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POST-TRAUMATIC STRESS DISORDER
 


Prediction: Half Recover Within 3 Months But Some Go For Years

      Occupational-Economic:
  • Disabled (only when severe; most spontaneously recover)
  • Requires financial assistance (when disabled)
      Social:
  • Detachment (socially withdrawn if severe)
  • Negative emotion (anxiety, phobia, panic attacks, depressed mood, guilt)
      Medical:
  • Increased arousal (increased: heart rate, sweating, startle response, insomnia)


SYNOPSIS

Post-Traumatic Stress Disorder F43.1 - ICD10 Description, World Health Organization

Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0).

Enduring Personality Change After Catastrophic Experience F62.0 - ICD10 Description, World Health Organization
Enduring personality change, present for at least two years, following exposure to catastrophic stress. The stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement. Post-traumatic stress disorder (F43.1) may precede this type of personality change.

Post-Traumatic Stress Disorder (Age 7 And Older) - Diagnostic Criteria, American Psychiatric Association

An individual (aged 7 or older) diagnosed with post-traumatic stress disorder needs to meet all of the following criteria:

  • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

    • Directly experiencing the traumatic event(s).

    • Witnessing, in person, the event(s) as it occurred to others.

    • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

  • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:.

    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.

    • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

    • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

  • Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as experienced by one or both of the following:

    • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

    • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

  • Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

    • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

    • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined").

    • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

    • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

    • Markedly diminished interest or participation in significant activities.

    • Feelings of detachment or estrangement from others.

    • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

  • Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (o more) of the following:

    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

    • Reckless or self-destructive behavior.

    • Hypervigilance.

    • Exaggerated startle responose.

    • Problems with concentration.

    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

  • Duration of the disturbance is more than 1 month.

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

  • The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.


Post-Traumatic Stress Disorder (Age 6 And Younger) - Diagnostic Criteria, American Psychiatric Association

A child (6 or younger) diagnosed with post-traumatic stress disorder needs to meet all of the following criteria:

  • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

    • Directly experiencing the traumatic event(s).

    • Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

    • Learning that the traumatic event(s) occurred to a parent of caregiving figure.

  • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:.

    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

    • Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play.

    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

    • Marked physiological reactions to reminders of the traumatic event(s).

  • One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

    • Persistent Avoidance of Stimuli

    • Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).

    • Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

    • Negative Alterations in Cognition

    • Substantially increased frequency of negative emotional states (e.g., fear, horror, anger, guilt, shame, confusion).

    • Markedly diminished interest or participation in significant activities, including constriction of play.

    • Socially withdrawn behavior.

    • Persistent reduction in expression of positive emotions.

  • Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).

    • Hypervigilance.

    • Exaggerated startle responose.

    • Problems with concentration.

    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

  • The duration of the disturbance is more than 1 month.

  • The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Post-traumatic Stress Disorder is a condition characterized by intense fear, helplessness, or horror (or disorganized or agitated behavior in children) resulting from the exposure to extreme trauma. An arbitary distinction is made between acute stress disorder (in which similar symptoms are present for less than 1 month) and PTSD (where the same symptoms are present for at least 1 month). It is characterized by 3 types of symptoms: re-experiencing (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares); avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event); and hyperarousal (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems). These symptoms must cause significant distress or life impairment for a diagnosis to be made.

Effective Therapies

Individual trauma focused cognitive-behavioural therapy (TFCBT) is effective in the treatment of PTSD. Other non-trauma focused psychological treatments do not reduce PTSD symptoms as significantly. SSRI antidepressant medication is also a first line treatment for PTSD (NNT= 4.8; SSRI response rate= 59.1% vs. placebo response rate= 38.5%). It is not yet known whether combination therapy (TFCBT + SSRI antidepressant medication) is more effective than either treatment used alone. Unfortunately, more than one-third of people with this disorder fail to recover even after many years.

Ineffective Therapies

Certain treatments worsen PTSD. Research has shown that compulsory psychological intervention offered to everyone after a trauma (e.g., school tragedy) is harmful and may make PTSD worse. Watchful waiting, with treatment given only to those individuals that develop PTSD, is far more effective than compulsory "Psychological Debriefing" (to "prevent" PTSD) given to every traumatized individual.

Vitamins and dietary supplements are ineffective for this disorder.

Complications

Individuals with this disorder may describe painful guilt feelings about surviving when others did not survive or about the things they had to do to survive. Avoidance patterns may interfere with interpersonal relationships and lead to marital conflict, divorce, or loss of job. Auditory hallucinations and paranoid ideation can be present in some severe and chronic cases.

Comorbidity

This disorder often co-occurs with increased rates of major depressive disorder, substance use disorders, panic disorder, agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, social anxiety disorder, specific phobia, and bipolar disorder. These disorders can either precede, follow, or emerge concurrently with the onset of post-traumatic stress disorder. Chronic post-traumatic stress disorder may be associated with increased rates of somatic complaints and general medical conditions.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder. However, often individuals with this disorder have increased arousal which may be measured through studies of autonomic functioning (e.g., heart rate, electromyography, sweat gland activity).

Prevalence

In a community sample in the United States, the lifetime prevalence rate for post-traumatic stress disorder is 8%. However, the highest rates (ranging between one-third to more than half of those exposed) is found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Course

Post-traumatic stress disorder can occur at any age, including childhood. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before symptoms appear. Frequently, the person first has an acute stress disorder in the immediate aftermath of the trauma. The duration of post-traumatic stress disorder varies, with complete recovery occurring within 3 months in approximately half of the cases, with many others having persisting symptoms for longer than 12 months after the trauma. In some cases, the course is characterized by waxing and waning of symptoms. Symptom reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events.

Outcome

The severity, duration, and proximity of an individualís exposure to the traumatic event are the most important factors affecting the likelihood of developing this disorder. This disorder can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme.

Familial Pattern

There is evidence of a heritable component to the transmission of post-traumatic stress disorder. A history of depression in first-degree relatives has been related to an increased vulnerability to developing post-traumatic stress disorder.

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