Post traumatic stress disorder: A known problem

This is a class presentation.

1. Presenter: Dr. Sunil Timilsina Moderator: Assoc. Prof. Dr. S. N. Suwal

2. Contents Introduction Epidemiology Etiology Diagnosis Course and Prognosis Treatment

3. Introduction Post traumatic stress disorder ( PTSD ) has been described as the complex somatic, cognitive, affective , and behavioural effects of a trauma for more than one month. Trauma refers to events or experiences that are shocking and overwhelming, typically involving major threat to physical, emotional, or psychological safety and well being of the individual victim(s) and loved ones and friends.

4. Four core Symptoms: Recurrent, involuntary, and intrusive recollections of events Avoidance of stimuli associated with trauma Negative alterations in cognition or moods associated with the event, or numbing (or both) Alterations in arousal and reactivity, including a heightened sensitivity of potential threat

5. Epidemiology The lifetime prevalence - 6 to 9 % United States(US ) Female:Male : 4:1 In Nepal, Natural disaster was the most common trauma type (84%) compared to other types of trauma. Sexual Assault was reported as the most traumatizing. Current PTSD was found in 15% Koirala et.al “Trauma related psychiatric disorders and their correlates in a clinical sample: A cross-sectional study in trauma affected patients visiting a psychiatric clinic in Nepal” PMCID :  PMC7295578

6. Etiology Triggers Risk Factors Sexual violence Female gender Physical violence Lower Socio economic status VS Upper middle class (Nepal) Accidents Younger age at the time of trauma Natural disasters Lack of Social Support War Prior traumatic exposure Diagnosis of severe disease Initial severe reaction to traumatic event Witnessing the death of another person Psychiatric co morbidities Personailty

7. Etiology Neurobiology: Increased central norepinephrine levels with downregulated central adrenergic receptors . Dysfunctional HPA axis Neuroanatomy: Decreased volume of hippocampus, amygdala and anterior cingulate cortex Neuroimaging: increased reactivity of the amygdala and anterior paralimbic region to trauma-related stimuli Genetics: Presence of one of four polymorphisms at the stress related gene FKBP5 ,

8. Diagnosis

9. Course AND Prognosis 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. Approx. 60% of those receiving treatment achieve full recovery within an average timespan of 36 months. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology , clinical manifestations, course, and diagnosis Author - Paul Ciechanowski , MD

10. Treatment Case basis approach explanation and de-stigmatization . Specific treatment approaches include the use of – pharmacotherapy – psychotherapy First line: Psychotherapy with or without adjunctive pharmacotherapy

11. Psychotherapy Trauma focused cognitive behavioral therapy Exposure therapy Cognitive processing therapy Eye movement desensitization and reprocessing therapy

12. Pharmacotherapy 1 st line: SSRIs or SNRIs Nightmares: Prazosin 1mg HS and gradually Increased to 3 to 10 mg as tolerated

13. Pharmacotherapy BZPs Usually used for hyperarousal and anxiety symptoms Better to avoid due to lack of evidence supporting benefits and risk of misuse No improvement: Increase dose OR Switch class Inadequate improvement in core symptoms: Switch from SSRI to SNRI or SNRI to NaSSA

14. Pharmacotherapy Persistent Insomnia, nightmares A1AAs , low dose TCAs to be added If still present, Atypical Antipsychotics to be considered. If still not controlled, other diagnoses to be considered With co-morbid Psychosis: Atypical Antipsychotics to be considered With comorbid depression, anxieties, stable bipolar: Mood stabilizers, anti- convulsants , lithium or atypical antipsychotics to be added.

15. References Statistical Manual of Mental Disorders. American Psychiatric Association; 2013 Ursano et al.. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.. The American journal of psychiatry. 2004; 161(11 Suppl ): p.3 -31. pmid : 15617511 . Bisson JI, Wright LA, Jones KA, et al. Preventing the onset of post traumatic stress disorder.. Clin Psychol Rev. 2021; 86: p.102004 . doi : 10.1016/ j.cpr.2021.102004 . Vieweg WVR , Julius DA, Fernandez A, Beatty-Brooks M, Hettema JM, Pandurangi AK. Posttraumatic Stress Disorder: Clinical Features, Pathophysiology, and Treatment. Am J Med. 2006; 119(5): p.383 -390. doi : 10.1016/ j.amjmed.2005.09.027 . VA/DOD. VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Clinician Summary.. Focus (Am Psychiatric Publ ). 2018; 16(4): p.430 -448. doi : 10.1176/ appi.focus.16408 . Kessler et al.. How well can post-traumatic stress disorder be predicted from pre-trauma risk factors? An exploratory study in the WHO World Mental Health Surveys.. World psychiatry : official journal of the World Psychiatric Association ( WPA ). 2014; 13(3): p.265 -74. doi : 10.1002/ wps.20150 .

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