Posttraumatic Stress Disorder

How experiencing trauma can haunt us long after the crisis has passed

PTSD in general

• The rare disorder in which the cause (trauma) is a necessary part of the diagnosis

• Basically when a severe trauma causes severe stress followed by avoidance, the re-experiencing of trauma, numbness, anxiety and heightened arousal

• Around for millennia, finally merited recognition after Vietnam

Changes from DSMIV

• No longer need to experience horror, grave fear, or helplessness at the time of the event

• Many didn’t but later had necessary symptoms

• Definition of requisite trauma is narrowed – no longer are media reports enough

• Symptoms must commence after the event• Need avoidance but not numbness in DSM5

Arises from only BIG traumas

• Must have experienced or witnessed an event that involved actual or near death, severe injury or sexual violation

• Rape can bring it on• Most common precipitating event• 1/3 of the time, it does• Four categories of symptoms

Uncontrolled reexperiencing

• Intrusive, repetitive memories or nightmares of event

• Reminders of event cause heightened arousal• Dark alley, if similar to site of rape• Flat roof buildings if similar to site of sniper

attack

Avoidance of Stimuli

• Anything that recalls event is avoided• Afghan war vet avoids deserts• Survivor of train crash won’t get on again• Avoiding even thinking about event often

backfires, causing reexperience instead

Mood and/or Cognitive changes

• Inability to recall aspects of the event• Persistent negative mood/thoughts• Blaming self for event• Difficulty experiencing pleasure• Lack of interest in old activities• Estrangement from others

Increased Arousal

• Easily angered and/or aggressive• Trouble with sleep• Hypervigilance• Reckless or self-endangering behavior• Trouble concentrating • Exaggerated startle response• All confirmed by objective physiological tests

Other aspects

• Symptoms tend to be chronic • Increased risk of suicide, self hurt• Higher risk of early death due to medical,

accidental causes• Women 2x more likely to receive diagnosis• Most likely because sex abuse predisposes• Ethnic considerations also can play a role

Acute Stress Disorder

• For people who suffer similar symptoms 3 days to one month after event

• Doesn’t last as long• High risk of PTSD in next 2 years.• Changed by DSM5 to be very similar to PTSD• But isn’t it natural to have a reaction shortly

after a harrowing event?• Also, most who develop PTSD don’t get ASD.

Comorbidity

• If at 26 you have PTSD, 90+% chance of another condition before 21 – 2/3s anxiety

• • Other common comorbid conditions include

depression, substance abuse and conduct disorder

Etiology – just like anxiety

• Marked similarity with anxiety disorders – explaining why they are grouped so closely in DSM

• Genetic risk for one = risk for the other• Also, hyperactivity of fear circuit and amygdala• Too much attention to threat cues• Neuroticism predicts both both

Return to two-factor model

• The two-factor model for Phobias explains PTSD • Bagdad vet was attacked (UCS) while walking

through urban area with low rooftops (CS)• Now flat rooftops are so stressful he avoids them• The avoidance behavior is reinforcing (causes

feelings of belief) so it is engaged in repetitively • With no exposure to CS, extinction never occurs

Unique causal agents – severity

• More severe, higher chance• Fighting in Vietnam – 20% chance• POW in Nam – 50%• Assigned to collect body parts of dead – 65%• In WWII, incidence of PTSD correlated with

casualties in battalions• Prediction – 98% after 60 days of combat• Similar findings after 911

Another factor – Who’s responsible?

• Traumas caused by humans (war, rape, assault) are more likely to cause

• Challenge our assumption that humans are good or fair?

• Just world hypothesis flipped upside down?

The Brain’s role

• Amygdala too revved up• Medial prefrontal ineffective – failure to corral

the amygdala• Even more crucial may be the hippocampus,

our “gateway to memory”• Those with PTSD have a smaller hippocampus

which likely precedes the disorder

Coping with Trauma

• How we cope with the trauma both during and after effects whether PTSD will follow

• Avoiding thinking about the trauma backfires• Dissociation – event is split off from regular

consciousness• Those who drift away from trauma often

develop PTSD• Found true for rape victims and PTSD

Two things that help

• Intelligence – those with higher intelligence develop PTSD less

• Social Network – more high quality relationships to discuss and share experience, better chance of dodging PTSD

• Amazingly, some have used horrible traumas as a catalyst for personal growth

Treatment of PTSD & ASD

• Exposure – victims are encouraged and helped to face the memories and reminders of the original trauma to gain mastery

• Can either go to the actual scene or intentionally remember it – imaginal exposure

• Both work better than just meds or unstructured psychotherapy

• These are difficult, painful and time-consuming but they work

Medications & PTSD

• SSRIs have shown considerable effectiveness in helping overcome symptoms of PTSD in several controlled clinical trials

• However, once the meds stop, the problems return

Cognitive therapies

• Various cognitive strategies have helped victims overcome PTSD

• Cognitive Processing Therapy has shown success in decreasing self-blame and guilt

• But it is uncertain as to whether these provide benefits above and beyond exposure treatments

Treating ASD

• Using short-term cognitive behavioral techniques seems to prevent ASD from turning into PTSD

• Replicated 5 times• Risk drops from 58 to 32%• These gains can last for years