Post traumatic stress disorder

PTSD, introduction, historical aspect, presentation, DSM criteria, ICD 10 criteria, epidemiology, management, summary, critique

1. Post Traumatic Stress Disorder Presenter – Dr. Utkarsh Modi

2. Introduction Historical aspect Evolution of concept Epidemiology Indian scenario Pathophysiology Diagnosis Differential Diagnoses Assessment Course and Prognosis Treatment Controversies Recent advances OVERVIEW

3. INTRODUCTION   Post traumatic stress disorder (PTSD) has been described as "the complex somatic, cognitive, affective, and behavioural effects of psychological trauma“ Severe anxiety disorder that can develop after exposure to any event that results in psychological trauma overwhelming the individual's ability to cope. van der Kolk BA, Pelcovitz D, Roth S, et al. Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry 1996; 153:83.

4. PTSD is characterized by : I ntrusive thoughts N ightmares and flashbacks of past traumatic events A voidance of reminders of trauma H yper vigilance S leep disturbance A ll of which lead to considerable social, occupational, and interpersonal dysfunction. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

5. Common events Military combat Violent personal assault Natural and man-made disasters Severe motor vehicle accidents Rape Incest Childhood sexual abuse Diagnosis of a life-threatening illness Severe physical injury Hospitalization in an intensive care unit (ICU) Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

6. Describing trauma One of the central issues for this field has been defining and observing a traumatic event . ICD 10 : stressful event or situation (either short lived or long lasting) of an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress in almost everybody. DSM IV definition acknowledges the possibility of a personal subjective response to a significantly greater degree. APP Textbook of Anxiety Disorders

7. HISTORICAL ASPECT The symptoms of PTSD have been described since the inception of war. Epic of Gilgamesh. Homer’s Iliad and Ciceros’s Letters to his friends. Several accurate descriptions in Shakespeare’s work as well. PCNA 1994, The phenomenology of PTSD, Dr. David A Tomb

8. Epic of Gilgamesh Homer’s Iliad

9. Railway Spine – 19 th century Jon Eric Erichsen, British surgeon Avoided stigma of mental illness. http://moftasa.net/ngram-ptsd

10. Post American Civil War, soldiers developed weakness, heart palpitations and chest pain – soldier’s heart, irritable heart, effort syndrome, DaCosta’s syndrome . First World War produced fatigue, exhaustion and anxiety – Shell shock, Battle fatigue, Combat neurosis PCNA 1994, The phenomenology of PTSD, Dr. David A Tomb

11. Evolution of concept Kardiner’s work post World War II – Physioneurosis DSM I – Gross Stress Reaction DSM II – Transient Situational Disturbance DSM III (1980)– Borrowed from work of Horowitz and others to create the term “Post Traumatic Stress Disorder” under anxiety disorders. PCNA 1994, The phenomenology of PTSD, Dr. David A Tomb

12. Vietnam War (1 November 1955  – 30 April  1975) Post Vietnam syndrome - combat related nightmares, anxiety, anger, depression, alcohol and/or drug dependence, and poor responsiveness . Females in the military, especially nurses, were exposed to highly traumatic events suffered from PTSD. Policy for reimbursement flawed. http://historyofptsd.umwblogs.org/vietnam/

13. http://moftasa.net/ngram-ptsd

14. EPIDEMIOLOGY   The lifetime prevalence - 6.8 to 12.3 % United States ( US) One-year prevalence rates of 3.5 to 6 % Overall, women are four times more likely to develop PTSD than men, after adjusting for exposure to traumatic events . The rates of PTSD are similar among men and women after events such as accidents (6.3 versus 8.8 percent), natural disasters (3.7 versus 5.4 %), or sudden death of a loved one (12.6 versus 16.2 %) Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

15. The rate of PTSD is lower in men than in women after events such as molestation (12.2 versus 26.5 %) and physical assault ( 1.8 versus 21.3 %). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

16. Risk factors include – gender (overall , women are four times more likely to develop PTSD than men) age at trauma race education lower socioeconomic status previous trauma general childhood adversity personal and family psychiatric history reported childhood abuse poor social support initial severity of reaction to the traumatic event Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Brewin CR1, Andrews B, Valentine JD.

