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 16-24 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 12-14 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 factorData from 485 emergency service personnel, who had experienced an occupational trauma (see Andrews et al., 2006)