PTSD

Dr Peter Smith
OT II - May 2012
PTSD

 A psychiatric disorder that arises in response

to a stressful event or situation
 Exceptionally threatening or catastrophic eg
natural disaster, physical assault, rape, torture
 Common, but often missed
 Locally relevant due to endemic violence,
crime, social adversity, HIV
History of PTSD

 19th Century-Hysterical neurosis

 WWI- “Shell Shock”( ammunition shells)
 WWII-Traumatic Neurosis
 1960’s-Vietnam War
-Rape Crisis centres
 Formal Diagnosis-DSM III (1980)
Traumas

 War
 Violence
 Sexual or Physical Assault
 Natural disasters
 Terrorism
 Medical-Life threatening illness
-Medical procedures
 Severe accidental injuries ( MVA, Burns)
Core Features

 Exposure to Traumatic Event

 Threat of Serious Injury/Death

 Intense Fear, Helplessness, Horror

 Need a Stressor
 Not all Develop PTSD
 Not purely dependent on severity
 Subjective Response More Important
DSM IV Criteria
 Persistent Re-experiencing
-Recurrent Thoughts/Dreams
-Flashbacks/reliving Experience
 Marked Avoidance( conversations, places)
-Numbing
-Diminished Interest
-Detachment/Restricted Affect
 Increased Arousal (hyper vigilance, poor sleep, anxiety, heightened
startle response)

 Significant Distress/Impairment
Diagnostic Criteria

 Duration < 1 Month : Acute Stress Disorder (ASD)

 Duration > 1 Month : PTSD
 Chronic PTSD and Delayed Onset PTSD
 Clinical Features may Include
- Anger/Aggression
- Poor Impulse Control
- Shame/Self-blame/Survivor Guilt
- Depression
- Substance Abuse
Subtypes

 Type I - “one sudden blow”

– Classical DSM-IV symptoms

 Type II- Complex PTSD

– Multiple, long standing traumas eg childhood
sexual/physical abuse
– Associated with maladaptive behaviors, other
psychopathology
Epidemiology

 Few local studies

 Globally – 5-10% lifetime prevalence
 Women more likely than men
– Aftermath of single traumatic event
 8% men develop PTSD
 20% women develop PTSD
 Social adversity, armed conflicts, natural
disasters, violent crime
 Cultural / Existential factors
Risk Factors

 Female gender
 Nature, severity, duration of trauma
 Uncontrollability / Unpredictability
 Sexual vs non-sexual trauma
 Vulnerable groups (children/elderly)
 Lack of Social support / validation
 Migration / refugee status
Aetiology

 Biopsychosocial
 Traumatic event primary
 Biological factors
– Genetics – familial pattern confirmed
– Neurochemistry
 Serotonin – low mood, impulsiveness
 Noradrenaline - hyperarousal
 Opiate system – numbing
– Neuroendocrine – HPA axis (Cortisol)
Aetiology

– Brain structures
 Limbic system / amygdala
 Memory related structures eg Hippocampus
 Prefrontal cortex

 Psychological Factors
– Psychoanalytic – defense mechanisms
– Learning Theory – role of fear based memories in
entrenching patterns of feeling, thinking and
behavior
Aetiology

 Social / Environmental Factors

– Protective role of support/validation
– Endemic violence/insecurity
– Role of media
– Natural causes vs human violence
– Shared “meaning-making” of traumatic
experiences
Management

 Biopsychosocial
 Individualised
– Strengths / Vulnerabilities
– Past history of traumas
 Trauma focused psychotherapies
 Medications when appropriate
 Social support
Management

 Acute phase
– Usually self-limiting
– Psychological First-Aid
– Supportive counseling
– No place for single session debriefing
 PTSD
– Comprehensive psych assessment
– Exclude co-morbid depression, substance abuse,
personality factors
Management

 PTSD (cont’d)
– CBT
 Revisit traumatic cognitions
 Confront traumatic memories
 Challenge misinterpretations that overestimate and
generalise threat
 Achieve mastery over despair, helpless victimhood
 Dismantle avoidance behaviors
 Develop skills to cope with stressors
Management

 PTSD (cont’d)
– Eye Motion Desensitisation and Reprocessing
(EMDR)
 Client recalls an image of an important aspect of the
traumatic event
 Follows repetitive side to side eye movements, sounds
or taps as the image is focused on
Management

 Medication
– Not first line
– SSRI’s – evidence of benefit for all core
symptoms of PTSD
– Delayed onset of action
– Sedatives / tranquilisers in short-term
– Mood-stabilisers / antipsychotics rarely
Prevention

 Crisis Intervention
 Screen at risk groups / Early intervention
 Community based interventions
 Community Support
 Life skills / Psychoeducation
 Child protection services
 Media
Outcome/Prognosis

 30% recover
 40% mild
 20% moderate
 10% severe
 Ongoing / repeated traumas convey poor
prognosis
 Co-morbid conditions esp Depression,
Substance abuse, PD, Bulimia
Impact on Clinicians

 “Contagiousness” of trauma
 Trauma fatigue / burnout
 Need for introspection, self reflection
 Support - individual or group
 Ethical / legal concerns
– Conflicts around confidentiality / child protection,
military/police etc
 Advocacy role
Conclusion

 PTSD is common
 Relatively recent diagnostic category
 Often missed with potentially harmful
consequences
 Can be treated effectively
 Early diagnosis / intervention needed
 ? Resilience - what it means for PTSD
 Public health / Social priority to reduce levels of
trauma