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PTSD - EPIDEMIOLOGY
A. Prevalence a. PTSD 3.6% b. Estimated that ~50% of men and 60% of women are exposed to a lifethreatening traumatic event i. 8.2% of men exposed will develop PTSD ii. 20% of women exposed will develop PTSD c. Previous exposure to trauma and intensity of the response increase the risk of PTSD d. Individuals with a history of childhood sexual abuse are at a higher risk e. Genetic factors can increase vulnerability
Lifetime Prevalence Rates of Trauma and Their Association with PTSD Men Natural Disaster Criminal Assault Combat Rape Any trauma 18.9% 11.1% 6.4% 0.7% 60.7% PTSD 3.7% 1.8% 38.8% 65.0% 8.2% Women 15.2% 6.9% 0.0% 9.2% 51.2% PTSD 5.4% 21.3% -49.5% 20.4%
B. Age at onset is variable; can occur at any age C. Presentation is not predictable related to duration / intensity of trauma, other psychiatric disorders, how patient deals with the trauma D. Men with PTSD are more likely from exposure to military combat and witnessing someone being badly injured or killed E. Women with PTSD are more likely associated with rape and sexual molestation Severity, duration, and proximity of exposure to trauma are most important factors in likelihood of development of disorder Studies indicate lifetime prevalence is 1 to 14% Studies of at-risk persons (veterans of combat, victims of natural disasters or crimes) indicate lifetime prevalence of 3 to 58%
Anxiety Disorders
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3 fold increase has been observed in combat-exposed military personnel since 2001
I.
PATHOPHYSIOLOGY OF PTSD
A. NEUROENDOCRINE THEORIES
a. Abnormalities occurring pretrauma, during trauma, and posttrauma contribute to PTSD b. Normally, the immediate reaction to stress occurs as an autonomic response from the amygdala to the sympathetic and parasympathetic systems and the HPA axis c. Release of corticotropin-releasing factor stimulates cortisol secretion from the adrenal gland d. Cortisol reduces the stress response by tempering the sympathetic reaction through negative feedback on the pituitary and hypothalamus e. Patients with PTSD have hypersecretion of corticotropic-releasing factor but demonstrate subnormal levels of cortisol at the time of trauma and chronically
B. NEUROCHEMICAL THEORIES
f. 5HT and NE are associated with processing of emotional and somatic contents of memories in the amygdala g. Noradrenergic theory posits that the autonomic nervous system of anxious patients is hypersensitive and overreacts to stimuli h. The alarm center, the locus ceruleus, releases NE to stimulate the sympathetic and parasympathetic nervous systems i. Patients with PTSD tend to experience sustained elevated heart rates during trauma and enhanced startle effects starting a month after trauma exposure j. Patients with chronic central NE overactivity have downregulated alpha-2 adrenoreceptors k. Dysregulation of the processing of sensory input and memories may contribute to the dissociative and hypervigilant symptoms in PTSD l. Abnormalities of GABA inhibition may lead to increased awareness or response to stress, as seen in PTSD
C. NEUROIMAGING STUDIES
m. Increased activation of the amygdala n. Decreased hippocampal volume o. Hypofunctioning of the ventromedial prefrontal cortex
II.
Anxiety Disorders
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Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness as evidenced by three or more of the following: o Efforts to avoid thoughts, feelings, or conversations associated with trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall important aspect of trauma Markedly diminished interest or participation in significant activities Feelings of detachment or estrangement from others Restricted range of affect
o o o o
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Persistent symptoms of increased arousal (not present prior to trauma) as evidenced by two or more of the following: o o o o o Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response
Duration of symptoms for greater than one month Causes clinically significant distress or impairment in functioning
Detachment Reexperiencing the event Event had emotional effects Avoidance Month in duration Sympathetic hyperactivity or hypervigilance
B.
SYMPTOMS
May initially be diagnosed with acute stress disorder o Characterized by anxiety and dissociative symptoms emerging within 1 month after exposure to a traumatic stressor (can last for at least 2 days and resolve within 4 weeks)
May describe intense guilt feelings about surviving when others did not May include depression, anxiety, poor concentration May also exhibit aggression, violence, poor impulse control, depression, and substance use or abuse 1/3 to of substance abusers also have PTSD
Anxiety Disorders
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In children: Dreams may be generalized of monsters, other threats, etc. Reliving of trauma may occur by repetitive play Physical symptoms stomachaches and headaches
C.
ONSET
Can occur at any age Symptoms usually begin within first 3 months after trauma Symptoms can be delayed months or years in some cases
D.
DIFFERENTIAL DIAGNOSIS
Adjustment disorder Acute stress disorder (duration of < 4 weeks) Obsessive-compulsive disorder Substance-induced disorders Mood disorder with psychotic features Schizophrenia Delirium Malingering
E.
III.
A. DESIRED OUTCOME
Short-term: reduction in core symptoms intrusive reexperiencing, avoidance and hyperarousal
Anxiety Disorders Improvements in disability, concurrent psychiatric conditions, QOL Long-term: remission
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C. NONPHARMACOLOGIC THERAPY
Psychotherapy used for mild symptoms, in patients who prefer not to use medications, or in conjunction with drugs for severe symptoms to improve response o Stress management o Group therapy o Hypnosis o Psychodynamic therapy Cognitive / behavioral therapies are more effective than stress management or group therapy to reduce PTSD symptoms Psychoeducation information about disease state, treatment options, and avoidance of excessive use of alcohol, nicotine, and other substances of abuse
2) OTHER ANTIDEPRESSANTS
Venlafaxine, TCAs and MAOIs can also be effective Side effect profiles may limit their use compared to SSRIs
Anxiety Disorders
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2) CONTINUATION PHASE
Dosages may vary with ongoing psychotherapy dealing with past experiences Symptoms continue to improve and maximal drug benefit accrues Low-relapse rates seen with fluoxetine and sertraline compared to placebo
F. PHARMACOECONOMIC CONSIDERATIONS
PTSD compares with depression in the level of disability it imposes on patients with the disorder fail to realize potentials for career development, marriage and education Decreased productivity leads to financial loss of more than $3 billion per year
Anxiety Disorders
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