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Recovery from Traumatic Stress Thomas C. Neylan, M.D. University of California, San Francisco History of Posttraumatic Stress Disorder Homer: Trojan War Veterans Civil War: Soldier’s Heart 19th Century Europe: Railroad Spine WW I: Shell Shock Vietnam War: Vietnam Syndrome 1976 Horowitz: Stress Response Syndromes 1980 DSM III: PTSD Case Study 29-year-old single women Combat helicopter pilot from Iraq War Shot down, and R shoulder rotator tear, and upper arm laceration Recovered quickly from injury, but insisted on early retirement Seeks help for poor sleep and irritability Case Study (cont.) What additional information would you want to obtain to evaluate her? PTSD DSM-IV Criteria Exposure to traumatic event with Actual or threatened death or serious injury and Response involving intense fear, helplessness, or horror American Psychiatric Association. DSM-IV. 1994. PTSD DSM-IV Criteria (cont.) Re-experiencing the traumatic event Persistent avoidance of stimuli associated with event Numbing of general responsiveness Symptoms of increased arousal At least 1 month’s duration (otherwise can diagnose Acute Stress Disorder) Significant distress or impairment in social, occupational, or other functioning American Psychiatric Association. DSM-IV. 1994. 7 PTSD Associated Features Alcohol/drug problems Aggression/violence Suicidal ideation, intent, attempts Dissociation Distancing Problems at work Marital problems Homelessness Epidemiology of PTSD National Comorbidity Study 7.8% of adults in the U.S. (lifetime) Type of trauma most often the basis for PTSD: – rape in women (46% risk) – combat in men (39% risk) 1/3 of cases have duration of many years 88% of cases have psychiatric comorbidity Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60. Combat-Related PTSD: Epidemiology Lifetime Prevalence: 30% in Vietnam veterans 5-10% of Gulf War I deployed veterans 10-20% in Operation Enduring Freedom and Operation Iraqi Freedom VIETNAM: Kulka RA, et al. Trauma and the Vietnam war generation: Report of the findings from the National Vietnam Veterans Readjustment Study. 1990, New York: Brunner/Mazel. GULF WAR: Stretch RH et al. Military Medicine. 1996;161:407-410. IRAQ WAR: Hoge, C.W., et al. R.L. N Engl J Med. 2004;351:13-22. Primary Psychiatric Disorder 6 Months Following Trauma Number of Individuals Responses to Trauma Are Heterogeneous 80 70 60 50 40 30 20 10 0 McFarlane, et al. Ann N Y Acad Sci. 1997;821:437-441 Longitudinal Course of PTSD Symptoms 94% 47% 42% ? W 3m 9m Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60. 30% Years Twelve-Month Prevalence of DSM-IV Major Psychiatric Disorders % Mood Disorders Major depressive episode Dysthymia Manic episode 6.7 1.5 2.6 Anxiety Disorders Social Phobia Simple Phobia PTSD Agoraphobia without panic GAD Panic disorder 6.8 8.7 3.5 0.8 3.1 2.7 Substance Use Disorders Alcohol abuse/dependence Drug abuse/dependence 4.4 1.8 Adapted from Kessler RC, et al. Arch Gen Psychiatry. 2005;62:617-627. Prevalence of Trauma and Probability of PTSD 40 Prevalence of Trauma 1 Male Female 30 % 20 10 0 Witness % Accident Threat w/ Weapon 70 60 50 40 30 20 10 0 Physical Attack Molestation Probability of PTSD Witness Accident Threat w/ Weapon 1. Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14. 2. Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060. Physical Attack Combat Rape Combat Rape 2 Molestation Risk Factors for PTSD Severity of trauma (ie, threat, duration, injury, loss) Prior traumatization Gender Ethnicity Prior mood and/or anxiety disorders Family history of mood or anxiety disorders Education Screening Questions for PTSD “What’s the worst thing that ever happened to you?” “How did you react when it happened?” “Do memories of _______ still bother you? Did you get over it?” “Do you avoid situations that might remind you of ____? Have your relationships suffered because of ____?” “Have you become more nervous since ___? Is it hard for you to relax because of ____?” Functional Neuroanatomy of Traumatic Stress Stress Parietal Cortex Cerebral Cortex Prefrontal Cortex Conditioned fear Hippocampus Orbitofrontal Cortex Extinction to fear through amygdala inhibition Output to cardiovascular system Long-term storage of traumatic memories Amygdala Glutamate CRF Hypothalamus Pituitary ACTH NE Attention and vigilance - fear behavior Dose response effect on metabolism Locus Coeruleus Adrenal Cortisol PTSD Treatment Options Psychotherapy Pharmacotherapy Complementary Alternative Interventions – Yoga – Exercise – Meditation Multimodal treatment Early Post-Trauma Interventions Crisis Interventions—Short cognitive behavioral therapy (CBT): Psychological Debriefing—equivocal or harmful Cognitive Behavioral Prevention Programs: Prolonged Exposure (PE) Prolonged Exposure + Stress Inoculation Training (PE/SIT) Psychotherapy Brief dynamic psychotherapy for traumatic grief Supportive counseling Spiritual counseling Pharmacotherapy Propranolol Foa EB, et al. J Clin Psychiatry. 1999;60(suppl 16):1-34. Mitchell JT. JEMS. 1983;8:36-9. Psychological Treatments for Chronic PTSD Psychotherapy Exposure therapy Cognitive processing therapy Anxiety management Additional treatments Eye Movement Desensitization and Reprocessing (EMDR) Hypnotherapy Psychodynamic therapy Expressive therapies Meta-analysis of Pharmacotherapy for PTSD 35 RCTS with 17 positive placebo-controlled trials Medication response in 59.1% Placebo response in 38.5% SSRIs most effective Medication effects greater for co-morbid depression and disability 3 maintenance trials suggest long-term medication Adrenergic-Inhibiting Agents: Alpha1-Adrenergic Blockers Prazosin* 7 to 15 mg qhs Alpha1- post-synaptic adrenoceptor receptor antagonist Alpha1 receptors widely distributed in the brain, including the amygdala and hippocampus Alpha1 receptors modulate sleep and startle responses Double-blind RCT in 40 veterans, 13.3 +/- 3 mg 1 – Robust improvement in sleep quality and distressing dreams – Medium to large effect size in each PTSD Sx cluster – Adverse reactions include: syncope, dizziness, drowsiness, decreased energy, headache *Not FDA approved for the treatment of PTSD 1. Raskind, et al. Biol Psychiatry. 2007; 61: 928-34. Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami. Descilo T, Vedamurtachar A, Gerbarg PL, Nagaraja D, Gangadhar BN, Damodaran B, Adelson B, Braslow LH, Marcus S, Brown RP. The Trauma Resolution Center of Miami, Miami, FL, USA Acta Psychiatr Scand. 2009 Aug 19. [Epub ahead of print] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(1), 17--33 (2010) Exercise and Neurogenesis? Growth factor signaling genes Growth factor signaling genes upregulated by exercise VGF involved in energy balance & synaptic activity; increased by ECS Sedentary Exercise Exercise increases VGF mRNA in the hippocampus Slide adapted from D. Shin Summary: Recommendations for Immediate Management Move to safety and reduce terrifying arousal Psychological First Aid – Low arousal, facilitate cognitive processing Education and support Emphasize need to sustain interpersonal connections Screening for risk factors and follow up