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.

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Definition/Description

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:
• Recollections of the event
• Avoidance of stimuli
• Increased anxiety and irritability

Prevalence

• Up to 80% of all acute stress disorders develop into PTSD
• An estimated 8% of Americans have PTSD at any given time
• Twice as many women as men develop the disorder with 20% of women exposed to trauma and 8% of men
• On average, 13% of veterans experience PTSD in their lifetime
• Research is examining the influence of race and culture with findings suggestive of increased incidence and risk in Hispanic Americans
• 5% of adolescents have met the criteria for PTSD in their lifetime (8% girls vs 2.3% boys)

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[4]

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
• Symptoms of anxiety include dizziness, heart palpitations, fainting, headaches, etc
• 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
Symptoms may present themselves immediately following trauma or may be delayed months or years.

Children and adolescents 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

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-morbidities most commonly seen in patients with PTSD:
• substance abuse[9]
• 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 (FDA approved)
• Paroxetine (FDA approved)
• Mirtazapine
• Venlafaxine
• Mood Stabilizers
• Carbamazepine
• Divalproex
• Others
• Prazosin – decreases nightmares
• Tricyclic Antidepressants
• Monoamine Oxidase Inhibitors

Diagnostic Tests/Lab Tests/Lab Values

The DSM-V criteria for diagnosis of PTSD: Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. Criterion A: stressor • The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence via direct exposure, witnessing, indirectly, or repeated exposure. Criterion B: intrusion symptoms • The traumatic event is persistently re-experienced in one of the following ways: recurrent memories, traumatic nightmares, dissociative reactions (flashbacks), prolonged distress, or marked physiologic reactivity. Criterion C: avoidance • Persistent effortful avoidance of distressing trauma related stimuli after the event via thoughts/feelings or external reminders. Criterion D: negative alterations in cognitions and mood • Negative alterations in cognitions and mood that began or worsened after the traumatic event in two of the following ways: dissociative amnesia, persistent negative beliefs, persistent distorted blame, persistent negative trauma related emotions, markedly diminished interest in significant activities, feeling alienated from others, or constrictive affect. Criterion E: alterations in arousal and reactivity • Trauma related alterations in arousal and reactivity that began or worsened after the traumatic event in two of the following ways: irritable or aggressive behavior, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, problems in concentration, or sleep disturbances. Criterion F: duration • Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. Criterion G: functional significance • Significant symptom related distress or functional impairment (e.g. social, occupational). Criterion H: exclusion • Disturbance is not due to medication, substance use, or other illness.

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

Etiology/Causes

Any person, even if psychologically healthy, may develop PTSD when exposed to an extremely traumatic event.
An individual’s 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

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.

Risk Factors

• Age
• Gender – women are four times more likely
• Race
• Previous trauma
• Lower socioeconomic status
• Personal and family psychiatric history
• Occupations – military, rescue workers, emergency personnel

Systemic Involvement

Research shows that people with PTSD are at an increased risk of developing diseases of nervous system, hypertensive, circulatory systems, digestive system, musculoskeletal system, and ill-defined conditions. Furthermore, veterans with PTSD have a higher prevalence of physical illnesses in these areas when compared to veterans without PTSD.
• Central Nervous System
o Abnormal functioning of hypothalamic-pituitary-adrenal (HPA) axis – needed to manage both daily challenges of life and to overcome real and perceived threats[18]
o Abnormal activity of cortisol and norepinephrine
o Damaged amygdala and hippocampus – leads to abnormal regulation of hormones, memory, and control of emotional response
• Cardiovascular System
o Anxiety can lead to increased heart rate, heart palpitations, and increased blood pressure
o Altered ratio of T-cell lymphocytes – can alter diastolic function[19]

The following table was taken from a study using veteran samples examining the association of PTSD with physical health, specifically autoimmune diseases.

      Joseph A. Boscarino:

Image:Boscarino04_(dragged)_1.jpg
      

Medical Management

• Drug Therapy (see Medications above)
• Psychotherapy:
o Cognitive restructuring (seen as the most effective treatment other than drug therapy) –provides the patient with a better understanding of what happened
o Family therapy
o Group therapy
o Psychological debriefing/critical incident stress debriefing – crisis intervention often administered in a group setting: gives opportunities to share experiences; therapists provide feedback and tips, may refer
o Exposure techniques – patients are exposed to aspects of their traumatic experience in a safe environment and guided by the therapist to manage their emotions
• Prevention – the strategies mentioned above are hypothesized to assist in the prevention of PTSD when large groups are affected by traumatic events

Physical Therapy Management 

• A physical therapist is not involved in the primary treatment of PTSD. However, patients with PTSD may have experienced an injury during their traumatic event, i.e. military personnel, emergency personnel, first responders, etc, who need PT interventions.
• 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.
• Treating a patient who present with a co-morbidity of PTSD, or who is exhibiting signs and symptoms of the disorder, may pose challenges throughout the course of therapy. Challenges may include patient’s response to treatment, patient's relationship with the physical therapist, compliance, fear of symptoms, etc.
o “Clinically, it could be hypothesized that exposing patients with PTSD to the physiological symptoms they fear, such as rapid heart rate, in the context of physical activity increases tolerance for such symptoms. This repeated exposure may reinforce that the feared physiological sensations may be uncomfortable, but do not pose a serious threat and consequently could facilitate habituation.”
o One study found that yoga intervention in women with PTSD improved exercise motivation.
o Aquatic therapy can be an effective intervention in patients with PTSD based on the similar sensory deficits as children with sensory integration disorder, but further research is needed to determine its effectiveness.
• Having a list of resources related to PTSD available in the physical therapy setting may also be beneficial.

Differential Diagnosis

Other disorders besides PTSD can present with the same symptoms and be triggered by a traumatic event. In addition, all of the following may exist simultaneously with PTSD.
• Depression – predominantly low mood
• Generalized Anxiety Disorder – mimics symptoms of hyperarousal
• Specific phobias – i.e. agoraphobia
• Dissociative disorders – involve breakdown of memory, awareness, identity, or perception
• Psychosis – i.e. hallucinations, delusions, etc.
• Personality Disorder – changes in personality traits with prolonged extreme stressor
• Adjustment Disorder – less severe stressor with different pattern of symptoms
• Obsessive Compulsive Disorder – any repetitive or intruding thoughts that are not related to trauma
• Panic Disorder – anxiety attacks are not a result of re-living trauma

Case Reports/ Case Studies

PTSD and Early Childhood Trauma[15]

PTSD treatment in Battered Women

Virtual Reality Exposure Therapy for Vietnam Veterans

PTSD Treatment Cochrane Review[18]

^{PTSD, Sexual Trauma, and PT[29]}

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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References

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