Post-traumatic Stress Disorder

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Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Samantha Sowder from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Samantha Sowder, Lucinda hampton, Kim Jackson, Admin, Aminat Abolade, Abigail Litts, WikiSysop, Elaine Lonnemann, Naomi O'Reilly, Simisola Ajeyalemi, Amanda Ager, 127.0.0.1, Wendy Walker and Colleen Baliga  

Definition/Description

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Photo available at: http://edmetheny.wordpress.com/2009/01/02/firefighter-photographer-brought-together-by-tragic-picture/

Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by psychological symptoms that continue to be experienced long after a traumatic event.  Any physical or psychological trauma can trigger PTSD, but there is most often an involvement of actual or threatened serious injury to the person or someone close to them.  The most common traumatic events leading to PTSD are combat, natural disasters, and abuse and victimization, including sexual assault and terrorism. The psychological pattern, characterized by persistent and chronic symptoms, that arise in certain individuals in response to such events define this disorder.  The three primary symptoms of PTSD are frequent recollections of the event which have become intrusive to daily life, avoidance of stimuli or situations triggering memories of the event with a resulting emotional numbness or unresponsiveness, and increased physical arousal with anxiety including extreme irritability or angry outbursts.

                                

Prevalence

-Up to 80% of all acute stress disorders develop into PTSD.

-Approximately 3.5% of people/year in the US experience PTSD and 7% in their lifetime.

-Studies of at-risk individuals have resulted in rates ranging from 3% to 58% lifetime prevalence. 

-Two times as many women as men develop the disorder with 20% of women exposed to trauma and 8% of men.

-Research is examining the influence of race and culture with findings suggestive of increased incidence and risk in Hispanic Americans.

-A study evaluating symptoms of PTSD in an orthopaedic trauma center found that "51% of 580 patients met the criterion for PTSD"

-The following table has been reproduced from a longitudinal study performed in 2007 outlining results of mental health assessments completed by a sample of 88,235 US Soldiers post-deployment to Iraq:

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Personal Photo: Samantha Sowder, Bellarmine University

Characteristics/Clinical Presentation

Symptoms of PTSD can include: 

-re-experiencing the traumatic event (recurring thoughts, memories, dreams, nightmares, flashbacks)

-avoidance 

-reduced responsiveness

-increased arousal, anxiety, and guilt

-feelings of detachment and dissociation

-dazed feeling

-difficulty remembering

-feeling that surroundings, thoughts, or body are strange and unnatural

-hyper-alertness

-difficulty concentrating

-sleep disturbances

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Personal Photo: Sally Sowder

Children and teens may have other signs and symptoms than those described above:

        -new/unusual bedwetting

-inability to talk

-acting out traumatic events during playtime

-heightened need for attention

-extreme dependence on parent/adult

-extreme disruptive behaviors

-lack of guilt in not preventing harm to others

-need for revenge

Symptoms associated with anxiety, stress, and tension:           

-excitability

-dizziness

-fainting

-heart palpitations

-fever

-headaches

Symptoms may present themselves immediately following trauma or may be delayed months or years.

Associated Co-morbidities 

Research shows that at least 83% of persons in the general population with PTSD have at least one other mental health diagnosis with 16% having one, 17% having two, and 50% having three or more.

The following are the co-morbities most commonly seen in patients with PTSD:

-substance abuse[8]

-depression

-suicidal tendencies

-panic disorder

-generalized anxiety disorder

The traumatic events that result in the development of PTSD may also result in physical trauma. 

Medications

-Antidepressants (including SSRIs)

           -Sertraline & Paroxetine are two FDA approved antidepressant drugs used for adult treatment of PTSD.

-Sedatives (useful for treatment of sleep disturbances and anxiety)

           -Benzodiazepines, Barbiturates, and others

-Antipsychotics

          -These drugs were first used for patients with psychotic disorders, but are now being utilized in other disorders such as PTSD.  The medication influences dopamine and serotonin which may help improve symptoms of hyper-arousal and re-experience in PTSD patients.

Diagnostic Tests/Lab Tests/Lab Values

The DSM-IV criteria for diagnosis of PTSD: -History of experienced, witnessed, or confronted  event(s) presenting death, injury, or threat to the physical integrity of self or another with a reaction of intense fear, helplessness, or horror.  -Re-experiencing the event in at least one of the following ways: -recollections, dreams, illusions, flashbacks, or a sense of reliving the experience -distress or physical arousal produced by reminders of the event   -Persistent avoidance of reminders of the event and a subjective sense of numbing, detachment, or emotional unresponsiveness. -Two or more symptoms of increased arousal:                        -sleep disturbances                        -irritability                        -poor concentration                        -hyper-vigilance                        -exaggerated startle response         -Significant distress or impairment in carrying out activities of daily life, with symptoms enduring for at least one month.

The disorder is considered acute if symptom duration is less than 3 months, chronic if more than 3 months, and delayed onset if symptom onset is at least 6 months after the traumatic experience.

Increased arousal may be measured through studies of autonomic functioning such as heart rate, electromyography, and sweat gland activity.

Etiology/Causes

video available at: http://www.nimh.nih.gov/media/video/tuma-short-ptsd.shtml?WT.mc_id=rss

“Even well-adjusted and psychologically healthy people may develop PTSD when exposed to an extremely traumatic event.”

Factors influencing the development of PTSD:

-Biological factors

-Personality

-Childhood experiences

                   Childhood experiences connected to PTSD:

                 -poverty 

                 -experiences of trauma at a young age

                 -age less than 10 at time of parent’s divorce. 

