Epidemiology of PTSD Incidence: proportion of the population that falls ill within a specified time period (e.g., annual incidence rate) Prevalence: proportion of the population that has the disorder within a specified time period (e.g., annual prevalence rate, current prevalence, lifetime prevalence)

Epidemiologic Catchment Area (ECA) Survey Helzer et al. (1987) 2,493 adults in St. Louis area Lifetime prevalence of PTSD: 1% 3.5% in civilians exposed to physical attack 20% in vets wounded in Vietnam

Epidemiologic Catchment Area (ECA) Survey Davidson et al. (1991) 2,985 adults in North Carolina 1.3% lifetime prevalence 0.44% current (past six months) prevalence About half became chronic Suicide attempt in PTSD vs. no disorder (19.8% vs. 0.8%)

These ECA studies suggested that PTSD was a relatively rare disorder in the general communiy Based on DSM-III criteria

National Comorbidity Survey - Replication (2005) Ron Kessler Lifetime prevalence of DSM-IV PTSD in USA is 6.8% 9.7% of women 3.6% of men Not attributable to differential trauma exposure Current prevalence (during the past 12 months) –3.5% in the NCS-R

Breslau’s Detroit-area studies 90% of adults have been exposed to a DSM-IV trauma But the vast majority of respondents did not develop PTSD Conditional probability (% of trauma- exposed persons who met PTSD diagnostic criteria) –13% of trauma-exposed women got PTSD –6% of trauma-exposed men got PTSD

Breslau’s Detroit-area studies Likelihood of PTSD depended on the type of event –40% of the cases of lifetime PTSD were caused by assaultive violence Combat, rape, physical violence –Almost 30% of the cases were caused by sudden, unexpected death of friend or relative

How long does PTSD last? Kessler’s NCS (1995) DSM-III-R study –After one year, about two-thirds of the cases remit –Among those who fail to remit after one year, about 50% will eventually remit (regardless of treatment) Breslau’s data –By one year, 50% of the male cases had remitted –By four years, 50% of the female cases had remitted

Prevalence in children and adolescents Kilpatrick et al. (2003) –National survey12-17 year-olds –3.7% males, 6.3% females Breslau et al. (1991) –Large Midwestern sample of year-olds –10.4% female, 6% male Breslau et al. (2004): more recent study –Large Eastern U.S. city –7.9% females, 6.3% males –15.1% for individuals exposed to interpersonal violence Perkonigg et al. (2000): Munich, Germany –7.8% lifetime PTSD (DSM-IV A1+A2) –1% males, 2.2% females

Prevalence in children and adolescents Youth in urban juvenile detention –11.2% in past year (Abram et al., 2004) Higher PTSD prevalence rates in studies with youth exposed to events affecting entire community –terrorism, hurricanes, earthquakes, fires, armed conflict) –sniper attack: 60.4% of school children 1-month later (Pynoos et al., 1987) –9/11 attack: 10.6% of NYC school children 6-months later (Hoven et al., 2005) –Taiwanese earthquake: 21.7% of year-olds 6 weeks after (Hsu et al., 2002) –Australian brush fire: 52.8% at 8 months, 57.2% at 26 months (McFarlane, 1987) –Lebanese and Palestinian children exposed to war: roughly one- third met criteria for PTSD (Saigh, 1988; Khamis, 2005)

Traumatic experiences versus PTSD in children and adolescents Essau et al., 1999: Munich, Germany Traumatic experience (22.5%) –28.5% males, 18.4% females –11.8% 12-13y, 27% 14-15y, 30.2% 16-17y PTSD (1.6%) –1.4% males, 1.8% females –0.3% 12-13y, 2.3% 14-15y, 2.6% 16-17y

Problems of studying trauma and PTSD in very young children Reactions often determined by parental reports Research on posttraumatic stress symptoms involving very young children (< 9 years) has generally been rare Notable exception: study of PTSD in young children following the Buffalo Creek dam collapse (Green et al., 1991) –group of 43 children between 4 and 9 years –results indicate fewer PTSD symptoms in the youngest age group (compared to two other older age groups)

Problems of studying trauma and PTSD in very young children The prevalence of PTSD and PTSD symptoms in preschool-age children reported to be far lower than in older children (Scheeringa et al., 2003) –interpreted to suggest that young children generally more resilient (Garmezy & Rutter, 1985). –However, young children’s failure to report PTSD symptoms (such as intrusive thoughts) may also be the result of their limited ability to report on their cognitive symptoms (Scheeringa, Wright, Hunt & Zeanah, 2006)

Other Trauma Syndromes? Acute Stress Disorder (David Spiegel) –No diagnosis for posttraumatic stress arising within one month –ASD should be recognized as a disorder because it predicts PTSD

Criterion A –Traumatic event Criterion B (dissociative symptoms - 3) –Numbing, detachment, absence of emotional responsiveness –Reduction in awareness (being in a daze) –Derealization Criterion B –Depersonalization –Dissociative amnesia Criterion C (1) –Recurrent images, dreams, flashbacks –Distress on exposure to reminders

Criterion D –Marked avoidance Criterion E –Anxiety or increased arousal (startle, sleep problems, hypervigilance, poor concentration) Criterion F –Distress and impairment Criterion G –Last for at least 2 days, maximum of 4 weeks

Other Trauma Syndromes? Dissociative symptoms supposedly especially predictive Richard Bryant –Between 72% and 83% of those diagnosed with ASD have PTSD 6 months post-trauma –But between 37% and 73% who develop PTSD first had ASD Early PTSD predicts later PTSD? Critique –Are we medicalizing normal responses to terrible events? –Dissociative symptoms are not that predictive

Complex PTSD Judith Herman DESNOS (Disorders of Extreme Stress Not Otherwise Specified) Believed to be a trauma syndrome arising from chronic trauma, especially that beginning in childhood

Complex PTSD Multiplicity of symptoms –Anxiety –Chronic depression –Paranoia –Somatic complaints –Self-mutilation –Dissociation –Insomnia –Affect regulation problems

Complex PTSD Characterological change –Disturbed interpersonal relationships –Destroy autonomy and identity (losing name) –Forced to betray or harm others –increased likelihood of getting in harm’s way

Complex PTSD Critique –DSM-IV field indicated that individuals meeting criteria for complex PTSD also meet criteria for PTSD –Multiple co morbidities, including borderline personality disorder? –How plausibly can we trace the syndrome to early childhood trauma?

Secondary posttraumatic stress in emergency personal (Andrews et al., 2006) 485 emergency service personnel, who had experienced an occupational trauma Same posttraumatic stress symptoms –Intrusions –Avoidance –Numbing E.g. „Have you felt that your ability to experience the whole range of emotions is impaired?“ –Arousal –+general PTSD factor

Same posttraumatic stress reaction in emergency personnel Intrusions Avoidance Numbing –E.g. „Have you felt that your ability to experience the whole range of emotions is impaired?“ Arousal +general PTSD factor Data from 485 emergency service personnel, who had experienced an occupational trauma (see Andrews et al., 2006)