17. Personality factors: Negative emotionality Neuroticism harm avoidance novelty-seeking trait hostility/anger trait anxiety. Negatively associated with : Extraversion Conscientiousness self-directedness high positive and low negative emotionality optimism Nenad Jakšić 1 , Lovorka Brajković 1 , Ena Ivezić 2 , Radmila Topić 1 & Miro Jakovljević

18. Sexual assault : 32% of women with PTSD had been raped and 31% had experienced sexual assault other than rape. Mass conflict and displacement : A meta analysis of 145 studies of 64,332 refugees and other conflict affected individuals internationally found a mean PTSD prevalence rate of 30.6% Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

19. Combat : Strongly correlated with the extent of injury and with the occurrence and severity of traumatic brain injury The prevalence of PTSD was 4.2% at 1 month and 12.2% by 4 months. Experiencing traumatic brain injury during military deployment was a strong predictor of subsequent PTSD symptoms. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

20. ICU hospitalization : A 2008 systematic analysis of 15 studies found the prevalence of PTSD in patients who survived intensive care unit (ICU) hospitalization to be approximately 20% Risk factors for PTSD symptoms were benzodiazepine use, early memories of frightening ICU experiences, and pre ICU comorbid psychopathology. Neither the severity of critical illness nor length of ICU stay were predictors of PTSD. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

21. Trauma exposure and PTSD have also been associated with physical illness. PTSD was associated with increased risks for angina, heart failure, bronchitis , asthma , liver , and peripheral artery disease after adjusting for socio-demographic factors, smoking, body mass index, blood pressure, depression , and alcohol use disorders. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

22. Co-morbidity 16 % have one coexisting psychiatric disorder, 17 % have two psychiatric disorders, and 50 % have three or more. Somatization disorder is as much as 90 times more likely in patients with PTSD. Depressive disorders, anxiety disorders, and substance abuse are 2 - 4 times more prevalent in patients with PTSD substance abuse is often due to the patient's attempts to self-medicate symptoms Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

23. Indian scenario Recent Trends in the Socio-demographic , Clinical Profile and Psychiatric Comorbidity Associated with Posttraumatic Stress Disorder: A Study from Kashmir, India Of the total 3400 subjects (age≥18 years), the prevalence of PTSD among general population was found to be 3.76 % Death of near one comprised the major traumatic event. Acute onset PTSD was the commonest type, previous history of psychiatric illness was found in 12 % of patients and drug abuse was present in 22.6%. Shoib S, Mushtaq R, Jeelani S, Ahmad J, Dar MM, Shah T.

24. Lessons from the 2004 Asian tsunami: Epidemiological and nosological debates in the diagnosis of  PTSD in non-Western post-disaster communities . The prevalence of PTSS was 15.1% (95% CI 12.3%-17.9%). PTSS was significantly associated with traumatic grief, female gender, physical injury, death of children and financial losses. Rajkumar AP, Mohan TS, Tharyan P

25. Intimate Partner Violence and Sexual Coercion among Pregnant Women in India: Relationship with Depression and Post-Traumatic Stress Disorder Self-reported physical violence in the last year was reported by 14% of women, psychological abuse by 15%, and sexual coercion by 9 %. Depression, somatic, and PTSD symptoms were higher in those with a history of abuse or sexual coercion Alcohol abuse in the spouse was a predictor of the presence and severity of abuse . Interestingly, the majority of women had sub-threshold PTSD scores . Such PTSD symptoms are not only prevalent but frequently disabling (Stein et al., 1997) Varma D, Chandra PS, Thomas T, Carey MP. Intimate Partner Violence and Sexual Coercion among Pregnant Women in India: Relationship with Depression and Post-Traumatic Stress Disorder. Journal of affective disorders. 2007;102(1-3):227-235. doi:10.1016/j.jad.2006.09.026.

