Post-traumatic stress disorder (PTSD) develops after exposure to a terrifying event in which serious physical harm occurred or was threatened. PTSD can occur in people of any age and women are affected more than men. Some events that can trigger this disorder comprise: accidents, natural or human-caused disasters, violent personal assaults or military combat. Troops who serve in wars and conflicts, rescue workers involved in the aftermath of disasters; survivors of accidents, rape, physical and sexual abuse, bombing or other crimes are exposed to highly stressful events and have increased risk for developing PTSD. Autoimmune rheumatic diseases are due to a compromised immune response against the self. Physicians have commonly observed that stress adversely affects patient’s disease and many studies have demonstrated that a high percentage of patients have reported unusual emotional stress before disease onset. Stress is now days an important risk factor for the pathogenesis of autoimmune disease. Research among veterans showed that those diagnosed with PTSD had higher risk for diagnosis with an autoimmune disorder like rheumatoid arthritis, systemic lupus erythematosus autoimmune thyroiditis, multiple sclerosis, alone or in combination, compared to veterans with no psychiatric disorder. A large longitudinal study of civilian women, demonstrated that exposure to trauma and PTSD were associated with increased risk of SLE occurrence. A group of patients with fibromyalgia and PTSD reported significantly greater levels of avoidance, hyperarousal, anxiety, and depression than did the patients without PTSD symptoms. Conclusion. Rheumatic diseases are common chronic disorders. Several risk factors contribute to their pathophysiology like genetic factors, sex hormones, infections and stress. Research has showed that psychological stress and stress-related hormones are involved in immune modulation, which may result in autoimmune disease. Further studies are needed to clarify the pathophysiological implications of stress and trauma on the onset and activity of rheumatic autoimmune diseases and to determine whether treatment of PTSD and lifestyle changes can decrease the risk for developing autoimmune disorders in patients with this severe psychological disorder.

1. Post traumatic stress disorder and
rheumatic autoimmune diseases
Dr. Enida Xhaferi

2. Post traumatic stress disorder
• Post-traumatic stress disorder (PTSD) develops
after exposure to a terrifying event in which serious
physical harm occurred or was threatened. It can
arise in people of any age and women are affected
more than men.
• Some events that can trigger this disorder comprise:
accidents, natural or human-caused disasters, violent
personal assaults, combat, rape, diagnosis with a life
threatening disease, severe physical injury,
hospitalization in intensive care unit.
Dr. Enida Xhaferi

3. Post traumatic stress disorder
• Rescue workers involved in the aftermath of disasters,
troops who serve in wars and conflicts, survivors of
accidents, physical and sexual abuse, bombing or other
crimes are exposed to highly stressful events and have
increased risk for developing PTSD.
• Victims of disasters are classified in primary casualties,
secondary and tertiary victims (rescue workers and
healthcare providers)
Dr. Enida Xhaferi

4. Symptoms of PTSD
Dr. Enida Xhaferi
• Nightmares and flashbacks of past traumatic events
• Avoidance of reminders of trauma
• Emotional numbing
• Severe anxiety
• Fleeing or combative behavior
• Intrusive thoughts
• Detachment from others
• Loss of interest in everyday activities
• Hypervigilance
• Easily startled
• Sleep disturbance
• Social, occupational, and interpersonal dysfunction
• Dissociation
• Self-destructive behavior
• Somatization
• Suicidal behavior

5. Pathophysiology. Biologic factors
Dr. Enida Xhaferi
• Even thought it is not completely clear studies have
shown that patients with PTSD have smaller volume of
the hippocampus, left amygdala, and anterior cingulate
cortex
• Increased central norepinephrine levels with down-
regulated central adrenergic receptors
• Decreased glucocorticoid levels with up-regulation of
their receptors
• Abnormalities in the opioid system
• Genes may contribute to the disease susceptibility
through an interaction with environmental factors

6. Psychodynamic themes in PTSD
• Trauma may reactivate a previously dormant, unsettled
psychological conflict
• The subjective meaning of a stressor may determine the
nature of the trauma it induces
• Inability to regulate affect can produce trauma.
• Traumatic events can reverberate with childhood traumas
• Somatization and alexithymia (inability to identify and
verbalize feelings) may be the effects of trauma.
• The following defenses are commonly used - denial,
minimization, projective, dissociation, splitting, and guilt.
• Projection and introjection of the following roles : omnipotent
rescuer rescuer, abuser, victim
Dr. Enida Xhaferi

