PTSD Post Traumatic Stress Disorder

PTSD Post Traumatic Stress Disorder Poonam Khanna D. O. Diplomat of Adult, Adolescent, and Child Psychiatry Assistant Professor of Psychiatry at KCUMB Minds That Matter, P.A.

Objectives: 1.) Identifying changes in PTSD criteria in DSM-5 for adults 2.) Identifying symptoms in children < 6 yo 3.) Identifying precursors to developing PTSD 4.) Identifying risk factors for PTSD 5.) Treatment Options

Case Study Last June, 35 yo male with a past history of depression, was involved in a MVA in which the other driver smashed into his passenger side of his car, killing his girlfriend. Since that time, he has had severe panic attacks, is not able to drive, and continues having intrusive thoughts of his horn going off. If he hears any loud sounds, he starts to cower. He also has images of his girlfriend,though he can t recall many of the details of the accident.

He has been unable to work, and his fear of driving keeps him isolated from others. He has frequent nightmares & intrusive images of his girlfriend at the scene, though he can t recall many details of the accident.

PTSD There is development of symptoms after exposure to traumatic events. The person may have been harmed themselves, harm may have befallen a loved one, or they may have witnessed a traumatic event. Normal reactions to trauma continue and increase in intensity. Symptoms usually start w/in 3 mths of trauma but can begin years later. Symptoms last longer than 1 month and negatively impact daily functioning

Criterion A: stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (1 required) Direct exposure. Witnessing, in person.

Indirectly, by learning that a close relative or close friend was exposed to trauma. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: intrusion symptoms Re-experiencing The traumatic event is persistently re-experienced in the following way(s): (1 required) Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).

Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli.

Intrusion Symptoms Flashbacks Upsetting Dreams Physical reactions Images or memories that are distressing

Criterion C: avoidance Persistent effortful avoidance of distressing traumarelated stimuli after the event: (1 required) Trauma-related thoughts or feelings. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

Avoidance Symptoms Avoid thinking or talking about the traumatic event Avoid interests/ activities one used to enjoy Avoid people, places, and situations that remind one of the trauma

Criterion D: negative alterations in cognitions and mood Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs). 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 for resulting consequences.

Symptoms of Negative alterations in cognition & mood 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. Hopelessness about the future Emotionally numb Memory problems Difficulty concentrating Difficulty maintaining close relationships

Criterion E: alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required) Irritable or aggressive behavior. Self-destructive or reckless behavior. Hypervigilance. Exaggerated startle response. Problems in concentration. Sleep disturbance.

Symptoms of hyperarousal Irritability Auditory or visual hallucinations Constantly alert to signs of danger

Criterion F: duration Persistence of symptoms (in Criteria B, C, D and E) for more than one month. Most symptoms of PTSD occur within 3 mths of trauma.

Criterion G: functional significance Significant symptom-related distress or functional impairment

Criterion H: exclusion Disturbance is not due to medication, substance use, or other illness.

Specify if: With dissociative symptoms. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: 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 6 months after the trauma(s), although onset of symptoms may occur immediately.

Case History Sammy is an 8 yo cm who presented with a 1- year history of increased aggression and temper outbursts. His parents had divorced fourteen months earlier, and Sammy moved into his maternal grandparents home with his 35 yo mom.

Approximately 2 weeks after this major transitional time, Sammy was playing a board-game with his mom when she slumped to the floor. Sammy called out for help and began trying to wake up his mom She was unresponsive and was rushed to the hospital while Sammy stayed with his elderly grandparents.

His mom now lives fulltime in a nursing home. Sammy rarely refers to her unless asked, and he avoids any discussion related to her. Sammy no longer enjoys playing with other children and has separation anxiety related to his GPs. He is constantly worried that something will happen to his GPs and is afraid to go to sleep at night because he has scary dreams.

In play therapy, pt always has a figure who dies and leaves a young child alone. The child character is scared and yells out for help all the time. His temper tantrums have disrupted his academic life and home life with his GPs.

PTSD in Preschool Children (PTSD in children younger than 6 yo.) In the Immediate Reaction to Traumatic Event - Children show extreme distress has been removed. Intrusion Symptoms Recurrent & Intrusive Distressing Recollections of the event has been changed to re-experiencing.

Avoidance symptoms & negative alterations in cognitions and mood only need 1 symptom in either of these. Sense of a foreshortened future & inability to recall important aspects of the event have been deleted.

