Posttraumatic Stress Disorder

Epidemiology of PTSD

• Kessler et al. (1995) Posttraumatic Stress Disorder in the National Comorbidity Study

• Representative National Sample– N = 5877 AGE 15-54 Years old– Lifetime prevalence of PTSD is 7.8%– More than 1/3 of people with an initial episode

of PTSD fail to recover after 10 years

Kessler National Comorbidity• Women: Most Common Experiences

– Rape– Sexual Molestation– 50% had experienced a trauma that met DSM-IV

stressor criterion

• Men: Most Common Experiences– Combat– Witnessing death or severe injury– 60% had experienced an event that would meet DSM-

IV stressor criterion

Kilpatrick et al (1992)

• Nationally representative sample

• 4008 women

• 13% reported a completed rape

• Of those who were raped– Lifetime PTSD 32%– Current PTSD 12%

Prevalence of PTSD

• 5th Most Common Psychiatric Condition– Behind

• Major Depression

• Attention-deficit/hyperactivity disorder

• Specific phobia

• Social phobia

Comorbidity

• PTSD/Depression: Nearly 50% Comorbid

• Specific phobia, social phobia, and dysthymic disorder also prevalent

• Male PTSD/Alcohol Abuse: (52%)

Criterion A: Exposure Criteria

• Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity

• Person’s response involved fear, helplessness, or horror or in children agitated behavior

Criterion B: Re-experiencing Criteria

• Recurrent and Intrusive distressing recollections of the event (images, thoughts, or repetitions)

• Recurrent distressing dreams of the event

• Acting or feeling as if the traumatic event were recurring

Criterion B continued…

• Intense Psychological Distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

• Physiological Reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C1: Persistent Avoidance Criteria

• Efforts to avoid thoughts, feelings, or conversations associated with the trauma

• Efforts to avoid activities, places, or people that arouse recollections of the trauma

• Inability to recall an important aspect of the trauma

Criterion C2: Numbing of Gen. Responsiveness Criteria

• Markedly diminished interest or participation in significant activities

• Feeling of detachment or estrangement from others

• Restricted range of affect

• Sense of foreshortened future

Criterion D: Increased Arousal Criteria

• Difficulty falling or staying asleep

• Irritability or outbursts of anger

• Difficulty concentrating

• Hypervigilance

• Exaggerated startle response

Criterion E

• Symptoms in criteria B, C, and D are more than 1 month

Criterion F

• The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning

Specifications

• Acute: if duration of symptoms is less than 3 months

• Chronic: if duration of symptoms is 3 months or more

• With delayed onset: if onset of symptoms is at least 6 months after the stressor

Green’s Generic Dimensions to Stressors

• Threat to one’s life• Threat to bodily integrity• Severe physical harm/injury• Exposure to grotesque• Witnessing/learning of violence or severe harm to

others• Learning of exposure to a noxious agent• Causing death or severe harm to another

Dohrenwend

• National Veterans Readjustment Study– Congressional Mandate in 1983

– Representative sample of 1632 US Vietnam Theater Veterans and matched sample of 716 Vietnam era veterans and 668 civilian comparison

– NVVRS rates for Male VTV 30.9% lifetimeAnd 15.2% current

CDC rates reported 14.7% lifetime and 2.2% current all 11 to 12 years after the Vietnam war ended

Dohrenwend contd.

• National Veterans Readjustment Study– Perplexing in these relatively high rates of PTSD was

the relatively low rates of ‘combat’

– Used data from archival sources to develop a record based military historical measure for exposure

– Impairment wasn’t formerly a part of the criteria

– Adjusted Rates for impairment and verification are • 18.7% lifetime and 9.1% current

• Dose response relationship between combat and exposure

Cultural Factors and PTSD

• Hispanic veterans report significantly higher rates of PTSD than AA or Caucasian veterans. Hypotheses include:– Greater exposure to war zone stressors

– Greater prewar vulnerability

– Culturally driven differences in reporting symptoms

– Different post war stressful events

– Greater experiences with racial/ethnic prejudice and discrimination

Sample• Subsample NVVRS

– 94 Majority White– 70 African American– 84 Hispanic (Mostly Mexican American (63), Puerto Rican (15),

Latin American (6)• War Zone stressor severity measured• Peri- and Post-War Discrimination• Vulnerability Factors Measured

– Younger age at entry to Vietnam– Lower Armed Forces Qualification Tests– Disciplinary Actions– Pre-Vietnam educational level– Pre war psychiatric disorder

