Posttraumatic Stress Disorder

1. Posttraumatic Stress Disorder

2. Epidemiology of PTSD • Kessler et al. (1995) Posttraumatic Stress Disorder in the National Comorbidity Study • Representative National Sample • N = 5877 AGE 15-54 Years old • Lifetime prevalence of PTSD is 7.8% • More than 1/3 of people with an initial episode of PTSD fail to recover after 10 years

3. Kessler National Comorbidity • Women: Most Common Experiences • Rape • Sexual Molestation • 50% had experienced a trauma that met DSM-IV stressor criterion • Men: Most Common Experiences • Combat • Witnessing death or severe injury • 60% had experienced an event that would meet DSM-IV stressor criterion

4. Kilpatrick et al (1992) • Nationally representative sample • 4008 women • 13% reported a completed rape • Of those who were raped • Lifetime PTSD 32% • Current PTSD 12%

5. Prevalence of PTSD • 5th Most Common Psychiatric Condition • Behind • Major Depression • Attention-deficit/hyperactivity disorder • Specific phobia • Social phobia

6. Comorbidity • PTSD/Depression: Nearly 50% Comorbid • Specific phobia, social phobia, and dysthymic disorder also prevalent • Male PTSD/Alcohol Abuse: (52%)

7. Criterion A: Exposure Criteria • Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity • Person’s response involved fear, helplessness, or horror or in children agitated behavior

8. Criterion B: Re-experiencing Criteria • Recurrent and Intrusive distressing recollections of the event (images, thoughts, or repetitions) • Recurrent distressing dreams of the event • Acting or feeling as if the traumatic event were recurring

9. Criterion B continued… • Intense Psychological Distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event • Physiological Reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

10. Criterion C1: Persistent Avoidance Criteria • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma

11. Criterion C2: Numbing of Gen. Responsiveness Criteria • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect • Sense of foreshortened future

12. Criterion D: Increased Arousal Criteria • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

13. Criterion E • Symptoms in criteria B, C, and D are more than 1 month

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

15. Specifications • Acute: if duration of symptoms is less than 3 months • Chronic: if duration of symptoms is 3 months or more • With delayed onset: if onset of symptoms is at least 6 months after the stressor

16. Green’s Generic Dimensions to Stressors • Threat to one’s life • Threat to bodily integrity • Severe physical harm/injury • Exposure to grotesque • Witnessing/learning of violence or severe harm to others • Learning of exposure to a noxious agent • Causing death or severe harm to another

17. Dohrenwend • National Veterans Readjustment Study • Congressional Mandate in 1983 • Representative sample of 1632 US Vietnam Theater Veterans and matched sample of 716 Vietnam era veterans and 668 civilian comparison • NVVRS rates for Male VTV 30.9% lifetime And 15.2% current CDC rates reported 14.7% lifetime and 2.2% current all 11 to 12 years after the Vietnam war ended

18. Dohrenwend contd. • National Veterans Readjustment Study • Perplexing in these relatively high rates of PTSD was the relatively low rates of ‘combat’ • Used data from archival sources to develop a record based military historical measure for exposure • Impairment wasn’t formerly a part of the criteria • Adjusted Rates for impairment and verification are • 18.7% lifetime and 9.1% current • Dose response relationship between combat and exposure

19. Cultural Factors and PTSD • Hispanic veterans report significantly higher rates of PTSD than AA or Caucasian veterans. Hypotheses include: • Greater exposure to war zone stressors • Greater prewar vulnerability • Culturally driven differences in reporting symptoms • Different post war stressful events • Greater experiences with racial/ethnic prejudice and discrimination

20. Sample • Subsample NVVRS • 94 Majority White • 70 African American • 84 Hispanic (Mostly Mexican American (63), Puerto Rican (15), Latin American (6) • War Zone stressor severity measured • Peri- and Post-War Discrimination • Vulnerability Factors Measured • Younger age at entry to Vietnam • Lower Armed Forces Qualification Tests • Disciplinary Actions • Pre-Vietnam educational level • Pre war psychiatric disorder

