Epidemiology, Etiology, & Treatment

What is PTSD?

•Anxiety disorder•Traumatic stressor•Core features:•Reexperiencing•Avoidance•Numbing•hyperarousal

Traumatic Stressor

•DSM-III – Beyond normal range of human experience

•DSM-IV –experiences, witnesses, or is exposed to an event that is life threatening, that causes serious injury or that leads to a subjective response of intense fear,

helplessness, or horror.PTSD is unique among mental disorders• Symptoms are directly linked to traumatic stressor

Historical OverviewDiagnostic category in DSM-III

IssuesSymptoms aloneSocial ConstructionUnreliability of memory Euro-American category

But

• Traumatic neurosis (Oppenheim in 1892)

• Fright neurosis or schreckneurose (Kraeplin in 1896)

•WWs I & II•Shell shock•Combat fatigue•War neurosis

•DSM-I: GSR

• DSM-II: Transient situational disturbances

Epidemiology

Four levels

•Prevalence of Trauma Exposure•Risk Factors for Trauma Exposure•Prevalence of PTSD•Risk and Protective Factors

Prevalence of Trauma ExposureCommon or uncommon?

•NCS ≥ 60.7% of men; ≥ 51.2% have had at least 1 traumatic event in their lifetime

•Most common traumatic events•Witnessing•Natural disasters•Life-threatening accidents•Rape•Sexual molestation•Physical abuse•Childhood neglect

Risk Factors For Trauma Exposure

Random or non-random?•Gender •Age•Prior exposure•Preexisting personal characteristics•CDD•Pretrauma substance use•Genetic Vulnerability

Prevalence of PTSDSeveral factors

•PTSD ratio of women to men is 2:1 in USA

•Different among VTV – •Higher for men •Roles, stressors, education levels

•Demographics •Age •Ethnicity •Population

•Gender•Trauma type – 32 % of rape; 26% of criminal victims•Closeness to Traumatic event - WTC

Prevalence of PTSD

• International data varies•Economies and PTSD•Political turmoil, wars, disasters

•PTSD manifests itself in similar manner across culture, language, region, race•Importance of this observation?

Risk and Protective Factors

Many are exposed but few develop PTSD

Ratio of 3:1

•Categories of Risk Factors•Trauma•Peri-and post-trauma events•Individual Characteristics

Risk and Protective Factors

Trauma •Type •severity

Peritrauma Fear, helplessness, horror (r =.26)•Dissociation: blanking out, altered sense of time•PTSD is exercerbated by cognitions of panic (fear of death, fear of losing control)•Posttrauma•Social support • PTSD SS vs SS PTSD

Individual CharacteristicsDemographics & Familial Psychopathology

Demographics: age, gender, race, SES, immediate response, marital status, psychiatric history, prior trauma, personality

Familial Psychopathology•VVTR (no genetic linkage); •In general population (small but sig.) – through D2 dopamine alleles•Environment

•(greater than genetics)

Predictor Effect

Direct•War-zone stressors, malevolent war-zone environment•Hardiness, structural social support (not sig. for w/men), functional social support, and recent stressors

Indirect •Traditional combat exposure – moderated by perceived threat

Etiological Theories

Multiple Theories•Classical Conditioning

– stimulus & response connection •Schema Theories

– faulty schemas that filter info•Emotional Processing Theory

- abnormal fear structures•Cognitive Theory

- (i) classical (ii) Ehler & Clark•Multiple Representation Structures

– (i) Dual – VAM & SAM – (ii) SPAARS – schematic, proporsitional,

analogue, & associative representational systems

Classical Conditioning

Triple vulnerability

Learned Alarm (or strong mixed emotions)

Generalized Psychological Vulnerability

True Alarm (or intense basic emotion – anger, distress)

Anxious Apprehension (focused on re-experiencing emotions)

Generalized Biological Vulnerability

Advance or Numbing or Emotional Response

Moderated by Social Support and Ability to Cope

Experience of Trauma

PTSD

Concern about CC

•Startle responses•Reexperiencing•Nightmares

Treatment

Approaches (influenced by Psychoanalysis)

•Exposure Therapies•Narrative therapies•CT•CPT•PE•IR (imagery rescripting)•IRT (imagery rehearsal therapy)

Concerns? •Anxiety Management Training•Stress innoculation techniques

Treatment

•Combination Treatments•E+AMT+ CR eg CPT•CBT•TF-CBT •DBT•“Power Therapies:” TIR, VK/D, EMDR – (concern?)•ACT•Interapy•VRE

•Pharmacotherapy

Pharmacotherapy

Challengemultiple rather than single neurobiological

systemsAssumption

Brain Circuitory Excessive activation of

Amygdala

Recurrent fear conditioning of ambiguous stimuli perceived as threatening

Disinhibition of Amygdala

Target Systems•Adrenergic•HPA•Serotonergic•Dopaminergic

Medication

Antidepressants•SSRI – sertraline, paroxetine, fluoxetine•TCA – amitriptyline, desipramine•MAOI - phenelzine

Antiadrenergic•prozasin

Antikindling •Carbamazepine

•Atypical antipsychotic•resperidone, quetiapine, olanzapine

Research

Efficacious in comparison to WLDecline in anxiety, arousal, & reliving Narrative therapy cf psychoeducationExposure (alone)Active therapies vs supportive therapiesPE (60-80%, Foa, Rothbaum, & Faurr, 2003)IRT 65% (Jacobson & Traux, 1991)VRE 15-67% (Rothbaum et al. 1999)

Limitation

Resources

Friedman, M., Keane, T, & Resick, P. (Eds.) (2007). Handbook of PTSD: Science and practice. New York: The Guilford Press.

Keane, T., Marshall, A., & Taft, C. (2006). Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome. Annual Review Clinical Psychology, Vol. 2, 161-197.

Vasterling, J., Brewin, C. (Eds.) (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York: The Guilford Press.