Increased arousal symptoms Extreme temper tantrums included in the symptomatology http://www.ptsd.va.gov/professional/pages/ptsd_childr en_6_and_younger.asp

Symptoms in kids (under 6) Include: - Being afraid of the dark - Regressive changes - Bedwetting - Crying/emotional outbursts - Clinginess - Trembling - Thumbsucking

Risk Factors Childhood Trauma Chronic Adversity Familial Stressors Being Female Feeling lack of control Poor social supports Comorbidities Proximity to, duration of, & severity of trauma

Risk Factors Contd. Intensity of the trauma Experienced a trauma earlier in life First degree relatives with mental health issues First degree relative with depression Abused or neglected as a child Physical disabilities Head trauma Being hurt or losing a loved one

Genetics: Polygenetic disorder Hereditary component - Monozygotic twin w/ptsd associated with increased risk of PTSD in co-twin Some evidence that those with smaller hippocampus may be more likely to develop PTSD in response to trauma Shares some genetic variances with Panic D/O, GAD, alcohol, drug, and nicotine dependence

Other Potential Causes: Stathmin Gastrin- Releasing Peptide 5-HTTLRP FK506

Neuroanatomy Amygdala Important in learning to fear

Combat veterans who had served in Iraq and Afghanistan after 9.01 studied. Those diagnosed with PTSD had significantly smaller volume in R & L amygdala The amygdala volume does not seem to be affected by the severity, frequency or duration of the trauma, indicating that such exposures do not cause the amygdala to shrink.

Morey, Rajendra A., M.D., M.S. "PTSD and Amygdala Size." Journal Archives of General Psychiatry (2012): n. pag. DukeHealth.org. Duke Medicine News and Communications, 5 Nov. 2012. Web. 09 Sept. 2013. <http://www.dukehealth.org/>.

Most common types of trauma leading to PTSD Rape Child Abuse Combat Exposure Physical Attack Threatened with a weapon

Clinical Features Usually occurs within 3 mths of stressor guilt Rejection Humiliation Dissociative states Panic attacks Illusions Hallucinations Poor impulse control Violence Depression Substance Abuse

Case Study A 37 yo separated cm returned from Afghanistan a couple of years ago. Within 2 mths of returning back to his wife and family, pt began to struggle with adapting back to his old life. Before he was deployed, pt had a very close knit circle of friends and family. However, upon his return, he had trouble opening up and confiding in any of them. He didn t trust many people and felt that no one would understand what he was feeling.

Pt felt angry most of the time and spent much of his time alone in his study. He didn t watch tv because the news, movies, and any program that had violent images disturbed him. Pt had flashbacks where he would be very still and then start pushing away from everyone. This scared his children.

On the 4 th of July, pt got very agitated and tried to pull people to safety when he heard the fireworks. He would also run for cover. It was at this point that pt s wife encouraged him to seek help. He refused and began drinking to help calm his nerves Pt and wife separated 8 mths ago due to his behavior, isolation, drinking, and anger issues.

War 14% of returning soldiers from Iraq and Afghanistan have PTSD (Per Dept of Veteran s Affairs) Women soldiers with higher rate Concise Textbook of Clinical Psychiatry, Kaplan& Sadock, pp262

Risk Factors for Military Personnel Exposure to combat Intensity of combat Injury Torture or captivity

Military and Post-Military Factors Social support at homecoming Current social supports Perceived control High Resilience

Natural (& other) Disasters The Tsunami in 2004 Hurricane Katrina Earthquakes September 11,2001 Mass Shootings in Schools/Communities

PTSD Can Lead To: Depression Alcohol and Drug Abuse Suicidal Thoughts/Actions Eating Disorders Medical Illnesses

Psychological Debriefing It was the therapy most used as a preventative measure

Course and Prognosis Symptoms can fluctuate over time Increased symptoms during stress Untreated: 30% - recover completely 40% - mild symptoms 20% - moderate symptoms 10% - remain the same or worsen Textbook of Clinical Psychiatry, Kaplan&Sadock, pp. 262

Differential Diagnosis Head trauma Epilepsy Alcohol use or other substance-related disorders Panic Disorder Generalized Anxiety Disorder

Good Prognosis Rapid onset of symptoms Short duration of the symptoms Good Premorbid functioning Strong social supports Absence of other comorbidities Middle aged

Treatment Therapies: Cognitive Behavioral Therapy Exposure/Response Prevention Eye movement desensitization and reprocessing (EMDR) Interpersonal Therapy

Pharmacotherapy ANTIDEPRESSANTS: Sertraline (zoloft) and Paroxetine (paxil) are FDAapproved for PTSD Help with depression and anxiety Help with sleep

Pharmacotherapy Antipsychotics: Aggression Agitation Sleep Dysfunction Anger Mood instability

Pharmacotherapy Alpha-adrenergic Antagonist (Prazosin, Clonidine): - Prazosin may help in reducing nightmares - Clonidine can help with hyperarousal symptoms.

Pharmacotherapy Beta-Blocker Propranolol (Inderal) May be able to decrease stress and the formation of traumatic memories

Acupuncture Alternative Therapies

Get support Prevention

Case History 25 yo scf with history of rape her freshman year at college by a friend s friend. Within 2 months of this trauma, this patient began having difficulty going to class. Though she had always been a strong student, she found herself unable to pay attention in class but was hypervigilant regarding who was around her. She began avoiding her friend,tom, and eventually withdrew from her group of friends all together.

This patient was afraid to go to sleep at night because of the reoccurring nightmares she would have detailing the rape. She felt unsafe both in her dreams and in her reality and turned to alcohol to drown out the memories and to help her sleep.

Within 1 year of her trauma, pt had failed out of 2 colleges. She drank alone and was unable to hold a job. She began having symptoms of social phobia and could not tolerate being around groups of people or those she did not know.

