Posttraumatic Stress Disorder (PTSD)

1. Posttraumatic Stress Disorder (PTSD) Epidemiology, Etiology, & Treatment

2. What is PTSD? • Anxiety disorder • Traumatic stressor • Core features: • Reexperiencing • Avoidance • Numbing • hyperarousal

3. Traumatic Stressor • DSM-III – Beyond normal range of human experience • DSM-IV –experiences, witnesses, or is exposed to an event that is life threatening, that causes serious injury or that leads to a subjective response of intense fear, helplessness, or horror. • PTSD is unique among mental disorders • Symptoms are directly linked to traumatic stressor

4. Historical Overview Diagnostic category in DSM-III Issues Symptoms alone Social Construction Unreliability of memory Euro-American category

5. But • Traumatic neurosis (Oppenheim in 1892) • Fright neurosis or schreckneurose (Kraeplin in 1896) • WWs I & II • Shell shock • Combat fatigue • War neurosis • DSM-I: GSR • DSM-II: Transient situational disturbances

6. Epidemiology • Four levels • Prevalence of Trauma Exposure • Risk Factors for Trauma Exposure • Prevalence of PTSD • Risk and Protective Factors

7. Prevalence of Trauma Exposure • Common or uncommon? • NCS ≥ 60.7% of men; ≥ 51.2% have had at least 1 traumatic event in their lifetime • Most common traumatic events • Witnessing • Natural disasters • Life-threatening accidents • Rape • Sexual molestation • Physical abuse • Childhood neglect

8. Risk Factors For Trauma Exposure • Random or non-random? • Gender • Age • Prior exposure • Preexisting personal characteristics • CDD • Pretrauma substance use • Genetic Vulnerability

9. Prevalence of PTSD • Several factors • PTSD ratio of women to men is • 2:1 in USA • Different among VTV – • Higher for men • Roles, stressors, education levels • Demographics • Age • Ethnicity • Population • Gender • Trauma type – 32 % of rape; 26% of criminal victims • Closeness to Traumatic event - WTC

10. Prevalence of PTSD • International data varies • Economies and PTSD • Political turmoil, wars, disasters • PTSD manifests itself in similar manner across culture, language, region, race • Importance of this observation?

11. Risk and Protective Factors • Many are exposed but few develop PTSD • Ratio of 3:1 • Categories of Risk Factors • Trauma • Peri-and post-trauma events • Individual Characteristics

12. Risk and Protective Factors • Trauma • Type • severity • Peritrauma • Fear, helplessness, horror (r =.26) • Dissociation: blanking out, altered sense of time • PTSD is exercerbated by cognitions of panic (fear of death, fear of losing control) • Posttrauma • Social support • PTSD SS vs SS PTSD

13. Individual Characteristics Demographics & Familial Psychopathology • Demographics: • age, gender, race, SES, immediate response, marital status, psychiatric history, prior trauma, personality • Familial Psychopathology • VVTR (no genetic linkage); • In general population (small but sig.) – through D2 dopamine alleles • Environment • (greater than genetics)

14. Predictor Effect • Direct • War-zone stressors, malevolent war-zone environment • Hardiness, structural social support (not sig. for w/men), functional social support, and recent stressors • Indirect • Traditional combat exposure – moderated by perceived threat

15. Etiological Theories • Multiple Theories • Classical Conditioning • – stimulus & response connection • Schema Theories • – faulty schemas that filter info • Emotional Processing Theory • - abnormal fear structures • Cognitive Theory • - (i) classical (ii) Ehler & Clark • Multiple Representation Structures • – (i) Dual – VAM & SAM • – (ii) SPAARS – schematic, proporsitional, analogue, & associative representational systems

16. Classical Conditioning Triple vulnerability

17. Concern about CC • Startle responses • Reexperiencing • Nightmares

18. Treatment • Approaches • (influenced by Psychoanalysis) • Exposure Therapies • Narrative therapies • CT • CPT • PE • IR (imagery rescripting) • IRT (imagery rehearsal therapy) • Concerns? • Anxiety Management Training • Stress innoculation techniques

19. Treatment • Combination Treatments • E+AMT+ CR eg CPT • CBT • TF-CBT • DBT • “Power Therapies:” TIR, VK/D, EMDR – (concern?) • ACT • Interapy • VRE • Pharmacotherapy

20. Pharmacotherapy Challenge multiple rather than single neurobiological systems Assumption • Target Systems • Adrenergic • HPA • Serotonergic • Dopaminergic

21. Medication • Antidepressants • SSRI – sertraline, paroxetine, fluoxetine • TCA – amitriptyline, desipramine • MAOI - phenelzine • Antiadrenergic • prozasin • Antikindling • Carbamazepine • Atypical antipsychotic • resperidone, quetiapine, olanzapine

22. Research • Efficacious in comparison to WL • Decline in anxiety, arousal, & reliving • Narrative therapy cf psychoeducation • Exposure (alone) • Active therapies vs supportive therapies • PE (60-80%, Foa, Rothbaum, & Faurr, 2003) • IRT 65% (Jacobson & Traux, 1991) • VRE 15-67% (Rothbaum et al. 1999)

23. Limitation • Cultural issues

24. Resources Friedman, M., Keane, T, & Resick, P. (Eds.) (2007). Handbook of PTSD: Science and practice. New York: The Guilford Press. Keane, T., Marshall, A., & Taft, C. (2006). Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome. Annual Review Clinical Psychology, Vol. 2, 161-197. Vasterling, J., Brewin, C. (Eds.) (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York: The Guilford Press.