26. Measures in the Indian Armed Forces to deal with combat stress . • Liberalized leave. • Increased provision of free warrants to home town. • Government family accommodation in peace areas • Enhanced officer–soldier interaction . • Establishment of Rest and Recoup Centers in operational areas . • Improved financial condition following last pay revision . • Significant enhancement of hardship related allowances . • Establishment of educational institutions for the wards of the soldier. • Establishment of placement cells for better post retirement prospects . • Modification of pay distribution method by direct collaboration with banks . • Effective and faster grievance redressal. • Creation of pool of trained counsellors at unit level by ongoing training programs for RT JCOs and NCOs at psychiatric centers.

27. ETIOLOGY PTSD is defined in terms of etiology as much as phenomenology. The relative severity of the traumatic event, predisposing factors, and peri-traumatic environmental factors must be considered. A consistent relationship occurred between magnitude of stress exposure and risk of developing PTSD. American Psychiatric Publication Text book of Anxiety Disorders

28. Etiology : Neurobiological Increased central norepinephrine levels with down-regulated central adrenergic receptors. A meta-analytic review found a positive association between the diagnosis of PTSD and basal cardiovascular activity Yehuda et al. 1998 Buckley et al. 2001

29. The HPA axis has been the most extensively studied neuroendocrine system in PTSD. In a large sample of Vietnam veterans, combat-exposed veterans with current PTSD had lower cortisol compared to noncombat-exposed veterans without PTSD or combat-exposed veterans with lifetime PTSD but without current PTSD 1 Administration of yohimbine, an alpha- 2-adrenergic antagonist, provoked symptoms of PTSD in combat veterans who had PTSD, as did the serotoninergic challenge with m-chlorophenylpiperazine. Boscarino 1996 Tasmann Psychiatry

30. Etiology : Imaging MRI scans : decreased volume of the hippocampus, left amygdala , and anterior cingulate cortex in patients with PTSD F-MRI and PET : increased reactivity of the amygdala and anterior paralimbic region to trauma-related stimuli 1. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD 2. Lieberzon et al. 1999

31. In response to trauma- related stimuli, there is decreased reactivity of the anterior cingulate and orbitofrontal areas. Hemispheric lateralization in which there is a relative failure of left hemispheric function (possibly accounting for confusion related to time sequence of traumatic events). Shin et al. 1999 2. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

32. Etiology : Genetic Researchers suspect that genetics may contribute to an individual's susceptibility to PTSD through an interaction with environmental factors. Presence of one of four polymorphisms at the stress related gene FKBP5, increased risk for PTSD in patients with a history of child abuse Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

33. The evidence suggests that psychiatric history, both personal or in family members, increases the likelihood of being exposed to a trauma and developing PTSD once exposed . Hidalgo and Davidson, True and Lyons 1999

34. Psychological Factors Behavioral Models - Conditioning theory has been helpful in explaining the process through which stimuli that are associated with a traumatic event can alone elicit intense emotional responses in individuals who have PTSD Guthrie and Bryant, 2006

35. Cognitive Models - The assumption of these cognitive theories is that exposure to trauma disrupts previously held beliefs about the world and that maladaptive belief changes may contribute to distress and functional impairment among trauma survivors (Boeschen et al. 2001)

36. Others Social/Environmental Factors Sleep pattern Tasmanns Psychiatry

37. DIAGNOSIS : ICD 10 A.     Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone . B.      Persistent remembering or "reliving" the stressor by intrusive flash backs, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor . C.      Actual or preferred avoidance of circumstances resembling or associated with the stressor (not present before exposure to the stressor ). D.     Either (1) or (2): (1)     Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor (2)       Persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor) shown by any two of the following: a) difficulty in falling or staying asleep; b) irritability or outbursts of anger; c) difficulty in concentrating; d) hyper-vigilance; e) exaggerated startle response    E.        Criteria B, C (For some purposes, onset delayed more than six months may be included but this should be clearly specified separately .)

