Download Psychiatry Symposium

Post Traumatic Stress Disorder
Dr Linda McCarthy
Senior Specialist Psychiatrist
Director, PTSD Program
RGH Daw Park
History of PTSD

Symptoms of traumatic syndromes date
back over centuries
– Ancient Rome
– Soldiers Heart
– Shell Shock
– PTSD
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)
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

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.
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.
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.

Diagnostic criteria for PTSD
DSM - 5

Criterion C: Avoidance symptoms
– Persistent effortful avoidance of distressing traumarelated stimuli after the event: (one required)
– Trauma-related thoughts or feelings.
– Trauma-related external reminders (e.g., people, places,
conversations, activities, objects, or situations).
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
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.
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
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.
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
other illness
not due to medication, substance use, or
PTSD
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…
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%
Risk factors for PTSD




Male gender:
– Assault
– MVA
– Combat
Female gender:
– Sexual assault
Others – low socio-economic status, high risk
occupations
Lower educational achievement, family
dysfunction, family psychiatric hx
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

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, smokingrelated illnesses)
– TBI
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
PTSD programme goals
 Manage
anxiety
 Anger
 Nightmares,
flashbacks
 Reduce impact on QOL
 Reduce impact on relationships and general
functioning
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
PTSD programme elements
 Exposure treatments
 Imaginal exposure (CBT technique)
 Cognitive
restructuring
 Management
 Alcohol
 Depression
of comorbid conditions
PTSD – Psychological interventions
 Strongest
evidence for exposure therapy
(Foa & Rothbaum)
 Imaginal exposure
Trauma emotionally processed or digested
 Cognitive processing
Exposure by writing
therapy
PTSD drug treatment options
 Antidepressants
 Antipsychotics
 Hypnosedatives
 Mood
stabilisers such as
anticonvulsants
 Adjuvant therapies
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
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
Antidepressants for PTSD
 Almost
all antidepressant 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
Antidepressants for PTSD
 SSRIs
 Mirtazapine
 Venlafaxine
 TCAs
 MAOIs
 Other
agents may also be effective
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
Hypnosedatives & PTSD
 BZDs
play multiple roles:
 Sedation
 Anxiolytic
 Substance
 Care
withdrawal management
required in view of high potential for
dependence and known association of
PTSD and substance use disorders
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
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
Adjuvant therapies for PTSD
 Prazosin
 Propranolol
 Baclofen
 Clonazepam
 Buspirone
 Others
under investigation
 Topiramate
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
Why use yoga for ptsd?
Yoga used for thousands of years to calm both mind and body, reduces
autonomic sympathetic activation, muscle tension, & BP
Normalises neuroendocrine & hormonal activity, decreases physical
symptoms and emotional distress, ultimately increasing quality of life
Yoga shows promise for cognitive, emotional, and physiological symptoms
of PTSD (Emerson et al., 2009)
Yoga
•
•
is known to increase vagal tone
increases GABA tone in the brain (main inhibitory neurotransmitter)
increases oxytocin and prolactin release → positive emotions like safety, bonding
Greater
heart rate variability → Well balanced ANS, equates to wellbeing
PTSD Neurology (Van der Kolk)
Recent research neurobiological and neuro-imaging suggests
that those with PTSD have changes in blood flow:
–
–
–
–
Decreased in (L) PFC
Decreased in Broca’s area – speech
Increased in (R) limbic area (Amygdalia)
Increased in visual cortex (Brodmann’s area 19)
Potential consequences include
–
–
–
–
–
Diminished working memory
Diminished problem solving – executive functioning
Diminished attention and verbal communication
Intense emotions and stress response
Flashbacks
PTSD Three Brain Systems
(Van der Kolk)
The Watchtower – the medial prefrontal cortex
 Interoception
 Meditative practices
–
–
–
Mindfulness
Yoga
Body work
The Cook – thalamus – dysfunctional, integrates sensations

Disintegration - flashbacks
The Smoke Detector
Primitive brain – amygdala – hyperactive
Fear/Fight/Flight/Freeze
EMDR
Yoga and PTSD
 Yoga is body-based & breath-based & exerts influence on
autonomic nervous system that cannot be achieved through
verbally based treatments or pharmacological manipulation
 Body/breath-based approaches facilitate re-connection of
brain functions allowing recognition of sensory input &
disruption of pathological feedback loops that perpetuate
symptoms (alarm/danger/threat)
 The results of RGH research accord with those emerging from
other research, mainly from the USA, in large part funded by
the Department of Defence
Yoga and PTSD
 Ironically, this also accords with ancient wisdom that has long been held
in non-Western cultures but which has been up until recently not well
understood in Western medicine
 Neuroplasticity may well underpin the effects of yoga by allowing the
brain to change and adapt in a positive way under the influence of
techniques that facilitate the re-establishment of functional neural
pathways and the down-regulation of other maladaptive connections.
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