
 Soldiers with PTSD-like symptoms exhibit
nervousness, increased blood pressure and heart
rate, palpitations, sweating, flushing, and tremor-
-symptoms associated with adrenergic drugs.
 Studies found increased 24-hour urine epinephrine
concentrations in veterans with PTSD and increased
urine catecholamine concentrations in sexually abused
girls.

19. Opioid System
 Abnormality in the opioid system is suggested by low
plasma B-endorphin concentrations in PTSD.
 Combat veterans with PTSD demonstrate a naloxone
(Narcan)-reversible analgesic response to combat-
related stimuli, raising the possibility of opioid system
hyperregulation similar to that in the HPA axis.

20. Corticotropin-Releasing Factor and
the HPA Axis
 Studies have demonstrated low plasma and urinary
free cortisol concentrations in PTSD.
 More glucocorticoid receptors are found on
lymphocytes, and challenge with exogenous
corticotropin-releasing factor (CRF) yields a blunted
ACTH response.
 Some studies have revealed cortisol hypersuppression
in trauma-exposed patients who develop PTSD,
compared with patients exposed to trauma who do not
develop PTSD, indicating that it might be specifically
associated with PTSD and not just trauma.

21. Diagnosis
 The DSM-IV-TR diagnostic criteria for PTSD specify
that the symptoms of experiencing, avoidance, and
hyperarousal must have lasted more than 1 month.
 symptoms present for less than 1 month - acute
stress disorder.
 Acute - If symptoms of PTSD have lasted less than 3
months
 Chronic - if the symptoms have lasted 3 months or
more..

22. CASE EXAMPLE

25. Table 16.5-5 DSM-IV-TR Diagnostic
Criteria for Acute Stress Disorder

26. Clinical Features
 The principal clinical features of PTSD are painful
reexperiencing of the event, a pattern of avoidance and
emotional numbing, and fairly constant hyperarousal.
 Mental status examination reveals feelings of guilt, rejection,
and humiliation.
 Patients may describe dissociative states and panic attacks,
and illusions and hallucinations may be present.
 Associated symptoms : aggression, violence, poor impulse
control, depression, and substance-related disorders.
 Cognitive testing may reveal that patients have impaired
memory and attention.

27. CASE EXAMPLE

28. PTSDs in Children and Adolescents
 Symptoms such as repetitive dreams of the event, nightmares
of monsters, and the development of physical symptoms
such as stomachaches and headaches.
 High rates of PTSD have been documented in children
exposed to such life-threatening events as combat and other
war-related trauma, kidnapping, severe illness or burns, bone
marrow transplantation, and a number of natural and man-
made disasters.

30. Stressor
Stressors in children
may be sudden, single-
incident trauma or
ongoing or chronic
trauma, such as physical
or sexual abuse.
Children also suffer as
the result of indirect
exposure that is, the
unwitnessed death or
injury of a loved one, as
in situations of disaster,
war, or community
violence.

31. Reenactment and Reexperiencing
 “Traumatic play”• - a specific form of reexperiencing seen
in young children, consists of repetitive acting out of the
trauma or trauma-related themes in play.
 Older children may incorporate aspects of the trauma into
their lives in a process termed reenactment.
 Related behaviors in child and adolescent victims of trauma
include sexual acting out, substance use, and delinquency.

32. Gulf War Syndrome
 On the return of American soldiers from the Persian
Gulf War, more than 100,000 US veterans reported a
vast array of health problems, including irritability,
chronic fatigue, shortness of breath, muscle and
joint pain, migraine headaches, digestive
disturbances, rash, hair loss, forgetfulness, and
difficulty concentrating. Collectively, these
symptoms were called the Gulf War syndrome.
 the soldiers may have been exposed to chemical
weapons and disorder may have been precipitated by
exposure to an unidentified toxin.

34.  Physicians need to acknowledge that many Gulf War
veterans are experiencing stress-related disorders and
the physical consequences of stress.
 Thousands of Gulf War veterans developed PTSD .
PTSD is caused by psychological stress and the Gulf
War syndrome is presumed to be caused by
environmental biological stressors. Signs and
symptoms often overlap and both conditions may exist
at the same time.

35. 9/11/01
 On September 11, 2001, terrorist activity destroyed the
World Trade Center (Fig. 16.5-1) in New York City and
damaged the Pentagon in Washington.
 More than 25,000 people continue to suffer symptoms
of PTSD related to the 9/11 attacks beyond the 1 year
mark.

37. Iraq and Afghanistan
 In October 2001, the United States, along with
Australia, Canada, and the United Kingdom, began
the invasion of Afghanistan in the wake of the
September 11, 2001 attacks.
 Both wars are ongoing and PTSD is a rising problem
with an estimated 17 percent of returning soldiers
having PTSD.