7. Cognitive factors
• Affected persons cannot manage or rationalize the trauma that lead
to the disorder.
• Trauma (unconditioned stimulus) that produces fear is paired with a
conditioned stimulus (mental reminder of trauma like sight, smell;
through instrumental learning, the conditioned stimuli produces the
fear response independent of the fearful unconditioned stimulus.
The person then avoids both the conditioned stimulus and the
unconditioned stimulus .
• They use avoidance techniques in an attempt to avoid experiencing
their enduring stress.
• Exhibit difficulty retrieving specific memories
• Attention control difficulties
• Gains from the external world (sympathy and monetary
compensation which reinforces the disorder
Dr. Enida Xhaferi

8. Risk factors for developing PTSD
• Poor family or peer support
• Lower socioeconomic status
• Family or personal history of a psychiatric condition
• Parental neglect
• Severity of initial reaction to the traumatic event
• Perception of an external locus of control not an
internal one
• Neuroticism
• Low IQ
Dr. Enida Xhaferi

9. Diagnosis of PTSD with DSM IV criteria
• Criterion A. The person has been exposed to a traumatic event in which both of the following
were present:
1. 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
2. The person's response involved intense fear, helplessness or horror. In children this may be
expressed instead by disorganized or agitated behavior.
• Criterion B. The traumatic event is persistently reexperienced in one (or more) of the
following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts,
or perceptions. In young children, repetitive play may occur in which themes or aspects of
the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: in children there may be frightening
dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the
experience, illusions, hallucinations and dissociative flashback episodes, including those that
occur on wakening or when intoxicated). In young children trauma-specific reenactment may
occur.
4. Intense psychological distress and/or physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic event.
Dr. Enida Xhaferi

10. Diagnosis of PTSD with DSM IV criteria
• Criterion C. 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:
1. Efforts to avoid thoughts, feelings or conversations associated with the trauma
2. Efforts to avoid activities, places or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest in participating in significant activities
5. Feeling detached or estranged from others
6. Restricted range of effect (eg, unable to have loving feelings)
7. Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a
normal life span)
• Criterion D. Persistent symptoms of increased arousal (not present before trauma), as indicated by
two (or more) of the following
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
• Criterion E. Duration of the disturbance (symptoms in criteria B, C, and D) is more than one
month.
• Criterion F. Disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
• Specification of duration Dr. Enida Xhaferi

11. Post traumatic stress disorder
duration
• Acute – if symptoms are present for less than three
months
• Chronic – if patients display symptoms for three
months or more
• With delayed onset - symptoms appear at least six
months after the stressor
Dr. Enida Xhaferi

12. Post traumatic stress disorder
management. Pharmacologic agents
• Treatment for PTSD include psychotherapies and medications.
• PTSD prevention is divided in three categories : primary
(preventing exposure); secondary (preventing symptoms
development immediately after exposure); tertiary (prevention
of PTSD worsening)
• Secondary interventions aim to target central nervous system
alterations with hydrocortizone and propranolol within weeks
after exposure for PTSD symptoms creation prevention.
• Tertiary procedures involve counseling and medication. Selective
serotonin reuptake inhibitors (SSRIs – sertraline, paroxetine) are
first-line pharmacologic agents for the treatment of PTSD.
• Other medications include include - tricyclic
antidepressants/TCAs (amytriptiline), monoamine oxidase
inhibitor/ MAOIs, anticonvulsants, benzodiazepins,
antiadrenergic agents,
• Critical incident stress management (CISM)
Dr. Enida Xhaferi

13. Post traumatic stress disorder.
Psychotherapeutic interventions
• Cognitive–Behavioral Therapy (CBT)
• Exposure Therapy
• Stress Inoculation Training (SIT)
• Cognitive therapy (CT)
• Cognitive Processing Therapy (CPT)
• Eye-Movement Desensitization and Reprocessing
(EMDR)
Dr. Enida Xhaferi

