Post Traumatic Stress Disorder

1. Post Traumatic Stress Disorder Dr Linda McCarthy Senior Specialist Psychiatrist Director, PTSD Program RGH Daw Park

2. History of PTSD • Symptoms of traumatic syndromes date back over centuries • Ancient Rome • Soldiers Heart • Shell Shock • PTSD

3. History of PTSD • Consistent description of features, but a lack of effective treatments for traumatic syndromes • Battle fatigue after WW2 • Battle shock • Implications about relationship to mental disorders (compensation)

4. History of PTSD • PTSD first described as such in DSM III in 1980 • Prototype for environmentally induced disorder triggered by an external event • Involved emotional deregulation and memory disturbance • Concept essentially the same, empirically validated, consensus achieved • Born from Vietnam war

5. Diagnostic criteria for PTSD DSM - 5 • Criterion A: stressor • Person exposed death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) • Direct exposure • Witnessing, in person. • Indirectly, learning that close relative or friend exposed to trauma. Must have been violent or accidental.

6. Diagnostic criteria for PTSD DSM - 5 • Criterion A: stressor • Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). • Does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

7. Diagnostic criteria for PTSD DSM - 5 • Criterion B: • Traumatic event persistently re-experienced in the following way(s): (one required) • Recurrent, involuntary, and intrusive memories • Traumatic nightmares • Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness • Intense or prolonged distress after exposure to traumatic reminders • Marked physiologic reactivity after exposure to trauma-related stimuli.

8. Diagnostic criteria for PTSD DSM - 5 • Criterion C: Avoidance symptoms • Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) • Trauma-related thoughts or feelings. • Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

9. Diagnostic criteria for PTSD DSM - 5 • Criteria D: Negative alterations, cognition and mood: • Inability to recall key features of the traumatic event (dissociative amnesia). • Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). • Persistent distorted blame of self or others for causing the traumatic event or resulting consequences

10. Diagnostic criteria for PTSD DSM - 5 Criteria D: (cont.) • Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). • Markedly diminished interest in (pre-traumatic) significant activities. • Feeling alienated from others (e.g., detachment or estrangement). • Constricted affect: persistent inability to experience positive emotions.

11. Diagnostic criteria for PTSD DSM - 5 • Criterion E: alterations in arousal and reactivity (two required): • Irritable or aggressive behaviour (angry outbursts, little or no provocation) • Self-destructive or reckless behaviour • Hypervigilance • Exaggerated startle response • Problems in concentration • Sleep disturbance

12. Diagnostic criteria for PTSD DSM - 5 • Specify if: With dissociative symptoms. • Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream) • Derealization: experience of unreality, distance, or distortion (e.g., "things are not real"). • Specify if: With delayed expression • Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

13. Diagnostic criteria for PTSD DSM - 5 • Criterion F: duration • Persistence of symptoms for more than one month • Criterion G: functional significance • Clinically significant functional impairment (e.g., social, occupational, other). • Criterion H: exclusion • Disturbance not due to medication, substance use, or other illness

14. PTSD

15. Complex PTSD • Major causes: trauma in childhood – abuse, neglect • Sx of PTSD also accompanied by personality changes – c.f. borderline traits • Emptiness • Emotional dysregulation • Hostility • DSM has not been adequate so far…

16. Post-Traumatic Stress Disorder • Estimates suggests that up to 90% of people will be exposed to a significant traumatic event during their lifetime • 20% of ♀ and 8% ♂ will go on to PTSD • Lifetime prevalence 10% ♀ and 5% ♂ • Lifetime prevalence amongst Australian Vietnam veterans > 17%

17. Risk factors for PTSD • Male gender: • Assault • MVA • Combat • Female gender: • Sexual assault • Others – low socio-economic status, high risk occupations • Lower educational achievement, family dysfunction, family psychiatric hx