38. Diagnosis : DSM V Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways : Directly experiencing the traumatic event(s). Witnessing , in person, the event(s) as it occurred to others. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse ). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

39. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s ), beginning after the traumatic event(s) occurred : Recurrent , involuntary, and intrusive distressing memories of the traumatic event(s ). Note : In children older than six years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed . Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s ). Note : In children, there may be frightening dreams without recognizable content . Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s ) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings .) Note : In children, trauma specific re-enactment may occur in play . Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s ). Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

40. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following : Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s ). Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects , situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

41. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following : Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs ). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world, for example : "I am bad'' "No one can be trusted'' "The world is completely dangerous" "My whole nervous system is permanently ruined" Persistent , distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others . Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame ). Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction , or loving feelings).

42. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following : Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects . Reckless or self-destructive behaviour. Hypervigilance . Exaggerated startle response. Problems with concentration. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

43. Duration of the disturbance (Criteria B, C, D, and E) is more than one month . The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning . The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

44. With dissociative symptoms — The individual's symptoms meet the criteria for posttraumatic stress disorder , and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following : 1. Depersonalization 2 . Derealisation With delayed expression — If the full diagnostic criteria are not met until at least six months after the event (although the onset and expression of some symptoms may be immediate).

45. Revision from DSM IV to DSM V Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This is a move from DSM-IV, which addressed PTSD as an anxiety disorder. The stressor criterion (Criterion A) in DSM5 requires being explicit as to whether the traumatic events were experienced directly, witnessed, or experienced indirectly. The criterion regarding the patient’s subjective reaction to the traumatic event (Criterion A2) in DSM-IV was eliminated in DSM-5 The categories of presenting symptoms were revised to intrusion, negative alterations in mood and cognitions , avoidance, and arousal Two new symptoms were added to criteria E (marked alterations in arousal and reactivity associated with traumatic event(s) including irritable behaviour and angry outbursts and reckless or self destructive behaviour .

46. Differentiating acute stress disorder — Presenting symptoms of posttraumatic stress and functional impairment after a highly traumatic event diagnosed as having acute stress disorder (ASD) for the first 30 days following the event. Most people recover completely within this period. For those who remain symptomatic (at the threshold established by DSM5 criteria ) after 30 days, their diagnosis is then reclassified as PTSD.

47. Tasmanns Psychiatry

48. DIFFERENTIAL DIAGNOSES Adjustment disorder Specific phobias Generalized anxiety disorder Obsessive–compulsive disorder (OCD ) Panic attack Depression Tasmanns Psychiatry

49. ASSESSMENT In screening patients for PTSD, e.g., primary care patients, returning veterans, or individuals experiencing domestic violence, particular attention should be paid to individuals presenting with new anxiety, fear, or insomnia Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

50. PTSD Checklist for veterans H elpful in screening patients for PTSD and monitoring the progress of treatment over time. T he sensitivity of the PCL ranges from 69 to 94 and the specificity is from 83 to 99. A score of 50 out of a maximum score of 85 is associated with a diagnosis of PTSD. S elf administered by patients. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

51. Adult PTSD Interviews # of items Time to Admin.  (in min.) Allows Multiple Trauma Corresponds to DSM-IV Criteria Clinician-Administered PTSD Scale (CAPS) 30 40-60 Up to 3 Yes PTSD Symptom Scale-Interview Version (PSS-I) 17 20-30 No Yes Structured Clinical Interview for DSM-IV PTSD Module (SCID) 21 20-30 No Yes Structured Interview for PTSD (SI-PTSD) 27 20-30 No Yes http://www.ptsd.va.gov/professional/assessment/adult-int/chart-adult-interviews.asp

52. Self-report measures – Posttraumatic Stress Diagnostic Scale (PDS ) Davidson Trauma Scale (DTS ) Mississippi Scale for Combat-Related PTSD (Mississippi Scale ) Child measures – Child Posttraumatic Stress Reaction Index (CPTS-RI) The Child PTSD Symptom Scale (CPSS) Children's Impact of Traumatic Events Scale-Revised (CITES-2) Parent Report of Child's Reaction to Stress Trauma Symptom Checklist for Children (TSCC) Trauma Symptom Checklist for Young Children (TSCYC) http://www.ptsd.va.gov/professional/assessment/child/index.asp

