POST TRAUMATIC STRESS DISORDER

DEFINITION

According to ICD 10, this disorder arises as a delayed and protracted response to an exceptionally stressful or catatrosphic life event or situation which is likely to cause pervasive distress in 'almost any person'.

Symptoms/ Signs

Symptoms arise within 6 months (ICD 10) of the traumatic event or are present for at least 1 month with clinically distress or impairment in social, occupational or other important areas of functioning (DSM IV).

Both ICD 10 and DSM IV include:

2 or more 'persistent symptoms of increased psychological sensitivity and arousal' (not present before exposure to stressor) - Difficulty falling or staying asleep - Irritability or outbursts of anger - Difficulty in concentrating - Hypervigilance - Exaggerated startle response

OTHER ICD 10 CRITERIA:

Persistent remembering or 'relieving' of the stressor in intrusive flashbacks, vivid memories or recuring dreams and in experiencing distress when exposed to circumstances resembling or associated with stressor. Actual or preferred avoidance of circumstances resembling or associated with stressor which was not present before exposure to the stressor. Inability to recall either partially or completely some important aspects or the period of exposure to the stressor.

EPIDEMIOLOGY

Risk of developing PTSD after a traumatic event:

8-13%

20-30%

Lifetime prevalence estimated as 7.8%.

AETIOLOGY

Psychological / biological Neuroimaging : Reduce hippocampal volume (enhanced reactivity to stimulation and memory deficit). Dysfunction of amygdala and associated projections may lead to enhanced fear response). Genetic : Higher concordance rates seen in MZ than DZ twins.

COMORBIDITY
About two thirds having at least two other disorders.

depressive disorders substance-related disorders other anxiety disorders bipolar disorders

Predisposing Vulnerability Factors

Presence of childhood trauma Borderline, paranoid, dependent or antisocial personality disorder traits Inadequate family or peer support system Being female Genetic vulnerability to psychiatric illness Recent stressful life changes Perception of an external locus of control (natural cause) rather than an internal one (human cause) Recent excessive alcohol intake

PSYCHODYNAMIC THEMES

The subjective meaning of a stressor may determine its traumatogenicity. Traumatic events can resonate with childhood traumas. Inability to regulate affect can result from trauma. Somatization and alexithymia may be among the after effects of trauma. Common defenses used include denial, minimization, splitting, projective disavowal, dissociation, and guilt (as a defense against underlying helplessness). Mode of object relatedness involves projection and introjection of the following roles: omnipotent rescuer, abuser, and victim.

MANAGEMENT: PSYCHOLOGICAL
CBT

Psychodynamic therapy

Education about nature of PTSD Self monitoring of symptoms Anxiety management Exposure to anxiety producing stimuli in a supportive environment Cognitive restructuring Anger management

Understand the meaning of the traumatic event for the individual and to work through and resolve the provoked unconscious conflict

Eye movement desensitization and reprocessing (EMDR)

uses voluntary multi saccadic eye movements to reduce anxiety associated with disturbing thoughts. the patient focuses on the lateral movement of the clinician's finger while maintaining a mental image of the trauma experience. The general belief is that symptoms can be relieved as patients work through the traumatic event while in a state of deep relaxation.

PHARMACOLOGICAL

Treatments should be directed towards predominant symptoms. - Depressive symptoms: SSRI (fluoxetine, fluvoxamine, sertaline); TCA (amitriptyline, imipramine) - Anxiety : BDZ (alprazolam, clonazepam),buspirone - Sleep disturbance : sedative antidepressants (trazodone)

Intrusive thoughts: carbamazepine,lithium

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