18. Biology of PTSD • Disturbance of key neurotransmission in the brain, and other hormonal axes: noradrenergic, thyroid, endogenous opioid, serotonin and HPA • Up-regulated catecholamines • Down-regulated adrenergic receptors • Typical fight or flight response • Reduced regulation of autonomic response to emotional arousal and external stressors • Disturbed appraisal, learning and memory

19. Comorbidities & PTSD • People with PTSD up to 80% more likely to satisfy diagnostic criteria for other psychiatric dx: • Alcohol use problems • Other substance misuse • Depression • Other anxiety disorders • Chronic pain • Medical issues (obesity, diabetes, CV disease, smoking-related illnesses) • TBI

20. PTSD treatment options • Psychological therapy (regarded as first line): • Psychoeducation • Cognitive behavioural therapy • Trauma focus therapy • Desensitisation • Little or no role for routine “debriefing” after a traumatic event • Drug therapy

21. PTSD programme goals • Manage anxiety • Anger • Nightmares, flashbacks • Reduce impact on QOL • Reduce impact on relationships and general functioning

22. PTSD programme elements • Psychoeducation • Anxiety management: • Physical • Controlled breathing strategies • Progressive muscle relaxation • Aerobic exercise •  stimulant intake (caffeine, nicotine) • Cognitive • Thought stopping • Distraction • Behavioural • To address avoidance and social withdrawal

23. PTSD programme elements • Exposure treatments • Imaginal exposure (CBT technique) • Cognitive restructuring • Management of comorbid conditions • Alcohol • Depression

24. PTSD – Psychological interventions • Strongest evidence for exposure therapy (Foa & Rothbaum) • Imaginal exposure • Trauma emotionally processed or digested • Cognitive processing therapy • Exposure by writing

25. PTSD drug treatment options • Antidepressants • Antipsychotics • Hypnosedatives • Mood stabilisers such as anticonvulsants • Adjuvant therapies

26. PTSD drug treatment options • Many drug treatment options have been examined, no treatment universally effective • Many patients need sequential trials of drug treatment • Many require combinations of drugs, also combined with psychological approach

27. PTSD drug treatment options • Many drugs are known to work for PTSD • Methodological difficulties with research, many studies short duration with high drop-out rates • Many drugs not examined thoroughly because of patent limitations

28. Antidepressants for PTSD • Almost all antidepressants drugs are known to work for PTSD • First research with TCAs and MAOIs • Greatest evidence now for SSRIs, some with FDA and TGA approval • Anxiolytic effect may be independent of antidepressant effects

29. Antidepressants for PTSD • SSRIs • Mirtazapine • Venlafaxine • TCAs • MAOIs • Other agents may also be effective

30. Antipsychotics for PTSD • Relative lack of controlled research • Clinical use in situations where there is severe agitation, anger or requirement for sedation • Not approved indication, no PBS subsidy but may attract RPBS subsidy • Generally reserved for time limited course of treatment or prn therapy

31. Hypnosedatives & PTSD • BZDs play multiple roles: • Sedation • Anxiolytic • Substance withdrawal management • Care required in view of high potential for dependence and known association of PTSD and substance use disorders

32. Hypnosedatives & PTSD • Avoid very short acting drugs (alprazolam) and favour longer acting drugs (e.g. diazepam) • May interact with SSRIs • Can potentiate sedation seen with other prescribed drugs, will also interact with alcohol

33. Mood stabilisers & PTSD • Not regarded as first line therapy • Valproate and carbamazepine most often used • Regarded as helpful for severe anger/impulse control issues • Many serious adverse effects, not safe in overdose or pregnancy

34. Adjuvant therapies for PTSD • Prazosin • Propranolol • Baclofen • Clonazepam • Buspirone • Others under investigation • Topiramate

35. Alcohol & PTSD • Use of treatments to decrease EtOH use: • Naltrexone • Acamprosate • Disulfiram (last choice) • Topiramate (strong evidence evolving) • May enhance the effectiveness of other interventions

36. In conclusion… • Relatively common, especially amongst specific groups • Unique amongst almost all Dx in DSM5 • Extreme variability in presentation, course, severity and outcome despite consistent core symptoms