53. COURSE AND PROGNSIS Approximately 25 % experience a delayed onset after six months or more. Only 1/3 of patients recovering at one year follow up 1/3 still symptomatic ten years after the exposure to the trauma. PTSD may increase the risk for attempted suicide Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

54. Higher rates of problems in intimate relationships, including marital difficulties, compared to people without PTSD. Individual psychotherapy has been found to improve overall psychosocial functioning Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis Author - Paul Ciechanowski, MD

55. TREATMENT Posttraumatic stress disorder (PTSD) is a heterogeneous and complex disorder that may require a multifaceted treatment approach . General principles of treating PTSD involve explanation and de-stigmatization. Regaining self- esteem and attaining greater control over impulses and affect are also desired in many instances. Tasmanns Psychiatry

56. A pproach Traumatized individuals are often more comfortable seeking assistance from their primary care provider. R eflection of reality to point out early that recovery may be a slow process and that some symptoms (e.g., phobic avoidance and startle response) may persist. Providers need to pay attention to secondary traumatization issues. Tasmanns Psychiatry

57. It is helpful to engage the spouse or significant family member in treatment because of the difficulties and stresses to which they may be subjected Specific treatment approaches include the use of pharmacotherapy psychotherapy anxiety management Tasmanns Psychiatry

58. Pharmacotherapy Casualties from the American Civil War were observed more than 100 years ago by Weir Mitchell. He commented on the use of bromides, opium, chloral, and brandy. Two main categories of PTSD symptoms respond to medication: core symptoms and secondary symptoms Davidson 1997 APP Textbook of Anxiety Disorders

59. Core symptoms : Intrusive re-experiencing Hyper arousal Numbing, estrangement and anhedonia Avoidance Secondary symptoms : impaired function poor resilience to stress comorbid conditions The end point of pharmacological therapy for PTSD is the same regardless of the conceptual model: to reduce symptom distress, strengthen resilience, and then restore function. APP Textbook of Anxiety Disorders

60. T he selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRI) are now first-line agents. Several placebo-controlled trials have shown positive effects for the SSRI medications, specifically fluoxetine 2 , sertraline 3 , and paroxetine 4 1. Tasmanns Psychiatry 2. Connor et al. 1999, Martenyi et al. 2002 , 2003 , van der Kolk et al. 1994 3. Brady et al. 2000 , Davidson et al. 2001 4. Marshall et al. 1998, Tucker et al. 2001 SSRI and SNRI

61. Pharmacotherapy for posttraumatic stress disorder in adults Author Murray B Stein, MD, MPH Section Editor, Peter P Roy-Byrne, MD, Deputy Editor Richard Hermann, MD

62. Amitriptyline and imipramine in combat veterans with PTSD. In both studies, the medication was effective on intrusive PTSD symptoms and, to a weaker extent, on avoidant symptoms. Davidson et al. 1990, Frank et al. 1988 Tricyclic antidepressants

63. MAOI Phenelzine has been found to be effective in symptom reduction. Rarely used. The side effects of phenelzine limit its use to a third- or fourth-line drug. Kosten et al. (1991)

64. Atypical antipsychotics The overall evidence from clinical trials does not support the use of atypical antipsychotics to augment SSRIs or SNRIs in the treatment of PTSD in military veterans. Adjunctive use of an atypical antipsychotic for PTSD symptoms resistant to SSRIs/SNRIs. Tasmanns Psychiatry

65. Alpha-adrenergic receptor blockers P razosin has been shown to reduce nightmares and improve sleep. Prazosin is typically started at 1 mg at bedtime and is gradually increased to 3 to 10 mg as tolerated. Sudden discontinuation of prazosin must be avoided Tasmanns Psychiatry

66. Benzodiazepines Rarely studied in PTSD Frequently used to treat symptoms of anxiety and hyperarousal. H igh prevalence of comorbid substance abuse in patients with PTSD, benzodiazepines should be avoided in patients with a history of substance use Tasmanns Psychiatry

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68. Early intervention A meta-analysis concluded that There is moderate quality evidence for the efficacy of hydrocortisone for the prevention of PTSD development in adults. The study found no evidence to support the efficacy of propranolol, escitalopram, temazepam and gabapentin in preventing PTSD onset. The findings, however, are based on a few small studies with multiple limitations. Pharmacological interventions for preventing post-traumatic stress disorder (PTSD). Amos T1, Stein DJ, Ipser JC.

