1. Associate Professor, Departments of Psychiatry and Pharmacology
Anxiety Disorders
Anita S. Kablinger MD
Associate Professor, Departments of Psychiatry and Pharmacology
LSUHSC-Shreveport

2. DSM-IV Anxiety Disorders
Specific phobias
Panic disorder
Agoraphobia
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
PTSD

4. PTSD: Presentation Outline
Introduction/History
Clinical Presentation/DSM-IV Criteria
Differential Diagnosis
Etiology/Risk Factors
Treatment Issues
Prevention

5. Introduction/History
First appeared in DSM-III (1980)
Recognized by Shakespeare in Henry IV
Civil War descriptions
WWI- shell shock and soldier’s heart
WWII- operational fatigue and combat neurosis
Organic origin vs psychogenic derivation

6. Diagnostic Criteria for PTSD
A. Exposed to traumatic event
The person experienced, witnessed, or was confronted with an event involving actual or threatened death, serious injury or a threat to physical integrity of self or others
The person’s response involved intense fear, helplessness or horror

7. Diagnostic Criteria for PTSD
B. The traumatic event is reexperienced in one or more of the following ways
Recurrent images, thoughts or perceptions
Recurrent distressing dreams of the event
Acting or feeling as if the event was recurring
Intense psychological distress OR physiologic reactivity at exposure to cues that symbolize or resemble an aspect of the event

8. Diagnostic Criteria for PTSD
C. Persistent avoidance of stimuli associated with trauma and numbing as indicated by 3 or more:
Avoiding thoughts, feelings, or discussion, activities, places or people that bring back recollections; sense of foreshortened future
Inability to recall; restricted affect
Diminished interest or participation
Feeling detached or estranged

9. Diagnostic Criteria for PTSD
D. Persistent symptoms of increased arousal by 2 or more:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
E. Duration for more than 1 month

10. Diagnostic Criteria for PTSD
F. Clinically significant impairment in functioning
Acute: Less than 3 months
Chronic: Greater than or equal to 3 months
With delayed onset: Onset at least 6 months after the stressor

11. Diagnostic Criteria for Acute Stress Disorder
A: Exposed to traumatic event
B. Experiences three or more of:
Subjective sense of numbing, detachment
Reduction in awareness of surroundings
Derealization
Depersonalization
Dissociative amnesia
C. Persistent reexperiencing of the event

12. Diagnostic Criteria for Acute Stress Disorder
D. Marked avoidance of stimuli that arouse recollections of the trauma
E. Marked symptoms of anxiety or increased arousal
F. Causes significant impairment
G. Lasts 2 days to 4 weeks and occurs within 4 weeks of the trauma

13. Epidemiology
Prevalence of PTSD: 1-14% community, 3-58% in at-risk populations
25-30% lifetime prevalence in Vietnam veterans
85% in concentration camp survivors
May be modulated by cultural differences
All ages; individuals or groups; F>M

14. Differential Diagnosis
Mental disorder secondary to GMC
(ex. head injury)
Substance-induced disorder
Dissociative disorders
Major depressive episode
Borderline personality disorder
Malingering

15. Etiological Factors Magnitude of the stress exposure
Cognitive appraisal factors
Intense fear or helplessness predictive
Sympathetic hyperactivity
Psychological factors
psychodynamic
cognitive
behavioral

16. Examples of Traumatic Events
Complicated or unexpected bereavements
Accidents
Captivity
Violent crime
Sexual trauma
Chronic physical abuse
Military combat
Natural disasters
Manufactured disasters

17. Risk Factors Lack of social support
Family psychiatric history, esp. anxiety
Previous psychiatric history
Certain personality traits
Early separation of parents
Parental poverty
Abuse in childhood
Childhood behavioral problems
Limited education
Adverse life-events prior to trauma
Female

18. Six Strongest Predictors of Trauma Exposure
Male
Absence of college education
Extroversion
Neuroticism
Early misconduct
Family psychiatric illness

19. Six Strongest Predictors for Risk of PTSD
Female
Neuroticism
Early separation from parents
Prior anxiety or depression
Familial anxiety
Familial antisocial personality disorder

20. Associated Symptoms Important for Treatment
Survival and behavioral guilt
Somatic distress
Paranoia
Interpersonal alienation
Vegetative changes of depression
Hopelessness
Impulsivity

21. Course and Prognosis 30% recover completely
40% continue with mild symptoms
20% moderate symptoms
10% unchanged or worsen
Startle, nightmares, irritability and depression often worsen with age
Comorbidity is high (MDD, OCD, Panic, substance abuse)

22. Treatment: ASD Talking about the trauma allowing:
confrontation
acceptance
process
integration
Individual or group therapy, hypnosis
Followed by support and superficiality

23. Treatment: PTSD Requires multiple modalities
Initial education, support and referrals important to establish trust
Pharmacotherapy
Psychotherapy
Relaxation Training

24. Treatment: PTSD-Pharmacotherapy
Duration of at least 8-12 weeks
Adequate dosages
Maintenance treatment for at least 1 year
Antidepressants
Mood stabilizers
Propranolol, clonidine
Atypical antipsychotics

25. Drug Treatment of PTSD Amitriptyline Fluoxetine Sertraline*
Paroxetine*
Propranolol
Clonidine
Valproic Acid
Carbamazepine
mg/day
20-60
50-200
20-50
40-160
750-1,750
200-1,200

26. Drug Treatment of PTSD Lithium Quetiapine Risperidone Olanzapine
300-1,500 mg/day
25-700
0.5-6
2.5-20

27. Treatment: PTSD- Individual Psychotherapy
Crisis Intervention
establish rapport, promote acceptance
educate, attend to general health
Trauma-focused psychotherapy
Implosive therapy
Systematic desensitization
Hospitalization may be necessary at times

28. Points to Remember
If a patient has multiple complaints, think PTSD or personality disorder up front
Under-detected because we don’t ask the right questions
One of the few DSM disorders defined by it’s cause!

29. DREAMS Detachment Re-experiencing the event Emotional effects
Avoidance
Month in Duration
Sympathetic hyperactivity or hypervigilance

30. PTSD Questionnaire

31. DSM-IV Anxiety Disorders
Specific phobias
Panic disorder
Agoraphobia
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
PTSD