Posttraumatic Stress Disorder

Historical Overview of Traumatic Reactions: late 19th century Terms used in combat veterans populations –Cardiovascular: Soldier’s heart Da Costa’s Syndrome Neurocirculatory asthenia –Psychiatric Nostalgia Shell shock Combat fatigue War neurosis Terms used in civilian populations –Railway Spine

Later Descriptions of Traumatic Reactions (1940s-1980s) Later descriptions of post-traumatic responses were labeled according to the type of trauma –Rape trauma syndrome –Survivor syndrome –War neurosis –Shell shock

PTSD: DSM-III (1980) PTSD becomes an established diagnosis Traumatic event defined as “a recognizable stressor that would evoke significant symptoms of distress in almost anyone.” Three symptom clusters (based on clinical experience): reexperiencing, numbing and detachment, and changes in personality

PTSD: DSM-III-R (1987) Definition of trauma was narrowed: –“An event outside the range of usual human experience and that would be markedly distressing to almost anyone” Avoidance symptoms were added to numbing cluster Symptoms expanded from 12 to 17 Duration and onset criteria added Impairment in functioning and/or distress added. Issues with definition: –Definition proved too restrictive as traumas more common than originally believed –Did not allow for individual differences

PTSD: DSM-IV (1994) Exposure to a traumatic event in which the person: –experienced, witnessed, or was confronted by death or serious injury to self or others AND –responded with intense fear, helplessness, or horror Symptoms –appear in 3 symptom clusters: reexperiencing, avoidance/numbing, and hyperarousal –last for > 1 month –cause clinically significant distress or impairment in functioning

Acute Stress Disorder: DSM-IV (1994) Exposure to a traumatic event in which the person: –experienced, witnessed, or was confronted by death or serious injury to self or others AND –responded with intense fear, helplessness, or horror > 3 dissociative symptoms >1 reexperiencing symptoms >1 anxiety/arousal symptoms Onset: 2 days to 4 weeks Clinically significant distress or impairment in functioning

Criterion A: Exposure Criteria Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity Person’s response involved fear, helplessness, or horror or in children agitated behavior

Criterion B: Re-experiencing Criteria Recurrent and Intrusive distressing recollections of the event (images, thoughts, or repetitions) Recurrent distressing dreams of the event Acting or feeling as if the traumatic event were recurring

Criterion B continued… Intense Psychological Distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological Reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C1: Persistent Avoidance Criteria Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma

Criterion C2: Numbing of Gen. Responsiveness Criteria Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of foreshortened future

Criterion D: Increased Arousal Criteria Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

Criterion E Symptoms in criteria B, C, and D are more than 1 month

Criterion F The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning

Specifications Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more With delayed onset: if onset of symptoms is at least 6 months after the stressor

Acute Stress Disorder

Criterion A: Exposure Criteria Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity Person’s response involved fear, helplessness, or horror or in children agitated behavior

Criterion B: Dissociative Criteria Subjective sense of numbing, detachment, or absence of emotional responsiveness Reduction in awareness of one’s surroundings (e.g., “being in a daze”) Derealization Depersonalization Dissociative amnesia

Criterion C: Re-experiencing Criteria Recurrent images Thoughts, dreams, illusions Flashback episodes, or a sense of reliving the experience Distress on exposure to reminders of the traumatic event

Criterion D: Avoidance Criterion Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)

Criterion E: Physiological Criteria Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)

Criterion F: Psychosocial Criteria Clinically significant distress or impairment in social, occupational, or other important areas of functioning Impaired ability to pursue some necessary task, such as obtaining personal assistance or mobilizing personal resources

Criterion G: Time Criteria Minimum of 2 days Maximum of 4 weeks Occurs within 4 weeks of the traumatic event

Inter-relationship between ASD and PTSD EventASDPTSD 2 days – 4 weeks 4 weeks and on

How does someone develop PTSD? Classical Conditioning Unconditioned Stimulus Unconditioned Response Car Jacking Thoughts Feelings Behaviors CS CR

Validity is Well Established PTSD has proven to be a useful and valid diagnosis after 25 years of clinical use Although there have been minor revisions to the diagnostic criteria the core concept has withstood the test of time

PTSD Prevalence in US Adults National Comorbidity Survey (1995); NCS-Replication (2005) –Large national probability samples (Ns > 5000) –Benchmark for prevalence of mental disorders in US Lifetime PTSD prevalence = 6.8% (NCS-R) –9.7% women –3.6% men Current PTSD prevalence = 3.6% (NCS-R) –5.2% women –1.8% men

The Burden of PTSD Individuals with PTSD have: –Elevated risk of mood, other anxiety, and substance abuse disorders –Elevated risk of suicide attempts –Greater functional impairment –Reduced quality of life PTSD had the greatest impact of all anxiety disorders on economic burden to society (Greenberg et al., 1999)

PTSD and Functioning in the NCS In NCS, PTSD associated with: –40% elevated odds of academic failure –30% elevated odds of teenage parenthood –60% elevated odds of marital problems –150% elevated odds of current unemployment