69. Psychotherapy Exposure-based treatments Cognitive approaches EMDR Adding components Other approaches Tasmanns Psychiatry

70. Prolonged Exposure Depends on the fact that anxiety will be extinguished in the absence of real threat, given a sufficient duration of exposure in vivo or in imagination to traumatic stimuli. Imaginal exposure There are patients who will be reluctant to confront traumatic reminders due to transient increased anxiety. Tasmanns Psychiatry

71. Eye movement desensitization and reprocessing (EMDR) EMDR facilitates the accessing and processing of traumatic memories to bring closure and resolution. Patients are asked to bring to mind the disturbing image, sensations, and the negative cognition while tracking the clinician’s moving finger back and forth in front of their visual field. Although EMDR has been empirically supported in the literature, there is some controversy about the “active ingredient” in EMDR and the restricted access to this treatment protocol through a proprietary company. Shapiro 2001 Tasmanns Psychiatry

72. A meta-analysis confirmed that EMDR therapy significantly reduces the symptoms of PTSD, depression, anxiety, and subjective distress in PTSD  patients. Efficacy of eye-movement desensitization and reprocessing for patients with posttraumatic-stress disorder: a meta-analysis of randomized controlled trials . Chen YR1, Hung KW2, Tsai JC3, Chu H4, Chung MH1, Chen SR5, Liao YM1, Ou KL6, Chang YC7, Chou KR8

73. Anxiety management Designed to reduce anxiety by providing patients with better skills for controlling worry and fear . muscle relaxation self-distraction (thought stopping ) control of breathing and diaphragmatic breathing guided self-dialogue stress inoculation training Tasmanns Psychiatry

74. Cognitive therapy Focuses on challenging dysfunctional, automatic thoughts that may develop following trauma exposure. 1 In a comparison of cognitive therapy to imaginal exposure in the treatment of chronic PTSD, both treatments were associated with positive improvements at post-treatment and follow-up, with no differences in outcome between treatments 2 1. Tasmanns Psychiatry 2. Tarrier et al. 1999

75. As no single treatment for PTSD has been shown to be curative, patient characteristics, characterization of the nature and range of stress responses of trauma victims 2 , partial response 3 , treatment combinations, sequencing of treatment approaches, and further well-controlled investigations of current approaches are all important empirical topics to be addressed. 1. Tasmanns Psychiatry 2. McFarlane and Yehuda 2000 3. Taylor et al. 2001

76. Psychodynamic approach Emphasize the interpretation of the traumatic event as being a critical determinant of symptoms. Treatment is geared to alter attributions. Reinterpret the experience in a more realistic and adaptive fashion. Support needs to be provided throughout, and sometimes other treatment approaches are used adjunctively. Tasmanns Psychiatry

77. Horowitz ( 1973 ) developed a trauma-focused, time-limited, psychotherapeutic approach. Overwhelmingly intrusive symptoms are counteracted by means of structuring, and avoidance and numbing are met with procedures to minimize such behavior. Tasmanns Psychiatry

78. Factors affecting treatment Psychiatric Comorbidity General Medical Comorbidity Demographic Factors Tasmanns Psychiatry

79. Summary of treatment Goals are common to all and can be summarized as follows: reduce intrusive symptoms reduce avoidance symptoms reduce numbing and withdrawal dampen hyperarousal reduce psychotic symptoms when present improve impulse control when this is a problem . The three major treatment approaches, pharmacotherapeutic , cognitive–behavioral, and psychodynamic, all emphasize different aspects of the problem . Pharmacotherapy targets the underlying neurobiological alterations found in PTSD and attempts to control symptoms Cognitive–behavioral treatments emphasize confronting traumatic memories through exposure as well as identifying and challenging dysfunctional beliefs about the trauma The psychodynamic approach emphasizes the associations that arise from the trauma experience and that lead to unconscious and conscious representations Tasmanns Psychiatry

80. CONTROVERSIES As disability awards for PTSD have grown nearly fivefold over the last 13 years, so have concerns that many veterans might be exaggerating or lying to win benefits.