38. Natural Disasters
Tsunami
On December 26,
2004, a massive
tsunami struck the
shores of Indonesia,
Sri Lanka, South
India, and Thailand
and caused serious
damage.
Those survivors
continue to live in
fear and show signs
of PTSD.

39. Hurricane

40. Earthquake

41. Torture
 The intentional physical and psychological torture of
one human by another can have emotionally damaging
effects.
 Torture is any deliberate infliction of severe mental
pain or suffering, usually through cruel, inhuman, or
degrading treatment or punishment.
 This broad definition includes various forms of
interpersonal violence, from chronic domestic abuse
to broad-scale genocide.

42.  Torture is distinct from most other types of trauma
because it is human inflicted and intentional.
 Methods can be physical (e.g., beatings, burning of
the skin, electric shock, or asphyxiation) or
psychological, through threats, humiliation, or
being forced to watch others, often loved ones,
being tortured.
 One distinct method of torture that may combine
physical and psychological aspects is brainwashing.
 Treatment methods for survivors of torture are the
same as those for other posttraumatic symptoms and
disorders.

43. Differential Diagnosis
 head injury during the trauma
 Epilepsy
 alcohol-use disorders
 substance-related disorders
 Acute intoxication or withdrawal from some
substances
 Symptoms of PTSD can be difficult to distinguish from
both panic disorder and generalized anxiety
disorder, because all three syndromes are associated
with prominent anxiety and autonomic arousal.

44.  Keys to correctly diagnosing PTSD involve a careful
review of the time course relating the symptoms to a
traumatic event.
 Major depression is also a frequent concomitant of
PTSD.
 Borderline personality disorder can be difficult to
distinguish from PTSD.
 The two disorders can coexist or even be causally
related.

45. Course and Prognosis
 PTSD usually develops some time after the trauma.
 The delay can be as short as 1 week or as long as 30
years.
 If untreated :
 30 % recover completely
 40% with mild symptoms
 20% with moderate symptoms
 10% remained unchanged or become worst

46.  In general, the very young and the very old have more
difficulty with traumatic events than do those in
midlife.
 PTSD that is comorbid with other disorders is often
more severe and perhaps more chronic and may be
difficult to treat.

47. Treatment
 The major approaches are support, encouragement to
discuss the event, and education about a variety of
coping mechanisms (e.g., relaxation).
 The use of sedatives and hypnotics can also be
helpful.
 When a patient experienced a traumatic event in the
past and now has PTSD, the emphasis should be on
education about the disorder and its
treatment, both pharmacological and
psychotherapeutic.
 Additional support for the patient and the family can
be obtained through local and national support
groups for patients with PTSD.

48. Pharmacotherapy
 first-line treatments for PTSD
Selective serotonin reuptake inhibitors (SSRIs), such as
sertraline (Zoloft) and paroxetine (Paxil).
 Buspirone (BuSpar) is serotonergic and may also be of use.
 Other drugs :
 Monoamine oxidase inhibitors (MAOIs)
 phenelzine [Nardil]),
 trazodone (Desyrel),
 The anticonvulsants
 carbamazepine [Tegretol],
 valproate [Depakene].

49. Psychotherapy
 Reconstruction of the traumatic events with associated
abreaction and catharsis may be therapeutic, but
psychotherapy must be individualized because
reexperiencing the trauma overwhelms some patients.
 Psychotherapeutic interventions for PTSD include
behavior therapy, cognitive therapy, and hypnosis.
 The short-term nature of the psychotherapy
minimizes the risk of dependence and chronicity, but
issues of suspicion, paranoia, and trust often adversely
affect compliance.

50.  Patients should be encouraged to review and abreact
emotional feelings associated with the traumatic event and
to plan for future recovery.
 “Abreaction” -- experiencing the emotions associated with
the event-- may be helpful for some patients. The
amobarbital (Amytal) interview has been used to facilitate
this process.
 When PTSD has developed, two major psychotherapeutic
approaches can be taken.
1) Exposure therapy
2) Stress management

51. 1) Exposure therapy : in which the patient reexperiences the
traumatic event through imaging techniques or in vivo
exposure. The result of this therapy lasts longer.
2) Stress management : including relaxation techniques
and cognitive approaches to coping with stress. This shows
result more rapidly.
 eye movement desensitization and reprocessing
(EMDR) : the patient focuses on the lateral movement of the
clinician's finger while maintaining a mental image of the
trauma experience.
 It is possibly more effective than other treatments for PTSD.

52.  Group therapy include sharing of traumatic experiences
and support from other group members. Group therapy has
been particularly successful with Vietnam veterans and
survivors of catastrophic disasters such as earthquakes.
 Family therapy often helps sustain a marriage through
periods of exacerbated symptoms.
 Hospitalization may be necessary when symptoms are
particularly severe or when a risk of suicide or other
violence exists.

53. THANK YOU!!!