Post traumatic stress disorder

Reaction to severe stress and adjustment disorder

Classification

Ø  Acute stress disorder

Ø  Post traumatic stress disorder

Ø  Adjustment disorders

Acute stress disorder

·         Acute stress disorder involves the development of anxiety, dissociation, and other symptoms after a recent exposure to a traumatic stressor

·         Starts within 4 weeks of the traumatic event and lasting for at least 2 days

·         The patient continually re-experiences the event

·         Avoid situations that remind him or her of the event

·         Increased anxiety that negatively affect his or her lifestyle

·         The patient must have three dissociative symptoms, including numbing, detachment, a reduction of awareness to one’s surroundings, derealization, depersonalsiation or dissociative amnesia

·         After 1 month the diagnosis is changed to PTSD if symptoms persist

Post traumatic stress disorder

·         PTSD is a condition marked by the development of symptoms after exposure to traumatic life events

·         The person reacts to this experience with fear and helplessness, persistently relives the event, and tries to avoid being reminded of it

·         To make the diagnosis, the symptoms must last for more than a month after the event and must significantly affect important areas of life, such as family and work

Epidemiology:

Incidence about 9 to 15% and the prevalence about 8% of the general population

Examples of traumatic events that may precede PTSD

·         Combat-related experiences

·         Torture and other experiences of prisoners

·         Sexual assault

·         Physical assault

·         Sexual and physical abuse in childhood

·         Armed robbery, other violent crime

·         Road traffic accidents, other “man-made” accidents

·         Natural disasters

Development of PTSD

Unexpected/unpredictable event involving possible or actual death or serious injury (potential or real threat to one’s own life or life of others)----->

Appraisal of the meaning and/or consequences of the event----->

Reaction to the event: Intense  fear, helplessness, horror, other emotions (e.g., shame, guilt)------>

Long-lasting impact of the event

PTSD

    

Etiology

Risk factors:

·         Presence of childhood trauma

·         Borderline/paranoid/ dependent/ antisocial personality disorder traits

·         Inadequate family or peer support system

·         Being  Female

·         Genetic vulnerability to psychiatric illness

·         Recent stressful life changes

·         Recent excessive alcohol intake

Psychodynamic factors

·         The revival of the childhood trauma results in regression and the use of the defense mechanisms of repression, denial, reaction formation, and undoing

·         According to Freud, a splitting of consciousness occurs in patients who reported  a history of childhood sexual trauma

·         A pre existing conflict might be symbolically reawakened by the new traumatic event

Cognitive behavioral factors:

·         The cognitive model of PTSD assume that affected person cannot process or rationalize the trauma that precipitated the disorder

·         They continue to experience the stress and attempts to avoid experiencing it by avoidance techniques

Biological factors:

·         Altered function in the noradrenergic system

·         Abnormality in the opioid system

·         Dysfunction of the corticotropin releasing factor and the HPA axis.

·         mutations in a stress-related gene

DSM-IV-TR DIAGNOSTIC FACTORS

A. Exposure to a traumatic event

B. Persistent re-experience (e.g. flashbacks, nightmares)

C. Persistent avoidance of stimuli associated with the trauma (e.g. inability to talk about things even related to the experience. Avoidance of things and discussions that trigger flashbacks and re experiencing symptoms. Fear of losing control and harming another person.)

D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hyper vigilance)

E. Duration of symptoms more than 1 month

F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships)

Clinical features

·         The principal clinical features of PTSD are painful re experiencing  of the event, a pattern of avoidance and emotional numbing  and fairly constant hyper arousal

·         The mental status examination often reveals feelings of guilt, rejection and humiliation

·         Dissociative states, panic attacks, illusion and hallucinations

·         Aggression, violence, poor impulse control, depression and substance related disorders

·         Impaired memory and attention

Differential diagnosis

·         Panic disorder

·         Generalized anxiety disorder

·         Major depression

·         Borderline personality disorder

·         Dissociative disorder

Course and prognosis :  

PTSD usually develops some time after the trauma. The delay can be as short as 1 week or as long as 30years

Symptoms can fluctuate overtime and maybe most intense during the periods of stress

A good prognosis is predicted by rapid onset of the symptoms, short duration of the symptoms, good pre morbid functioning, strong social supports, and the absence of other psychiatric, medical or substance related disorders or other risk factors

Treatment:

Pharmcotherapy :

·         SSRIs- Sertaline and Paroxetine

·         Imipramine and Amitriptyline

·         MAOIs

·         Anticonvulsants (lamotrigine)

·         Clonidine, propranolol(anti adrenergic agents)

·         Atypical antipsychotics

Psychotherapy:

·         Psychodynamic psychotherapy

Behavior therapy, cognitive therapy

·         Hypnosis

Group therapy and family therapy

Critical incident stress management

Nursing management

·         Establish trusting relationship

·         Consistent Empathic approach

·         Simple re-orienting, reassuring statements to prevent suicidal ideation

·         Trusting relationship

·         Re-connect the individual with existing support system

·         Promote independence

·         Manage counter transference reaction

·         Group therapies

·         Encourage the client to verbalize feelings

·         Help the client identify community resources

·         Teach anxiety management strategies

·         Encourage changes in life style

·         Use crisis intervention techniques as needed

Mnemonics:

Post Traumatic Stress Disorder (PTSD) diagnosis

TRAUMA

·                 Traumatic event that would cause stress in any individual

·                 Reliving/re-experiencing event e.g. flashbacks, nightmares, intrusive thoughts

·                 Avoidance of things similar to event

·                 Unable to function e.g. socially, work

·                 Memory affected – inability to recall (partial or complete) important aspects of the event

·                 Arousal symptoms e.g. hyper-vigilance, startle reaction, irritability, poor concentration, poor sleep

Symptoms arise within 6 months (ICD-10) or 1 month (DSM-V)

Post Traumatic Stress Disorder (PTSD) features

IF AHEAD

·                 Insomnia – usually with nightmares (nocturnal flashbacks).

·                 Flashbacks – vivid reliving of trauma.

·                 Avoidance – of activities or events that resemble the traumatic event.

·                 Hypervigilance – autonomic hyperarousal and enhanced startle reaction.

·                 Emotional blunting – emptiness or numbness alternates with…

·                 Anxiety (intense) – experienced at similar events to trauma or anniversary of event.

·                 Detachment (emotionally) – from other people.