1. POST TRAUMATIC STRESS
DISORDER
PRESENTED BY:DR.A.GODSON,MD

2. INTRODUCTION
• Disorder driven by pathogenic memories of
past danger.
• Symptoms must last for more than a month
• Acute stress disorder, which occurs earlier
than PTSD

3. EPONYMS OF PTSD
• Civil War-Irritable heart
• World War I-shell shock
/Effort syndrome
• World war II – combat stress
syndrome
• Vietnam War- brought the
concept of PTSD.
• Gulf war syndrome
• PTSD entered the DSM-III in
1980

4. Common feature shared by all
syndromes
• Fatigue, fainting
• Shortness of breath,
• Palpitations,
• Headache, dizziness,
• Excessive sweating,
• Disturbed sleep,
• Difficulty in
concentration
• Forgetfulness

5. EPIDEMIOLGY
• Lifetime prevalence -8 percent in general
population
• 5 to 15 percent -subclinical forms of the
disorder.
• Among high-risk groups -5 to 75 percent.
• 10 to 12 percent among women
• 5 to 6 percent among men.
• Higher in women, single, divorced, widowed,
socially withdrawn, of low socioeconomic level

6. • Sexual assault-higher impact
• Sudden unexpected death
of a loved one and road
traffic accidents
• Men -more traumatic
events
• Women - higher impact
events.

7. COMORBIDITY
• Depressive disorders
• Substance-related disorders
• Anxiety disorders
• Bipolar disorders

8. ETIOLOGY

9. Stressor
• Prime causative factor
• Stressors of human design-rape and violent
assault, are usually more pathogenic
• Sudden, unexpected, and life-threatening
events
• Disasters related

10. Risk factors for being exposed to
trauma
• Less than a college education
• Being male
• History of childhood conduct
problems
• Family history of psychiatric
illness
• Extroverted
• More neurotic

11. Risk factors for PTSD Among those
exposed to trauma
• Female, neuroticism
• Lower social support
• Lower IQ
• Pre-existing psychiatric
illness
• Family history of mood,
anxiety, or substance
abuse disorders
• Neurological soft signs

12. PREDICTORS
• Previous exposure to trauma
• Peritraumatic responses
• Negative interpretations of one's acute
responses
• Borderline, paranoid, dependent, or antisocial
personality disorder traits
• Presence of childhood trauma
• Inadequate family or peer support system
• Recent stressful life changes
• Recent excess alcohol intake

13. GENETICS
• 1/3rd of variance in
symptoms is genetic
• Trauma exposure-little or
no effect on measures of
IQ &neurocognitive
functioning
• Similarity in the test
scores between co-twins
implies genetic influence
on cognitive performance
• Above average cognitive
ability -protect

14. Psychodynamic Factors
• Trauma has reactivated a previously quiescent, yet
unresolved psychological conflict
• The subjective meaning of a stressor may determine
its traumatogenicity.
• Traumatic events can resonate with childhood
traumas.
• Inability to regulate affect can result from trauma.
• Somatization and alexithymia may be among the after
effects of trauma.
• Common defenses -denial, minimization, splitting,
projective , dissociation, and guilt
• Mode of object relatedness involves projection and
introjection

15. COGNITIVE FACTORS
• Affected persons cannot process or rationalize
the trauma that precipitated the disorder.
• They continue to experience the stress and
attempt to avoid experiencing it by avoidance
techniques.
• Less decline in vividness, emotional intensity, and
accuracy of traumatic memories.
• Exhibit difficulty retrieving specific memories
• Difficulties of attentional control

16. Emotional Stroop paradigm
• Delayed naming
of the word's
colour
• Heightened
stroop
interference for
trauma words in
PTSD

17. Fear conditioning
Mowrer's two-factor conditioning theory
Traumatic stimuli (UCS) fear&arousal
UCS+CS fear response stimulus
generalization variety of stimuli become
triggers avoidance of CS negative
reinforcement by operant conditioning
prevents extinction of conditioned fear
responses maintains the problem.
•

18. Noradrenergic System
• Nervousness, increased blood
pressure and heart rate,
palpitations, sweating,
flushing, and tremors -
symptoms of adrenergic
drugs.
• Increased 24-hour urine
epinephrine concentrations in
veterans

19. • Increased urine
catecholamine
concentrations in sexually
abused girls
• Platelet alpha2- and
lymphocyte beta 2
adrenergic receptors are
downregulated

20. • Flashbacks after
yohimbine
administration

21. HPA Axis
• Low plasma and urinary
free cortisol
• CRF challenge yields a
blunted ACTH response
• DMST- enhanced
suppression of cortisol
• Indicates hyper-
regulation of HPA axis

