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Download Diagnostic criteria for PTSD
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Post Traumatic Stress Disorder Acute Stress Disorder Dr. A. Hadjebi History U. S. civil war : Soldier's heart syndrome 1900 s : Traumatic neurosis due to the influence of psychoanalysis World war I : shell shock World war II : combat neurosis or operational fatigue Vietnam war : post traumatic stress disorder History PTSD: DSM-III (1980) ASD; DSM-IV (1994) PTSD in DSM-III: reexperience(1),psychic numbing(2), other items(1), no duration criteria PTSD in DSM-III-R is similar to DSM-IV-TR In ICD-10 PTSD & ASD are stress related disoders Epidemiology Life time prevalence (8%) 30% of Vietnam veterans 25 % subclinical form of disorder In women : life time prevalence 10- 12% In men : life time prevalence 5- 6% PTSD is most prevalent in young adults Men's trauma : combat experience Women's trauma : assault or rape Epidemiology PTSD most likely to occur in single , divorced , widowed , socially withdrawn , low socioeconomic level First degree biological relatives of persons with a history of depression have an increased risk for developing PTSD following a traumatic event Comorbidity About 2/3 having at least tow other disorders Common comorbid conditions include : depressive disorders , substance related disorders , other anxiety disorders and bipolar disorders Etiology Stressor Risk factors Psychodynamic factors Cognitive – behavioral factors Biological factors Noradrenergic system Opioid system Corticotropin – releasing factor and the HPA axis Psychological aspects of PTSD Emotional response to trauma reminder Base line physiological activity Exaggerated startle reflex. Diagnostic criteria for PTSD Exposure to a traumatic event The traumatic event is persistently reexperienced Persistent avoidance of stimuli associated with the trauma Persistent symptoms of increased arousal Duration of the disturbance is more than 1 month Diagnostic criteria for PTSD Significant distress or impairment in social, occupational or … Specify if : acute : < 3 months chronic : > or = 3 months With delayed onset Diagnostic criteria for ASD The disturbance last for a min. of 2 days and a max. of 4 weeks and occurs within 4 weeks of the traumatic events PTSD in children and adolescents Child risk factors include : - demographic factors ( age, socioeconomic status ) - life events - psychiatric comorbidity - parental psychopathology - parental marital status Gulf war syndrome Health problems - Irritability - Chronic fatigue - Shortness of breath - Muscle and joint pain - Migraine headaches - Digestive disturbances - Rash - Hair loss - Forgetfulness - Difficulty concentrating Differential diagnosis organic; head trauma, epilepsy, alcohol use disorder Pain disorder Substance abuse Other anxiety disorders Mood disorders Borderline disorders Dissociative disorders malingering Course and prognosis 30 % recover completely 40 % mild symptoms 20 % moderate symptoms 10 % remain unchanged Good prognosis is predicted by : - rapid onset of the symptoms - short duration of the symptoms - good premorbi functioning - strong social supports - absence of other psychiatric, medical or substance – related disorders Course and prognosis The very young and very old have more difficulty with traumatic events than do these in midlife PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and difficult to treat Social support influence the development, severity and duration of PTSD Treatment Psychotherapy Pharmacotherapy Psychotherapy Psychodynamic psychotherapy Cognitive – behavior therapy Group therapy Family therapy pharmacotherapy SSRIs : Sertraline and Paroxetine Buspirone TCA: Impramine, Amitriptyline Some studies indicate that pharmacotherapy is more effective in treating the depression, anxiety and hyperarousal than in treating the avoidance and emotional numbing Other drugs ; MAOIs ( Phenelzine ), Trazodone, Anticonvalsants, (carbamazapine, valpoarate ), clonidine, propranolol Recommendation Strongly recommend selective serotonin reuptake inhibitors (SSRIs) as first line agents for the treatment of PTSD. Recommend tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as second-line treatments for PTSD. Consider an antidepressant therapeutic trial of at least 12 weeks before changing therapeutic regimen. Recommendation Consider prazosin to augment the management of nightmares and other symptoms of PTSD. Recommend medication compliance assessment at each visit. Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely; however it is recommended that maintenance treatment should be periodically reassessed Group Name Global Reexp. Avoid. Hypera imp. rousal SSRI Fluoxe tine Sertrali ne Paroxe tine * * * * * TCAs * * MAOIs * * * * * * * * * Group Name Global Reexp. Avoid. Hypera imp. rousal Sympa tholytic * Prazosi n * * Propran olol Novel Antidep. Trazod. * * * Nefaz. * * * Group Name Global Reexp. Avoid. Hypera imp. rousal Antico nvul. CBZ * * Valpro. * BDZ Atyp.a ntipsy. * * * * Special considerations on sep. 11. 2001 3500 deaths and injuries 45% of adults reported symptoms of stress , such as distressing recollections of the event, insomnia, nightmare,… 90% reported minor degrees of symptoms Susceptibility to symptoms was associated with : female, nonwhite, having previous psychological illness, being close to disaster site Special considerations on sep. 11. 2001 Over 80 % of parents reported that their children had one or more symptoms Survey of Manhattan residents conducted 5 to 8 weeks after the world trade center collapsed: - 9.8% (90000 ) people had PTSD or clinical depression - 3.7% ( 34000 ) people met the criteria for both diagnosis