21. Results • Both Blacks and Hispanics had higher rates of war-related first onsets of PTSD (current PTSD 10-11 years after the war) • PTSD course was more chronic for Hispanics than Blacks • Hispanics experiences more war-zone stressors compared with Caucasians • Controlling war zone exposure did not account for the greater rates of PTSD in Hispanics • Prewar vulnerability factors emerged as important: younger age, less education, lower AFQT scores

22. 9/11 • Explored stressor exposure and PTSD symptoms in 11,037 adults who live south of Canal Street in NYC on 9/11 (lower Manhattan) • PTSD Checklist Civilian Version • Within disaster exposure, e.g., residential proximity, direct exposure intensity (caught in the dust cloud from the tower collapse, an occupant of the north or south tower, sustaining an injury, witnessed horror, seeing people fall or jump from the buildings)

23. 9/11 Results • 43.6% reported reexperiencing, 20.4% reported avoidance, 38.6% reported hyperarousal • Most common symptoms were hypervigilance, being upset by reminders, and insomnia • Current PTSD prevalence 12.6%

24. 9/11 Results: Bivariate results • Increased risk was reported for African Americans, Hispanics, and other nonAsian minorities (Asian race was protective) • Increased risk for women • Lower education and lower income was associated with increased risk • Older age and female gender was assoc with increased risk • Being divorced, separated or separated was associated with increased risk • Within disaster risk factors were sustained injury, witnessed horror exposure to dust cloud, being in a building that was damaged or destroyed (except WTC towers), living less than 1000 feet from the towers • Post disaster risk was associated with evacuation from one’s home and involvement in rescue/recovery efforts.

25. 9/11 Results: Multivariate results • Risk for PTSD increased for all age groups relative to the younger groups (greatest risk for adults 45-64 years); • Increased risk for women • Risk for PTSD higher among Hispanics, African American, and other ethnicities • Divorced, widowed or separated continued to increase risk; • Lower education and income was associated with increased risk • Exposure intensity remained as a significant risk factor • Evacuation and involvement in rescue recovery efforts remained

26. Confluence of Factors • Discuss findings in terms of the diathesis, personality, stress model

27. Acute Stress Disorder

29. Criterion A: Exposure Criteria • Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity • Person’s response involved fear, helplessness, or horror or in children agitated behavior

30. Criterion B: Dissociative Criteria • Subjective sense of numbing, detachment, or absence of emotional responsiveness • Reduction in awareness of one’s surroundings (e.g., “being in a daze”) • Derealization • Depersonalization • Dissociative amnesia

31. Criterion C: Re-experiencing Criteria • Recurrent images • Thoughts, dreams, illusions • Flashback episodes, or a sense of reliving the experience • Distress on exposure to reminders of the traumatic event

32. Criterion D: Avoidance Criterion • Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)

33. Criterion E: Physiological Criteria • Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)

34. Criterion F: Psychosocial Criteria • Clinically significant distress or impairment in social, occupational, or other important areas of functioning • Impaired ability to pursue some necessary task, such as obtaining personal assistance or mobilizing personal resources

35. Criterion G: Time Criteria • Minimum of 2 days • Maximum of 4 weeks • Occurs within 4 weeks of the traumatic event

36. Inter-relationship between ASD and PTSD Event ASD PTSD 4 weeks and on 2 days – 4 weeks

37. How does someone develop PTSD? Classical Conditioning Unconditioned Stimulus Unconditioned Response CR CS Thoughts Feelings Behaviors Car Jacking

38. Classical Conditioning Triple vulnerability

39. Model for PTSD • PTSD develops through the process of classical conditioning • When cues are encountered, anxiety and other emotional reactions increase. Over time, habituation would occur. • Avoidance maintains PTSD because habituation can never occur. • Negative Reinforcement