Results• Both Blacks and Hispanics had higher rates of war-

related first onsets of PTSD (current PTSD 10-11 years after the war)

• PTSD course was more chronic for Hispanics than Blacks

• Hispanics experiences more war-zone stressors compared with Caucasians

• Controlling war zone exposure did not account for the greater rates of PTSD in Hispanics

• Prewar vulnerability factors emerged as important: younger age, less education, lower AFQT scores

9/11

• Explored stressor exposure and PTSD symptoms in 11,037 adults who live south of Canal Street in NYC on 9/11 (lower Manhattan)

• PTSD Checklist Civilian Version• Within disaster exposure, e.g., residential

proximity, direct exposure intensity (caught in the dust cloud from the tower collapse, an occupant of the north or south tower, sustaining an injury, witnessed horror, seeing people fall or jump from the buildings)

9/11 Results

• 43.6% reported reexperiencing, 20.4% reported avoidance, 38.6% reported hyperarousal

• Most common symptoms were hypervigilance, being upset by reminders, and insomnia

• Current PTSD prevalence 12.6%

9/11 Results: Bivariate results

• Increased risk was reported for African Americans, Hispanics, and other nonAsian minorities (Asian race was protective)

• Increased risk for women• Lower education and lower income was associated with increased risk• Older age and female gender was assoc with increased risk• Being divorced, separated or separated was associated with increased

risk• Within disaster risk factors were sustained injury, witnessed horror

exposure to dust cloud, being in a building that was damaged or destroyed (except WTC towers), living less than 1000 feet from the towers

• Post disaster risk was associated with evacuation from one’s home and involvement in rescue/recovery efforts.

9/11 Results: Multivariate results

• Risk for PTSD increased for all age groups relative to the younger groups (greatest risk for adults 45-64 years);

• Increased risk for women• Risk for PTSD higher among Hispanics, African

American, and other ethnicities• Divorced, widowed or separated continued to increase

risk;• Lower education and income was associated with

increased risk• Exposure intensity remained as a significant risk factor• Evacuation and involvement in rescue recovery efforts

remained

Confluence of Factors

• Discuss findings in terms of the diathesis, personality, stress model

Acute Stress Disorder

Diathesis/Personality/Stress: Posttraumatic Stress Disorder

DiathesisFemales more at risk than males (.13)

Family history of psychiatric Disorders

(.17)

Neurochemical factors assoc. with > startle (monoamine, opiate,neurochemical)

Neuroadrenergic (panic)

Diminished Serotonin

Race/ethnic status small

SES, education larger

~.1

Personality

Neuroticism

Pretrauma dispositions toward negative mood and emotion (NEM) This may be a general risk factor of anxiety disorders

< pretrauma PEM, positive emotionality

Appraisals dangerous, unpredictable, uncontrollable

Stressor

Severity of Exposure (.23) small/med

Injury

Lifethreat

Cumulative Stressors

Threat to physical integrity

Historical stressors child abuse (.14), other previous trauma (.12), other adverse child factors (.19)

Criterion A: Exposure Criteria

• Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity

• Person’s response involved fear, helplessness, or horror or in children agitated behavior

Criterion B: Dissociative Criteria

• Subjective sense of numbing, detachment, or absence of emotional responsiveness

• Reduction in awareness of one’s surroundings (e.g., “being in a daze”)

• Derealization

• Depersonalization

• Dissociative amnesia

Criterion C: Re-experiencing Criteria

• Recurrent images

• Thoughts, dreams, illusions

• Flashback episodes, or a sense of reliving the experience

• Distress on exposure to reminders of the traumatic event

Criterion D: Avoidance Criterion

• Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)

Criterion E: Physiological Criteria

• Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)

Criterion F: Psychosocial Criteria

• Clinically significant distress or impairment in social, occupational, or other important areas of functioning

• Impaired ability to pursue some necessary task, such as obtaining personal assistance or mobilizing personal resources

Criterion G: Time Criteria

• Minimum of 2 days

• Maximum of 4 weeks

• Occurs within 4 weeks of the traumatic event

Inter-relationship between ASD and PTSD

Event ASD PTSD

2 days – 4 weeks

4 weeks and on

How does someone develop PTSD?

Classical Conditioning

Unconditioned Stimulus

Unconditioned Response

Car Jacking

Thoughts

Feelings

Behaviors

CS CR

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

Classical Conditioning

Model for PTSD

• PTSD develops through the process of classical conditioning

• When cues are encountered, anxiety and other emotional reactions increase. Over time, habituation would occur.

• Avoidance maintains PTSD because habituation can never occur.– Negative Reinforcement