22. Structural changes
• Lower average volume
in the hippocampal
region
• Structural changes in
the amygdale

23. Exaggerated Startle Responses
• Larger EMG eye blink
responses to a sudden
auditory stimulus
• Increased HR

24. NEUROIMAGING
• PET Studies-less anterior cingulate activation
during the emotional Stroop task
• fMRI experiment- attenuated rostral anterior
cingulate activation when exposed to war-
related words
• Dysfunction in the medial prefrontal cortex
and amygdala
• Hypoactive medial PFC loss of inhibition
on amygdala hyper-responsive amygdala

25. DSM-IV-TR Diagnostic Criteria for
Posttraumatic Stress Disorder

26. The person has been exposed to a traumatic event
in which both of the following were present:
• The person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
• The person's response involved intense fear,
helplessness, or horror.
Note: in children, this may be expressed instead
by disorganized or agitated behavior

27. The traumatic event is persistently re-experienced in
one (or more) of the following ways:
 Recurrent and intrusive
distressing recollections of
the event, including
images, thoughts, or
perceptions. Note: in
young children, repetitive
play may occur in which
themes or aspects of the
trauma are expressed.
 Recurrent distressing
dreams of the event.
Note: in children, there
may be frightening
dreams without
recognizable content.

28.  Acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback
episodes, including those that occur on awakening or
when intoxicated). Note: in young children, trauma-
specific reenactment may occur.
 Intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
 Physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event

29. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the
trauma), as indicated by three (or more) of the following:
 Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
 Efforts to avoid activities, places, or people that arouse
recollections of the trauma
 Inability to recall an important aspect of the trauma
 Markedly diminished interest or participation in significant
activities
 Feeling of detachment or estrangement from others
 Restricted range of affect (e.g., unable to have loving
feelings)
 Sense of a foreshortened future (e.g., does not expect to
have a career, marriage, children, or a normal life span

30. Persistent symptoms of increased arousal (not present
before the trauma), as indicated by two (or more)
 Difficulty falling or staying asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response

31. • Duration of the disturbance (symptoms in Criteria
B, C, and D) is more than 1 month.
• The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
• Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With delayed onset: if onset of symptoms is at least
6 months after the stressor

32. DSM-IV ICD-10 research diagnostic
criteria.
• Avoidance/numbing cluster • Not included
of symptoms - requiring a • Patient could be diagnosed
minimum of three as having PTSD in the
• Increased arousal is absence of hyperarousal
necessary symptoms if amnesia is
• Minimum symptom present
duration of 1 month • Not included
• Significant distress or • Not included
impaired functioning

33. PTSDs in Children and Adolescents
• High rates –war related
trauma, kidnapping,
severe illness or burns,
bone marrow
transplantation, natural
and man-made disasters
• Underestimated in
children and adolescents.
• Family factors
• Parents' responses to
traumatic events

34. Reenactment and Reexperiencing
• Reexperience the traumatic
event in the form of
distressing, intrusive thoughts
or memories, flashbacks, and
dreams
• Nightmares, flashbacks also
play a role
• Traumatic play, a specific form
of reexperiencing seen in
young children, consists of
repetitive acting out of the
trauma or trauma-related
themes in play
•

35. • Older children may
incorporate aspects of the
trauma into their lives in
a process termed
reenactment.
• Impulsive acting out
secondary to anger,
sexual acting out,
substance use, and
delinquency
• Regressive behaviors,
such as enuresis or fear of
sleeping alone

36. Gulf War Syndrome
• Began in 1990 and ended
in 1991
• Irritability, chronic
fatigue, shortness of
breath, muscle and joint
pain, migraine headaches,
• Digestive disturbances,
rash, hair loss,
forgetfulness, and
difficulty concentrating .
• Amyotrophic lateral
sclerosis (ALS)

37. 11/9/01
• Terrorist activity
destroyed the world trade
center in new york city
and damaged the
pentagon in washington.
• Survey found a
prevalence rate of 11.4
percent for PTSD and 9.7
percent for depression in
US citizens 1 month after
11/9

38. Tsunami
• December 26, 2004.
• Many survivors continue
to live in fear and show
signs of PTSD
• Fishermen fear venturing
out to sea
• Children fear playing at
beaches they once
enjoyed
• Trouble sleeping in fear of
another tsunami

39. Hurricane
• In August 2005, a
category 5 hurricane,
Hurricane Katrina,
ravaged the Gulf of
Mexico, the Bahamas,
South Florida,
Louisiana, Mississippi,
and Alabama

40. Earthquake
• On October 8, 2005, a 7.6
magnitude earthquake hit
South Asia, affecting
Pakistan, Afghanistan and
Northern India.
• More than 85,000 casualties
have occurred .
• Up to 3 million people were
left homeless.
• Many cases of PTSD
developed among those
who experienced these
disasters
• Recently in japan

41. Torture
• Defined as any deliberate
infliction of severe mental pain or
suffering, usually through cruel,
inhuman, or degrading treatment
or punishment.
• Torture is distinct from most
other types of trauma because it
is human inflicted and
intentional.
• physical -beatings, burning of the
skin, electric shock, or
asphyxiation
• Psychological -threats,
humiliation, or being forced to
watch others, often loved ones,
being tortured.

