Post-traumatic Stress Disorder

&nbsp:

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.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Definition/Description

File:Fireman.jpg

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 disordered 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 and 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.

-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 Iraq⁴:

File:C.jpg

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

File:Haiti.jpg

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[7]

-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

           -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

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

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.

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.”³

Factors influencing the development of PTSD:

-biological factors

-personality

-childhood experiences

-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

Childhood experiences connected to PTSD:

-poverty 

-experiences of trauma at a young age

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

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.

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.”¹

-Drug Therapy

-Psychotherapy:

Exposure techniques

Insight therapy

Family therapy

Group therapy

Psychological debriefing/critical incident stress debriefing

Cognitive restructuring

Stress inoculation training

-Prevention

Physical Therapy Management (current best evidence)

add text here

Alternative/Holistic Management (current best evidence)

The Multidisciplinary Association for Psychedlic Studies (MAPS) has currently performed five clinical trials to include a pilot study in the U.S. examining the use of methylenedioxymethamphetamine (MDMA) in combination with psychotherapy for the treatment of patients with PTSD.  MAPS is currently preparing for a clinical trial involving U.S. Veterans of War as a Phase 2 Pilot Study.

                                        

 

                                                     ^{_{Video available at: http://www.youtube.com/watch?v=KYidpI1eMss}} 

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

     -Specific/Simple phobias

     -Independent Psychotic Disorders

     -Brief Psychotic Disorder

     -Personality Disorder

     -Depressive Disorder

     -Adjustment Disorder

     -Obsessive Compulsive Disorder

Case Reports/ Case Studies

PTSD and Early Childhood Trauma[13]

PTSD treatment in Battered Women

Virtual Reality Exposure Therapy for Vietnam Veterans

Resources

add appropriate resources here

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=10__S9PoH30LAMgg2rMTKAKTnEZ5qLChHaaC8VF6Liifbs3k1S|charset=UTF-8|short|max=10: Error parsing XML for RSS

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=14MpKbWO9zvMeau6W1NMSL2-OPgg48oKO-i488Zqg4j4ec5s3T|charset=UTF-8|short|max=10: Error parsing XML for RSS