PTSD

What is the history of PTSD

• The idea that trauma has long lasting psychological impact around WW1

• 80,000 British troops were treated for shell shock after WW1

• 25% were committed to psychiatric institutions

• Shell shock labelled as an ‘illness’ rather than admit that war itself is horrific (Stone, 1985)

How was the diagnosis of ‘gross stress reaction’ developed originally

• In 1952 the APA published the first edition of the DSM-I

• The diagnosis of ‘gross stress reaction was described as a condition that occurs:

• In response to an exceptional physical or mental stress, eg natural catastrophe

• Occurs in people who are otherwise ‘normal’ (no previous diagnosis)

• Most subside in days to weeks if not another diagnosis should be made

How were trauma disorders incorporated in the 2nd edition of the DSM

• They were actually removed from the 2nd edition

• Between 1968 and 1980 there was no official diagnosis for stress disorders

• No accepted diagnosis was available for those who had psychiatric symptoms

• Treatment facilities were minimal

How were trauma disorders incorporated in the 3rd edition of the DSM

• In 1980, the 3rd edition of the DSM-III included PTSD

• PTSD included 17 symptoms across 3 clusters

• ( Re experiencing, avoidance and emotional numbing and hyperarousal)

• The formulation of PTSD remained largely consistent across all revisions

DSM-5 PTSD criteria

• Must have been exposed to a major traumatic event

• For at least 30 days:

• At least one recurrent intrusion symptom associated with the traumatic event:

• Distressing memories

• Distressing dreams

• Flashbacks

• At least one avoidance symptom associated with the traumatic event:

• Avoidance of distressing memories, thoughts, feelings about the events

• Avoidance of reminders about the events

• At least 2 symptoms related to negative mood:

• Inability to remember important aspects of traumatic events

• Persistent negative emotional state

• Difficulty experiencing positive feelings

• At least 2 symptoms associated with arousal and reactivity associated with the traumatic event:

• Irritability

• Reckless behaviour

• Sleep problems

• Concentration problems

How long do symptoms of PTSD last

• Can only be diagnosed if these symptoms persist for 1 month following traumatic exposure

• 3 days- 1 month of symptoms = acute stress disorder

• Symptoms must be associated with impairment in at least one area of life eg social or relational

• Symptoms must not be due to other influences eg medication or substance use

What is the DSM’s criteria for trauma?

• Very specific about what meets the criteria

• Eg exposure to actual or threatened death

• Serious injury

• Sexual violence

• Exposure to media (only if it’s related to their job)

Prevalence of traumatic events ?

• Representative surveys from 24 countries

• 29 traumatic event types

• 70% of people have experienced lifetime trauma

What are the 5 most common traumas?

• Account for 51.9% of exposures:

  1. Unexpected death of a loved one

  2. Witnessing death, a dead body or someone seriously injured

  3. Being mugged

  4. Life threatening automobile accidents

  5. Life threatening illness or injury

What predicts trauma?

• Women are significantly more likely than men to experience intimate partner sexual violence

• Men are more likely than women to experience physical violence and accidents

• Traumas involving violence and accidents are more likely to occur in adolescence and young adulthood

Limitations of diagnosing trauma?

• Many studies are based on retrospective recall (memory bias)

• Evidence that false negatives are more common than false positives

• People are more likely to underreport trauma

• There is a difference in response rates per country eg cultural and societal norms around how acceptable it is to talk openly about trauma

Prevalence of trauma ?

• Lifetime prevalence rates of 13-20% for women and 6-8% for men (Breslau et al 1991, Kessler et al 1995)

• Rates of PTSD are considerably lower than rates of traumatic events

• Not everyone that experiences trauma develops PTSD

Risk factors for PTSD?

• Pre trauma risk factors, what happened to the person before the trauma

• Peri trauma risk factors, what happened to the person during the trauma

• Post trauma risk factors, what happened to the person after the trauma

Biological causes of pre trauma ?

• Heritability,

• Some evidence but limited, increased odds of developing PTSD if your parents had it (Roth et al, 2014)

• There is no ‘PTSD’ gene, we look at the gene x environment

• Lots of genes exert a small influence (Misganaw et al, 2019)

• Neuroimaging:

• A smaller hippocampus for those with ptsd (logue et al 2018)

Environmental causes of pre trauma ?

• Sociodemographic factors:

• Females are twice as likely to be diagnosed

• Men and women have different emotional, cognitive and neurobiological risk for PTSD

• Younger age at trauma

• Social factors:

• Social support

• Unstable family in early childhood

• Coping strategies:

• Emotion focused, avoidant, negative coping styles

Psychological factors of Peri trauma ?

• Peri traumatic dissociation is consistently found to be a risk factor for development of ptsd

• Depersonalisation

• Derealisation

• Dissociation amnesia (out of body experience)

Discuss post trauma ?

• Negative cognitive styles

• Eg catastrophic thinking (Bryant and Guthrie, 2005)

• Lack of social support (Hyman et al, 2003)

• ‘Mental defeat’ (Wilker et al 2017)

What is complex PTSD (cPTSD)

• Similar to PTSD but differs in two key ways:

• May include additional symptoms in relation to self organisation:

• Eg feelings of worthlessness, shame or guilt

• Finding it difficult to connect with other people

• Problems controlling emotions

• Caused by experiencing recurring or long term traumatic events:

• Child abuse or neglect

• Domestic violence

• War

Medical treatments for PTSD

• Data from 21 studies (n=3932) compared SSRI’s vs placebo

• SSRI’s were found to perform better than placebo but effect size was very small

• Medication is typically inferior to effect for trauma focused psychological intervention

• BZD’s:

• Ineffective for PTSD treatment and prevention

• They are effective in short term but may result in long term dependence/addiction

Therapy treatment for PTSD

• Trauma focused cognitive behavioural therapy

• A go to treatment, targets specific traumas, sensitive to the unique problems resulting from abuse, violence, grief

• 8-25 sessions

• Cognitive behavioural techniques are used to help modify distorted or unhelpful thinking

EMDR treatment for PTSD

• Eye movement desensitisation and reprocessing (EDMR)

• Psychotherapy treatment designed to alleviate the distress associated with traumatic memories (Shapiro, 1989)

• Shapiro’s adaptive information processing model (2001)

• Linked to information processing

• EDMR therapy facilitates the accessing and processing of traumatic memories

• Usually conducted in 8 parts

• The clinician determines which memory to target first, asks the client to hold different aspects of that event or thought and use their eyes to track the therapists hand as it moves back and forth across the clients field of vision

• Does alleviate distress to an extent