Fact Sheet: The National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families Since September 11, 2001, more than 2.5 million American service members have been deployed to Iraq and Afghanistan, and many others have been posted in a number of other dangerous regions around the world. Military service especially in these regions exposes service members to a variety of stressors, including sustained risk of and exposure to injury and death and an array of family pressures. As a Nation, we have a moral obligation to protect the well-being of veterans, service members and their families.

To improve prevention, diagnosis, and treatment of mental health conditions affecting veterans, service members, and military families, the President issued an Executive Order in 2012 directing Federal agencies to develop a coordinated National Research Action Plan. The Departments of Defense (DoD), Veterans Affairs (VA), Health and Human Services (HHS), and Education (ED) have responded to the President s call with a wide-reaching plan to improve scientific understanding; provide effective treatment; and reduce occurrences of Post-Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), various co-occurring conditions, and suicide. The plan builds on substantial work already underway in Federal agencies and provides a framework for improved coordination across government and with scientists from the academic and industrial sectors to share information, brainstorm innovations, and accelerate science.

The comprehensive plan takes action to: Within the next 6 months Establish two new Consortia. The DoD and VA are establishing two joint research consortia, at a combined investment of $107 million. The Consortium to Alleviate PTSD (CAP), a collaboration led by the University of Texas Health Science Center-San Antonio and other medical centers, seeks to discover and develop biomarkers that can be useful for diagnosis and for the development of therapies. The Chronic Effects of Neurotrauma Consortium (CENC), a collaboration led by Virginia Commonwealth University, will study the links between concussions, chronic mild TBI, neurodegeneration, and related conditions.

Continue collaboration with academia. Recent collaborative achievements make clear how much can get accomplished when the public and private sectors join forces.

Within the next 12 months Build a framework. Researchers will develop a more precise system for classifying TBI to enhance diagnostic accuracy and treatment. Continue to standardize, integrate, and share data as appropriate. Agencies will create a set of data identifiers, known as common data elements (CDEs), to be used across studies and across agencies. Specifically, they will expand upon the success of the Federal Interagency TBI Research Informatics System s CDE approach to advance PTSD and suicide research.

Build new tools and technologies. Agencies intend to fund innovative research through the President s BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative. Maximize impact of existing research. The NIH and DoD will build on their collaborative, comprehensive 100,000-servicemember study, known as Army STARRS. They will assess how a longitudinal follow-up can define risk and resilience to inform suicide prevention efforts. Focus on outcomes and prevention. Scientists will perform ongoing, coordinated analyses of existing and emerging diagnostics, therapeutics, and outcome measures. Agencies will unite all facets of research, from basic science to follow-up care, towards a common goal.

Within the next 2-4 years Explore genetic markers. Agencies will study and disseminate findings exploring the association between genome sequences and elevated risk for mental health conditions. Identify changes in brain circuitry. Agencies will study and disseminate findings from studies identifying brain circuitry changes related to positive treatment response. Confirm potential biomarkers. Agencies will identify potential predictive or diagnostic biomarkers for PTSD and TBI using data from a number of genetic and clinical studies. Establish data-sharing agreements. Agencies will share data and foster collaboration across agencies, service branches, and scientists, as appropriate. http://www.nimh.nih.gov

REFERENCES American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: Author. "DSM-5 Diagnostic Criteria for PTSD Released." - NATIONAL CENTER for PTSD. US Department of VeteransAffairs, n.d. Web. 16 Aug. 2013 Haagsma, Juanita A. "Prevalence Rate, Predictors, and Long-term Course of Probable Posttraumatic Stress Disorder after Major Trauma." BMC Psychiatry 12 (2012): n. pag. Abstract. (n.d.): n. pag. Print. Gore, Allen T., MD, MBA. "Posttraumatic Stress Disorder." Posttraumatic Stress Disorder. Medscape Reference, n.d. Web. 22 Aug. 2013. <http://emedicine.medscape.com/article/288154-overview>. Nimh.nih.gov/Health & Education/post-traumatic stress disorder/index. pp 1-11. Web. 11Aug. 2013

REFERENCES "PTSD for Children 6 Years and Younger." - NATIONAL CENTER for PTSD. US Dept of Veteran's Affairs, n.d. Web. 23 Aug. 2013. Morey, Rajendra A., M.D., M.S. "PTSD linked to smaller brain area regulating fear response." Journal Archives of General Psychiatry (2012): n. pag. DukeHealth.org. Duke Medicine News and Communications, 5 Nov. 2012. Web. 09 Sept. 2013. <http://www.dukehealth.org/>. Sadock, Benjamin J., Virginia A. Sadock, and Benjamin J. Sadock. "Posttraumatic Stress Disorder." Kaplan & Sadock's Concise Textbook of Clinical Psychiatry. 3rd ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2008. 258-63. Print.

References: Staff, Mayo Clinic. "Definition." Mayo Clinic. Mayo Foundation for Medical Education and Research, 08 Apr. 2011. Web. 23 Aug. 2013. <http://www.mayoclinic.com/health/post-traumatic-stressdisorder/ds00246/dsection=symptoms>.