1. Post Traumatic Stress Disorder
Dr Linda McCarthy
Senior Specialist Psychiatrist
Director, PTSD Program
RGH Daw Park

2. History of PTSD
Symptoms of traumatic syndromes date back over centuries
Ancient Rome
Soldiers Heart
Shell Shock
PTSD

3. History of PTSD
Consistent description of features, but a lack of effective treatments for traumatic syndromes
Battle fatigue after WW2
Battle shock
Implications about relationship to mental disorders (compensation)

4. History of PTSD PTSD first described as such in DSM III in 1980
Prototype for environmentally induced disorder triggered by an external event
Involved emotional deregulation and memory disturbance
Concept essentially the same, empirically validated, consensus achieved
Born from Vietnam war

5. Diagnostic criteria for PTSD DSM - 5
Criterion A: stressor
Person exposed death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
Direct exposure
Witnessing, in person.
Indirectly, learning that close relative or friend exposed to trauma. Must have been violent or accidental.

6. Diagnostic criteria for PTSD DSM - 5
Criterion A: stressor
Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse).
Does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

7. Diagnostic criteria for PTSD DSM - 5
Criterion B:
Traumatic event persistently re-experienced in the following way(s): (one required)
Recurrent, involuntary, and intrusive memories
Traumatic nightmares
Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness
Intense or prolonged distress after exposure to traumatic reminders
Marked physiologic reactivity after exposure to trauma-related stimuli.

8. Diagnostic criteria for PTSD DSM - 5
Criterion C: Avoidance symptoms
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)
Trauma-related thoughts or feelings.
Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

9. Diagnostic criteria for PTSD DSM - 5
Criteria D: Negative alterations, cognition and mood:
Inability to recall key features of the traumatic event (dissociative amnesia).
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 resulting consequences

10. Diagnostic criteria for PTSD DSM - 5
Criteria D: (cont.)
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.

11. Diagnostic criteria for PTSD DSM - 5
Criterion E: alterations in arousal and reactivity (two required):
Irritable or aggressive behaviour (angry outbursts, little or no provocation)
Self-destructive or reckless behaviour
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance

12. Diagnostic criteria for PTSD DSM - 5
Specify if: With dissociative symptoms.
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 six months after the trauma(s), although onset of symptoms may occur immediately.

13. Diagnostic criteria for PTSD DSM - 5
Criterion F: duration
Persistence of symptoms for more than one month
Criterion G: functional significance
Clinically significant functional impairment (e.g., social, occupational, other).
Criterion H: exclusion
Disturbance not due to medication, substance use, or other illness

14. PTSD

15. Complex PTSD Major causes: trauma in childhood – abuse, neglect
Sx of PTSD also accompanied by personality changes – c.f. borderline traits
Emptiness
Emotional dysregulation
Hostility
DSM has not been adequate so far…

16. Post-Traumatic Stress Disorder
Estimates suggests that up to 90% of people will be exposed to a significant traumatic event during their lifetime
20% of ♀ and 8% ♂ will go on to PTSD
Lifetime prevalence 10% ♀ and 5% ♂
Lifetime prevalence amongst Australian Vietnam veterans > 17%

17. Risk factors for PTSD Female gender: Male gender: Assault MVA Combat
Sexual assault
Others – low socio-economic status, high risk occupations
Lower educational achievement, family dysfunction, family psychiatric hx

18. Biology of PTSD
Disturbance of key neurotransmission in the brain, and other hormonal axes: noradrenergic, thyroid, endogenous opioid, serotonin and HPA
Up-regulated catecholamines
Down-regulated adrenergic receptors
Typical fight or flight response
Reduced regulation of autonomic response to emotional arousal and external stressors
Disturbed appraisal, learning and memory

19. Comorbidities & PTSD
People with PTSD up to 80% more likely to satisfy diagnostic criteria for other psychiatric dx:
Alcohol use problems
Other substance misuse
Depression
Other anxiety disorders
Chronic pain
Medical issues (obesity, diabetes, CV disease, smoking-related illnesses)
TBI

20. PTSD treatment options
Psychological therapy (regarded as first line):
Psychoeducation
Cognitive behavioural therapy
Trauma focus therapy
Desensitisation
Little or no role for routine “debriefing” after a traumatic event
Drug therapy

21. PTSD programme goals Manage anxiety Anger Nightmares, flashbacks
Reduce impact on QOL
Reduce impact on relationships and general functioning

22. PTSD programme elements
Psychoeducation
Anxiety management:
Physical
Controlled breathing strategies
Progressive muscle relaxation
Aerobic exercise
 stimulant intake (caffeine, nicotine)
Cognitive
Thought stopping
Distraction
Behavioural
To address avoidance and social withdrawal

23. PTSD programme elements
Exposure treatments
Imaginal exposure (CBT technique)
Cognitive restructuring
Management of comorbid conditions
Alcohol
Depression

24. PTSD – Psychological interventions
Strongest evidence for exposure therapy (Foa & Rothbaum)
Imaginal exposure
Trauma emotionally processed or digested
Cognitive processing therapy
Exposure by writing

25. PTSD drug treatment options
Antidepressants
Antipsychotics
Hypnosedatives
Mood stabilisers such as anticonvulsants
Adjuvant therapies

26. PTSD drug treatment options
Many drug treatment options have been examined, no treatment universally effective
Many patients need sequential trials of drug treatment
Many require combinations of drugs, also combined with psychological approach

27. PTSD drug treatment options
Many drugs are known to work for PTSD
Methodological difficulties with research, many studies short duration with high drop-out rates
Many drugs not examined thoroughly because of patent limitations

28. Antidepressants for PTSD
Almost all antidepressants drugs are known to work for PTSD
First research with TCAs and MAOIs
Greatest evidence now for SSRIs, some with FDA and TGA approval
Anxiolytic effect may be independent of antidepressant effects

29. Antidepressants for PTSD
SSRIs
Mirtazapine
Venlafaxine
TCAs
MAOIs
Other agents may also be effective

30. Antipsychotics for PTSD
Relative lack of controlled research
Clinical use in situations where there is severe agitation, anger or requirement for sedation
Not approved indication, no PBS subsidy but may attract RPBS subsidy
Generally reserved for time limited course of treatment or prn therapy

31. Hypnosedatives & PTSD BZDs play multiple roles:
Sedation
Anxiolytic
Substance withdrawal management
Care required in view of high potential for dependence and known association of PTSD and substance use disorders

32. Hypnosedatives & PTSD
Avoid very short acting drugs (alprazolam) and favour longer acting drugs (e.g. diazepam)
May interact with SSRIs
Can potentiate sedation seen with other prescribed drugs, will also interact with alcohol

33. Mood stabilisers & PTSD
Not regarded as first line therapy
Valproate and carbamazepine most often used
Regarded as helpful for severe anger/impulse control issues
Many serious adverse effects, not safe in overdose or pregnancy

34. Adjuvant therapies for PTSD
Prazosin
Propranolol
Baclofen
Clonazepam
Buspirone
Others under investigation
Topiramate

35. Alcohol & PTSD Use of treatments to decrease EtOH use:
Naltrexone
Acamprosate
Disulfiram (last choice)
Topiramate (strong evidence evolving)
May enhance the effectiveness of other interventions

36. In conclusion… Relatively common, especially amongst specific groups
Unique amongst almost all Dx in DSM5
Extreme variability in presentation, course, severity and outcome despite consistent core symptoms