42. BRAIN WASH
• Combine physical and
psychological aspects is
brainwashing.
• Prevalence rates of
PTSD among survivors
of torture are about 36
percent

43. DIFFERENTIAL DIAGNOSIS
• Organic considerations -epilepsy, alcohol-use
disorders, and other substance-related disorders, Acute
intoxication or withdrawal from some substances
• Panic disorder and generalized anxiety disorder: PTSD
associated with re-experiencing and avoidance of a
trauma
• Borderline personality disorder, dissociative
disorders, and factitious disorders.- do not usually
have the degree of avoidance behavior, the autonomic
hyperarousal, or the history of trauma
• Obsessive-compulsive disorder (OCD) and generalized
anxiety disorder.-PTSD concerns memory—the
intrusion of past stressors into the present. In contrast,
OCD concerns current and future threats

44. Course and Prognosis
• Symptoms can fluctuate ,most intense during
periods of stress.
• Untreated, about 30 percent of patients recover
completely,
• 40 percent continue to have mild symptoms,
• 20 percent continue to have moderate symptoms
• 10 percent remain unchanged or become worse.
• After 1 year, about 50 percent of patients will
recover

45. Good prognostic factors Poor prognostic factors
• Rapid onset of the • The very young
symptoms • very old
• Short duration <6 months • Pre-existing psychiatric
• Good premorbid disability, whether a
functioning personality disorder or a
• Strong social supports more serious condition
• Absence of other
psychiatric, medical, or
substance-related disorders

46. TREATMENT

47. Some principles for management
• Comorbid depression – treat PTSD first.
• Substance dependence should be addressed
first before treating PTSD
• Support, encouragement to discuss the event,
and education about a variety of coping
mechanisms
• Sedatives and hypnotics can be helpful.

48. Pharmacotherapy
• SSRI’S-sertraline and paroxetine are
considered first-line treatments for PTSD
• TCA’S-Imipramine and amitriptyline .Dosages
same as those used to treat depressive
disorders, trial should last at least 8 weeks.
continue the pharmacotherapy for at least 1
year if respond well

49. • MAOI’S -phenelzine ,trazodone are effective in
reducing re experiencing symptoms and
insomnia.,
• Anticonvulsants :carbamazepine , valproate
• Benzodiazepines-Benzodiazepines do not
appear to be effective although they may
show some effects on insomnia, irritability,
and general anxiety and arousal symptoms

50. CBT
Education
• about the symptoms of PTSD , treatment
rationales, Common reactions to trauma
,giving up behaviours that maintain the
problem such as avoidance and safety
behaviours.
Self-monitoring of symptoms
• self-monitoring may in itself be therapeutic

51. Exposure
• Imaginal exposure.
• In vivo exposure - going
to the site of the
traumatic event, driving
again after a road traffic
accident
• Exposure is repeated until
the patient no longer
responds with high levels
of distress.
• Helps in correcting
dysfunctional beliefs
about danger

52. Cognitive therapy
• For anxiety disorder focus on identification and
modification of misinterpretations that lead to
overestimation of threat and under estimation
of their coping abilities
• But in PTSD the perceived threat arise from the
interpretation of trauma and its consequences.
• The patient is encouraged to drop behaviour
and cognitive strategies that leads to negative
interpretation.

53. Eye-movement desensitization
reprocessing
• New and controversial treatment.
• Patient is instructed to focus on a
trauma-related image and its
accompanying feelings, sensations,
and thoughts, while visually
tracking the therapist's fingers as
they move back and forth in front
of the patient's eyes.
• After a set of approximately 24 eye
movements, cognitive and
emotional reactions are discussed
with the therapist.
• Once the distress to traumatic
image is reduced coping
statements are also introduced
while the scene is being imagined.

54. Psychodynamic therapy
• The goal of the treatment is to work through and
resolve an unconscious conflict which the
traumatic event is thought to have provoked.
Hypnotherapy
• The goal of this treatment is to enhance control
over trauma-related emotional distress and
hyperarousal symptoms and to facilitate the
recollection of details of the traumatic event
• The effect is below trauma focused CBT or EMDR

55. • Avoidance is one of
the main symptoms of
PTSD, and it can thus
take years for the
patient to seek help for
this condition

56. PTSD-NOT ALL WOUNDS ARE VISIBLE
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