Recovery from Traumatic Stress Thomas C. Neylan, M.D. University of California, San Francisco
History of Posttraumatic Stress Disorder • Homer: Trojan War Veterans • Civil War: Soldier’s Heart • 19th Century Europe: Railroad Spine • WW I: Shell Shock • Vietnam War: Vietnam Syndrome • 1976 Horowitz: Stress Response Syndromes • 1980 DSM III: PTSD
Case Study • 29-year-old single women • Combat helicopter pilot from Iraq War • Shot down, and R shoulder rotator tear, and upper arm laceration • Recovered quickly from injury, but insisted on early retirement • Seeks help for poor sleep and irritability
Case Study (cont.) • What additional information would you want to obtain to evaluate her?
PTSD DSM-IV Criteria • Exposure to traumatic event with • Actual or threatened death or serious injury and • Response involving intense fear, helplessness, or horror American Psychiatric Association. DSM-IV. 1994.
PTSD DSM-IV Criteria (cont.) • Re-experiencing the traumatic event • Persistent avoidance of stimuli associated with event • Numbing of general responsiveness • Symptoms of increased arousal • At least 1 month’s duration (otherwise can diagnose Acute Stress Disorder) • Significant distress or impairment in social, occupational, or other functioning American Psychiatric Association. DSM-IV. 1994.
PTSDAssociated Features • Alcohol/drug problems • Aggression/violence • Suicidal ideation, intent, attempts • Dissociation • Distancing • Problems at work • Marital problems • Homelessness
Epidemiology of PTSDNational Comorbidity Study • 7.8% of adults in the U.S. (lifetime) • Type of trauma most often the basis for PTSD: • rape in women (46% risk) • combat in men (39% risk) • 1/3 of cases have duration of many years • 88% of cases have psychiatric comorbidity Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.
Combat-Related PTSD: Epidemiology • Lifetime Prevalence: • 30% in Vietnam veterans • 5-10% of Gulf War I deployed veterans • 10-20% in Operation Enduring Freedom and Operation Iraqi Freedom VIETNAM: Kulka RA, et al. Trauma and the Vietnam war generation: Report of the findings from the National Vietnam Veterans Readjustment Study. 1990, New York: Brunner/Mazel. GULF WAR: Stretch RH et al. Military Medicine. 1996;161:407-410. IRAQ WAR: Hoge, C.W., et al. R.L. N Engl J Med. 2004;351:13-22.
Primary Psychiatric Disorder 6 Months Following Trauma Responses to Trauma Are Heterogeneous 80 70 60 Number of Individuals 50 40 30 20 10 0 MDD PTSD Panic Eating Anxiety No Disorder Drug Abuse McFarlane, et al. Ann N Y Acad Sci. 1997;821:437-441
94% 47% 42% 30% ? Longitudinal Course of PTSD Symptoms % with PTSD Symptoms W 3m 9m Years Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.
Twelve-Month Prevalence of DSM-IVMajor Psychiatric Disorders % Mood Disorders Major depressive episode 6.7 Dysthymia 1.5 Manic episode 2.6 Anxiety Disorders Social Phobia 6.8 Simple Phobia 8.7 PTSD 3.5 Agoraphobia without panic 0.8 GAD 3.1 Panic disorder 2.7 Substance Use Disorders Alcohol abuse/dependence 4.4 Drug abuse/dependence 1.8 Adapted from Kessler RC, et al. Arch Gen Psychiatry. 2005;62:617-627.
Witness Accident Threat w/ Weapon Physical Attack Molestation Combat Rape Prevalence of Trauma and Probability of PTSD 1 2 1. Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14. 2. Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060.
Risk Factors for PTSD • Severity of trauma (ie, threat, duration, injury, loss) • Prior traumatization • Gender • Ethnicity • Prior mood and/or anxiety disorders • Family history of mood or anxiety disorders • Education
Screening Questions for PTSD • “What’s the worst thing that ever happened to you?” • “How did you react when it happened?” • “Do memories of _______ still bother you? Did you get over it?” • “Do you avoid situations that might remind you of ____? Have your relationships suffered because of ____?” • “Have you become more nervous since ___? Is it hard for you to relax because of ____?”
Functional Neuroanatomy of Traumatic Stress Stress Parietal Cortex Cerebral Cortex Long-term storage of traumatic memories Amygdala Prefrontal Cortex Conditioned fear Hippocampus Orbitofrontal Cortex Glutamate CRF Extinction to fear through amygdala inhibition Hypothalamus NE Attention and vigilance - fear behavior Dose response effect on metabolism Pituitary ACTH Locus Coeruleus Output to cardiovascular system Adrenal Cortisol
PTSD Treatment Options • Psychotherapy • Pharmacotherapy • Complementary Alternative Interventions • Yoga • Exercise • Meditation • Multimodal treatment
Early Post-Trauma Interventions • Crisis Interventions—Short cognitive behavioral therapy (CBT): • Psychological Debriefing—equivocal or harmful • Cognitive Behavioral Prevention Programs: • Prolonged Exposure (PE) • Prolonged Exposure + Stress Inoculation Training (PE/SIT) • Psychotherapy • Brief dynamic psychotherapy for traumatic grief • Supportive counseling • Spiritual counseling • Pharmacotherapy • Propranolol Foa EB, et al. J Clin Psychiatry. 1999;60(suppl 16):1-34. Mitchell JT. JEMS. 1983;8:36-9.
Psychological Treatments for Chronic PTSD • Psychotherapy • Exposure therapy • Cognitive processing therapy • Anxiety management • Additional treatments • Eye Movement Desensitization and Reprocessing (EMDR) • Hypnotherapy • Psychodynamic therapy • Expressive therapies
Meta-analysis of Pharmacotherapy for PTSD • 35 RCTS with 17 positive placebo-controlled trials • Medication response in 59.1% • Placebo response in 38.5% • SSRIs most effective • Medication effects greater for co-morbid depression and disability • 3 maintenance trials suggest long-term medication
Adrenergic-Inhibiting Agents: Alpha1-Adrenergic Blockers • Prazosin* 7 to 15 mg qhs • Alpha1- post-synaptic adrenoceptor receptor antagonist • Alpha1 receptors widely distributed in the brain, including the amygdala and hippocampus • Alpha1 receptors modulate sleep and startle responses • Double-blind RCT in 40 veterans, 13.3 +/- 3 mg 1 • Robust improvement in sleep quality and distressing dreams • Medium to large effect size in each PTSD Sx cluster • Adverse reactions include: syncope, dizziness, drowsiness, decreased energy, headache *Not FDA approved for the treatment of PTSD 1. Raskind, et al. Biol Psychiatry. 2007; 61: 928-34.
Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami. Descilo T, Vedamurtachar A, Gerbarg PL, Nagaraja D, Gangadhar BN, Damodaran B, Adelson B, Braslow LH, Marcus S, Brown RP. The Trauma Resolution Center of Miami, Miami, FL, USA ActaPsychiatr Scand. 2009 Aug 19. [Epub ahead of print]
Exercise and Neurogenesis? Growth factor signaling genes Growth factor signaling genes upregulated by exerciseVGF involved in energy balance& synaptic activity; increased by ECS Sedentary Exercise Exercise increases VGF mRNA in the hippocampus Slide adapted from D. Shin
Summary: Recommendations for Immediate Management • Move to safety and reduce terrifying arousal • Psychological First Aid • Low arousal, facilitate cognitive processing • Education and support • Emphasize need to sustain interpersonal connections • Screening for risk factors and follow up