14. Post traumatic stress disorder and
physical disease
• A study of 3171 community responders (Spitzer C.
et al, 2009) showed that PTSD was associated with
increased risks for angina, heart failure bronchitis,
asthma, liver, and peripheral artery disease.
• Psychiatric comorbidity rates are high among
patients with PTSD and conditions include
depression, substance abuse, somatization, anxiety
and bipolar disorders.
Dr. Enida Xhaferi

15. Post traumatic stress disorder. CISM
Dr. Enida Xhaferi
• Are aimed at rescue workers, health care personnel, police
dispatchers, financial workers after robberies, people exposed
to traumatizing events, army personel and other tertiary
victims(Mitchell 1988).
• Critical incident stress debriefing (CISD)
• Pre crisis intervention programs
• Crisis intervention program (demobilization, staff
consultation and crisis management briefing
• Defusing
• CISD (introduction, fact phase, thought phase, reaction
phase, symptoms phase, teaching phase, reentry phase)
• Individual crisis prevention
• Pastoral crisis intervention
• Family CISM
• Follow up/referral

16. Stress and autoimmune diseases
• Epidemiological evidence supporting the association
between stress related disorders and autoimmune
diseases in humans is limited.
• Existing information is largely based on male, military
sample focusing on PTSD.
• A current study of a Swedish cohort (Huan Song et
al. 2018) showed that association of PTSD, but not
other stress-related disorders, was stronger for
multiple autoimmune syndromes than for single
autoimmune disease.
Dr. Enida Xhaferi

17. PTSD and autoimmune diseases
• Patients with PTSD manifest alterations in the
systems that regulate the stress response, including
the hypothalamic pituitary-adrenal (HPA) axis, and
development of a pro-inflammatory state.
• Somatic autoimmune and inflammatory diseases and
disorders have a high rate of co-morbidity with
PTSD
Dr. Enida Xhaferi

18. Potential mechanisms that might link
PTSD and immune dysregulations
• Reduced Circulating Cortisol
• Chronic Low Grade Inflammation. (Studies have found
that patients who develop PTSD have increased levelse of
cytokines like TNF alfa, IL-6, IL-β and perspective
association between PCR and PTSD.
• Alterations in Innate and Adaptive Immunity (alterations
of the Th1 versus Th2 cytokine balance; decrease in
number and function of peripheral Treg etc).
• Telomere shortening and premature immunosenescence
Dr. Enida Xhaferi

19. Rheumatic autoimmune diseases
• Autoimmune rheumatic diseases are due to a
compromised immune response against the self.
Physicians have commonly observed that stress
adversely affects patient’s disease and many studies
have demonstrated that a high percentage of
patients have reported unusual emotional stress
before disease onset.
Dr. Enida Xhaferi

20. Rheumatic autoimmune diseases
• Research among veterans showed that those
diagnosed with PTSD had higher risk for diagnosis
with an autoimmune disorder like rheumatoid
arthritis, systemic lupus erythematosus autoimmune
thyroiditis, multiple sclerosis, alone or in
combination, compared to veterans with no
psychiatric disorder (O’Donovan et al, 2014).
Dr. Enida Xhaferi

21. Post traumatic stress disorder and
LES
• A large longitudinal study of 116,430 civilian
women, showed that exposure to trauma and PTSD
were associated with increased risk of SLE
occurrence (Roberts et al. 2017).
• A group of patients with fibromyalgia and PTSD
reported significantly greater levels of avoidance,
hyperarousal, anxiety, and depression than did the
patients without PTSD symptoms (Cohen et al
2002). There is overlap between fibromyalgia and
PTSD.
Dr. Enida Xhaferi

22. Conclusion
• Rheumatic diseases are common chronic disorders.
Several risk factors contribute to their
pathophysiology like genetic factors, sex hormones,
infections and stress. Research has showed that
psychological stress and stress-related hormones are
involved in immune modulation, which may result in
autoimmune disease. Further studies are needed to
clarify the pathophysiological implications of stress
and trauma on the onset and activity of rheumatic
autoimmune diseases and to determine whether
treatment of PTSD and lifestyle changes can decrease
the risk for developing autoimmune disorders in
affected patients
Dr. Enida Xhaferi

23. References
Dr. Enida Xhaferi
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24. Dr. Enida Xhaferi