epidemiology, etiology, & treatment. what is ptsd? anxiety disorder traumatic stressor core...
TRANSCRIPT
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Epidemiology, Etiology, & Treatment
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What is PTSD?
•Anxiety disorder•Traumatic stressor•Core features:•Reexperiencing•Avoidance•Numbing•hyperarousal
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Traumatic Stressor
•DSM-III – Beyond normal range of human experience
•DSM-IV –experiences, witnesses, or is exposed to an event that is life threatening, that causes serious injury or that leads to a subjective response of intense fear,
helplessness, or horror.PTSD is unique among mental disorders• Symptoms are directly linked to traumatic stressor
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Historical OverviewDiagnostic category in DSM-III
IssuesSymptoms aloneSocial ConstructionUnreliability of memory Euro-American category
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But
• Traumatic neurosis (Oppenheim in 1892)
• Fright neurosis or schreckneurose (Kraeplin in 1896)
•WWs I & II•Shell shock•Combat fatigue•War neurosis
•DSM-I: GSR
• DSM-II: Transient situational disturbances
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Epidemiology
Four levels
•Prevalence of Trauma Exposure•Risk Factors for Trauma Exposure•Prevalence of PTSD•Risk and Protective Factors
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Prevalence of Trauma ExposureCommon or uncommon?
•NCS ≥ 60.7% of men; ≥ 51.2% have had at least 1 traumatic event in their lifetime
•Most common traumatic events•Witnessing•Natural disasters•Life-threatening accidents•Rape•Sexual molestation•Physical abuse•Childhood neglect
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Risk Factors For Trauma Exposure
Random or non-random?•Gender •Age•Prior exposure•Preexisting personal characteristics•CDD•Pretrauma substance use•Genetic Vulnerability
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Prevalence of PTSDSeveral factors
•PTSD ratio of women to men is 2:1 in USA
•Different among VTV – •Higher for men •Roles, stressors, education levels
•Demographics •Age •Ethnicity •Population
•Gender•Trauma type – 32 % of rape; 26% of criminal victims•Closeness to Traumatic event - WTC
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Prevalence of PTSD
• International data varies•Economies and PTSD•Political turmoil, wars, disasters
•PTSD manifests itself in similar manner across culture, language, region, race•Importance of this observation?
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Risk and Protective Factors
Many are exposed but few develop PTSD
Ratio of 3:1
•Categories of Risk Factors•Trauma•Peri-and post-trauma events•Individual Characteristics
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Risk and Protective Factors
Trauma •Type •severity
Peritrauma Fear, helplessness, horror (r =.26)•Dissociation: blanking out, altered sense of time•PTSD is exercerbated by cognitions of panic (fear of death, fear of losing control)•Posttrauma•Social support • PTSD SS vs SS PTSD
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Individual CharacteristicsDemographics & Familial Psychopathology
Demographics: age, gender, race, SES, immediate response, marital status, psychiatric history, prior trauma, personality
Familial Psychopathology•VVTR (no genetic linkage); •In general population (small but sig.) – through D2 dopamine alleles•Environment
•(greater than genetics)
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Predictor Effect
Direct•War-zone stressors, malevolent war-zone environment•Hardiness, structural social support (not sig. for w/men), functional social support, and recent stressors
Indirect •Traditional combat exposure – moderated by perceived threat
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Etiological Theories
Multiple Theories•Classical Conditioning
– stimulus & response connection •Schema Theories
– faulty schemas that filter info•Emotional Processing Theory
- abnormal fear structures•Cognitive Theory
- (i) classical (ii) Ehler & Clark•Multiple Representation Structures
– (i) Dual – VAM & SAM – (ii) SPAARS – schematic, proporsitional,
analogue, & associative representational systems
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Classical Conditioning
Triple vulnerability
Learned Alarm (or strong mixed emotions)
Generalized Psychological Vulnerability
True Alarm (or intense basic emotion – anger, distress)
Anxious Apprehension (focused on re-experiencing emotions)
Generalized Biological Vulnerability
Advance or Numbing or Emotional Response
Moderated by Social Support and Ability to Cope
Experience of Trauma
PTSD
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Concern about CC
•Startle responses•Reexperiencing•Nightmares
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Treatment
Approaches (influenced by Psychoanalysis)
•Exposure Therapies•Narrative therapies•CT•CPT•PE•IR (imagery rescripting)•IRT (imagery rehearsal therapy)
Concerns? •Anxiety Management Training•Stress innoculation techniques
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Treatment
•Combination Treatments•E+AMT+ CR eg CPT•CBT•TF-CBT •DBT•“Power Therapies:” TIR, VK/D, EMDR – (concern?)•ACT•Interapy•VRE
•Pharmacotherapy
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Pharmacotherapy
Challengemultiple rather than single neurobiological
systemsAssumption
Brain Circuitory Excessive activation of
Amygdala
Recurrent fear conditioning of ambiguous stimuli perceived as threatening
Disinhibition of Amygdala
Target Systems•Adrenergic•HPA•Serotonergic•Dopaminergic
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Medication
Antidepressants•SSRI – sertraline, paroxetine, fluoxetine•TCA – amitriptyline, desipramine•MAOI - phenelzine
Antiadrenergic•prozasin
Antikindling •Carbamazepine
•Atypical antipsychotic•resperidone, quetiapine, olanzapine
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Research
Efficacious in comparison to WLDecline in anxiety, arousal, & reliving Narrative therapy cf psychoeducationExposure (alone)Active therapies vs supportive therapiesPE (60-80%, Foa, Rothbaum, & Faurr, 2003)IRT 65% (Jacobson & Traux, 1991)VRE 15-67% (Rothbaum et al. 1999)
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Limitation
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Resources
Friedman, M., Keane, T, & Resick, P. (Eds.) (2007). Handbook of PTSD: Science and practice. New York: The Guilford Press.
Keane, T., Marshall, A., & Taft, C. (2006). Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome. Annual Review Clinical Psychology, Vol. 2, 161-197.
Vasterling, J., Brewin, C. (Eds.) (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York: The Guilford Press.