                 -social support

                 -severity of experienced trauma. 

An individuals personality, attitude, and coping mechanisms can all influence their susceptibility to developing PTSD.  Studies have found the following characteristics to be associated with people who have the disorder:

        -high levels of general anxiety

-psychological problems prior to trauma

-stressful life situations at the time of, or after trauma occurs

        -general sense of not being able to control one’s life

-inability to find any positivity during unpleasant situations

Occupations at increased risk: 

-rescue workers

-relief workers

-emergency service personnel

-military service members

Systemic Involvement

-Central Nervous System:

      PTSD has been linked to abnormal activity of the cortisol and norepinephrine in the urine, blood, and saliva.  There is also evidence that areas of the brain including the amygdala and hippocampus, which play a role in memory, regulation of stress hormones, and control of emotional responses may be damaged in those with PTSD.  

-Cardiovascular System:

      Anxiety can lead to increased heart rate, heart palpitations, and increased BP.

-Research has linked the diagnosis of physical health problems to patients with PTSD in both veterans and nonveterans. The increase in both prevalence and onset of physical disease in this population affects the nervous system, musculoskeletal system, cardiovascular system, endocrine system, immune system, and digestive system.  

-The following tables were taken from three different studies (using veteran samples) examining the association of PTSD with physical health.  

      Andersen et al.: 

      Joseph A. Boscarino:

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      Schnurr et al.:

Medical Management (current best evidence)

“One survey found that post-traumatic stress symptoms lasted an average of three years with treatment but five and a half years without it.”

-Drug Therapy (see Medications above)

-Psychotherapy:

-Exposure techniques: During this type of therapy, patients are exposed to aspects of their traumatic experience in a safe environment and guided by the therapist to manage their emotions.  

-Insight therapy: This therapy increases a patient's self awareness. 

-Family therapy

-Group therapy

-Psychological debriefing/critical incident stress debriefing: This therapy is a type of crisis intervention, often administered in a group setting that allows survivors of the same traumatic event to express their feelings and reactions.  The therapists then provide positive feedback, suggestions for managing stress, and possibly refer to an appropriate professional.  

-Cognitive restructuring: Often times patients with PTSD will view their experience in a way that is inconsistent with the actual events.  With this type of therapy, the therapist helps the patient to understand the reality of the trauma experienced. 

-Stress inoculation training: This type of therapy provides mechanisms for reducing anxious feelings when they arise. 

-Prevention: The debriefing strategies mentioned above are hypothesized to assist in the prevention of PTSD when large groups are effected by traumatic events.  Research is continuing to examine the most appropriate methods related to PTSD prevention. 

Physical Therapy Management (current best evidence)

-Screening the psychosocial condition of all patients is an important aspect of the initial evaluation in physical therapy that will influence the course of treatment in a variety of ways.  An article examining the prevalence of PTSD in an orthopedic trauma center suggests inquiring as to whether  "the emotional problems caused by the injury have been more difficult than the physical problems." 

-Treating patients presenting with a co-morbid diagnosis of PTSD or who is exhibiting signs and symptoms of the disorder may introduce challenges throughout the course of therapy.  This may include patient response to treatment, patient's relationship with the physical therapist, patient compliance, and others.  

-A physical therapist is not involved in the primary treatment of PTSD.  However, patients who have undergone a physically traumatic event resulting in injury may be at risk for developing this disorder.  It is also possible that patients being treated in physical therapy will undergo trauma within the course of their physical therapy treatment, or have experienced trauma in their past.  

-Acknowledging that the development of PTSD can occur quickly, or with a delayed onset, understanding the associated risk factors, and recognizing signs and symptoms allows for physical therapists to better address the needs of their patients.  

-A patient exhibiting warning signs of PTSD may indicate referral to a mental health professional.  Also, collaboration with mental health professionals may be necessary to ensure the highest quality of care for these patients.

-Having a list of resources related to PTSD available in the physical therapy setting may also be beneficial.

Differential Diagnosis

The following diagnoses may present with symptoms that are also present in PTSD, they are all potential co-morbities in persons with PTSD as well:

     -Agoraphobia: avoidance of social situations, however not directly related to trauma

     -Specific/Simple phobias: specific avoidance, but not trauma related

     -Brief Psychotic Disorder: avoidance, numbing, and increased arousal may all be present, but not as a direct result of a traumatic experience

     -Personality Disorder: personality traits/symptoms related to perception and behavior, present prior to any trauma

     -Depressive Disorder: numbing and avoidance without hyper-alertness and other symptoms

     -Adjustment Disorder: triggering event is less traumatic and symptoms are different

     -Obsessive Compulsive Disorder: any repetitive and intruding thoughts are understood to be inappropriate and not related to trauma

     -Panic Disorder: anxiety attacks are not a result of re-living trauma

     -Generalized Anxiety Disorder: mimics symptoms of hyperarousal seen in PTSD

NOTE: It is also important for professionals considering PTSD diagnosis to examine potential for gain if malingering is present.

Case Reports/ Case Studies

PTSD and Early Childhood Trauma[17]

PTSD treatment in Battered Women

Virtual Reality Exposure Therapy for Vietnam Veterans

PTSD Treatment Cochrane Review[20]

Resources

National Institute of Mental Health: PTSD

Medline Plus: PTSD

National Center For PTSD: US Department of Veterans Affairs

Gift from Within: Non-profit Organization

Recent Related Research (from Pubmed)

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