81. PTSD has been de-contextualized, its original meaning and links rendered invisible, its criteria loosened as it was moved to the civilian sector It pathologizes individuals, equates the problems of perpetrators of crimes (e.g.. Soldiers killing people) with the suffering of victims of trauma. It medicalizes personal distress, assumes biological causation, and argues for medical solutions Diagnostic and statistical manual-5: position paper of the Indian psychiatric society K. s. Jacob, r. a. Kallivayalil, a. K. Mallik, N. Gupta, j. K. trivedi, b. N. Gangadhar, K. praveenlal, V. Vahia, t. s. sathyanarayana Rao

82. RECENT ADVANCES A meta-analysis  shows that active rTMS applied to the DLPFC seems to be effective and acceptable for treating PTSD. A RCT examines the effectiveness of "Family of Heroes," an online avatar-based post-deployment stress and resiliency training simulation concluded that results strongly suggest that it is an effective tool to engage families in taking an active role in motivating their veterans who exhibit signs of post-deployment  stress to seek help at the VA. 1) http://www.ncbi.nlm.nih.gov/pubmed/25565694

83. The effectiveness of yoga in treating PTSD is unclear. Two RCTs found opposite effects in two dissimilar patient populations, while one systematic review concluded that yoga may be effective as a monotherapy or in combination with medication for treating patients with PTSD . The effectiveness of mindfulness in treating PTSD is unclear. Three RCTs found opposite effects in veterans with PTSD . Yoga for the Treatment of Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Depression, and Substance Abuse: A Review of the Clinical Effectiveness and Guidelines [Internet ]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2015 Jun . Mindfulness Interventions for the Treatment of Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Depression, and Substance Use Disorders: A Review of the Clinical Effectiveness and Guidelines [Internet]. Source Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2015 Jun. 

84. Sudarshan Kriya yoga - Reductions in startle correlated with reductions in hyperarousal symptoms immediately postintervention (r = .93, p < .001) and at 1-year follow-up (r = .77, p = .025). This longitudinal intervention study suggests there may be clinical utility for Sudarshan Kriya yoga for PTSD. Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study . Seppälä EM1, Nitschke JB, Tudorascu DL, Hayes A, Goldstein MR, Nguyen DT, Perlman D, Davidson RJ.

85. SUMMARY Posttraumatic stress disorder (PTSD) has been described as "the complex somatic, cognitive, affective, and behavioral effects of psychological trauma“ Clinical features – Intrusive thoughts, nightmares, flashbacks, avoidance, hypervigilance, sleep disturbance. Described since inception war and came into focus after the world wars and Vietnam war. Term first introduced in DSM III . Lifetime prevalence - 6.8 to 12.3 % US, 1 year prevalence 3.5 – 6% Associated with increased risk of physical illnesses. Pathophysiology- Neurobiological : ↑ central NE levels, ↓ cortisol levels, HPA axis dysfunction Imaging : MRI, PET changes in amygdala and ant. Para-limbic region . Genetic : FKBP5 gene related with risk of PTSD in children, interaction with environmental factors. Psychosocial factors, Sleep pattern ICD 10 and DSM V diagnostic criteria. Differential diagnoses – other anxiety spectrum disorders, depression, dissociation.

86. Assessment – Commonly used scales are CAPS, PTSD checklist. Course – Chronic condition, 1/3 pts symptomatic 10 years after exposure. Treatment – Pharmacological: SSRIs/SNRI → add TCA/ α 1AA/BZD → switch to TCA/MAOI Psychotherapy : Exposure based, CBT, EMDR, anxiety management, psychodynamic approach. Controversies Loosening of criteria Malingering for compensation. Converting personal distress into a pathology. Tasmanns Psychiatry Difficult to define trauma Absence of diagnosis post civilian disasters in Indian context. Recent advances rTMS Avatar based therapy Yoga Mindfulness interventions.