Post-traumatic stress disorder Flashcards
DSM-5
- now in a new class of ‘trauma and stressor related disorders’ rather than anxiety disorders
PTSD
-a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of the 4 symptoms clusters:
1/ intrusion
2. avoidance
3. negative alterations in cognitions and mood (includes self-blame and blame of others)
4. alterations in arousal and reactivity (includes reckless and destructive behaviour)
Point prevalence
1%
Lifetime prevalence
- 8%
- in men 3.6%, in women 9.7%
Exposure to traumatic events
- Males are more likely to be exposed to traumatic events (60%vs 50%)
- but females develop PTSD 2x more frequently
Trauma and PTSD
-up to 30% of people exposed to trauma may develop PTSD
Most common traumas
- witnessing someone being badly injured or killed
- exposure to fire, flood or natural disaster
- molestation and mugging are more common in females- more likely to develop PTSD
- men develop more PTSD after rape
Age
-PTSD is more common in younger than older individuals
Pretraumatic factors in PTSD
- previous psychiatric disorder
- female
- personality (external locus of control is greater than internal locus of control)
- lower socioeconomic and educational status
- ethnic minority status
- personality disorder (Cluster B)
Peritraumatic factors
- perceived threat to life
- high severity of trauma
- pertitraumatic dissociation
Post-traumatic factors
- perceived lack of social support
- subsequent life stress
- physical illness
Protective factors
- high IQ
- higher social class
- getting an opportunity to grieve for the loss
Neuroimaging
-hippocampus and amygdala show neuroimaging abnormalities
Cortisol
-high in PTSD
Beneficial interventions
-multiple session CBT to prevent PTSD in people with acute stress disorder
Initial management in primary care
- watchful waiting in mild symptoms present for less than 4 weeks
- non-benzo sleeping tablet after 4 consecutive nights sleep disturbance is recommended
Psychological treatment
- regular, weekly and single person
- trauma focused CBT should be offered in first month in severe PTSD or PTSD within 3 months of the event
If symptoms present for more than 3 months after trauma
- trauma focused CBT or eye movement desensitization and reprocessing (EMDR)
- if no improvement then paroxetine, mirtazapine, amitriptyline or phenelzine
Paroxetine
- good RCT evidence
- NICE second line
- licensed for PTSD
Sertraline
- RCT evidence but NICE not approved
- licensed for females but not males in UK
Fluoxetine
1 RCT
Not significant
Imiprazmine and Amitriptyline
-poor quality of evidence but statistically significant
Phenelzine
poor quality of evidence but statistically significant
Mirtazapine
- one small strongly positive RCT
- NICE second line
Venlafaxine
-one large RCT but no benefit
Olanzapine
-no good for monotherapy but good for augmentation of SSRIs
Risperidone
Tested only as an adjunct-no effect
Trauma focused CBT
- similar efficacy to EMDR
- uses exposure therapy and cognitions
- 8-12 sessions
Eye Movement desensitisation and reprocessing
- discovered by a psychologist accidentally (Shapiro)
- bilateral stimulation in the form of eye movements allows the processing of traumatic memories
- individual focuses on specific images, negative sensations and associated cognitons and bilateral stimulation is applied
- 50% remission at 2 years
Acute stress disorder
- must be an immediate and clear temporal connection between the impact of an exceptional stressor and the onset of symptoms
- symptoms usually appear within minutes of the impact of the event and disappear within 2-3 days
- partial or complete amnesia for the episode may be present
Symptoms of acute stress disorder
- mixed and usually changing picture
- resolves rapidly
