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Posttraumatic Stress Disorder (PTSD)
Dr. Anne Germain gives an overview of posttraumatic stress disorder.
Upon completion of this activity, participants should be able to:
- List risk factors for PTSD
- Identify symptoms of PTSD
- Describe PTSD treatment options
- Prins et al., Prim Care Psych, 2003.
- Weisberg et al., 2002, Psych Services.
- Boscarino et al., 2006 Annals Epid.
Dr. Germain has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
Grant/Research Support: NIH, DOD
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Release Date: 2/28/2013 | Last Modified On: 2/28/2013 | Expires: 2/28/2014
The overview for what I want to talk about is really just to start with defining stress and trauma so we are all on the same page, how it’s defined and what kind of trauma related outcome there are in addition to PTSD, and then I really want to focus on PTSD talking about diagnostic criteria, prevalence, risk factors and treatment, a little bit about the neurobiology but not too much and then give different examples of how it’s relevant to clinical practice in medicine or internal medicine specifically.
So when we think of stress really we refer to any kind of event that will change our usual normal level of functioning or routines or a challenge to homeostasis. And stress of course comes in different shapes and forms. When we think about stress we usually think about negative events but I do want to remind you that any change positive or negative is also a challenge to homeostasis. And what I’ve illustrated here is different forms of stress, but it can refer to a single acute event or a series of events that lasts for a long time, over time like caregiving stress or illness related stressors. Some of it comes from our environment, a messy bedroom, being stuck in traffic every day, different stressors that may be related to work and then there are real biologically meaningful stressors I would say like being chased by lions. What I do want to illustrate and the people in the Jeep there seem pretty calm, that’s probably better to be inside. What I do want to illustrate too in the lower corner here is this just a picture that to me illustrate the idea of resilience. We are constantly exposed to stress and different stressors and most of them – most of adapt well and we can find either return to our usual baseline level of functioning or we can find a new functional level if given stressors considerably altered our routine and our life generally speaking.
When we think of posttraumatic stress we refer to trauma, traumatic events, and those are a completely different kind of challenges that we face, and again I’ve illustrated some of these, the forms of traumas here. But when we think of a traumatic event we are really referring to events that involve a threat to one’s life or integrity that is associated by intense feelings of horror, helplessness and fear of course, and we may experience them differently or we may witness some of these events and witnessing events can be sufficient to cause long term posttraumatic symptoms. Again in the case of traumas we can refer to a single event like a car accident or a series of events that happen over a long time like is the case in domestic violence, it can be manmade or it can result from natural disasters. And sometimes traumas are experienced by a single individual and oftentimes they are experienced by a group of people.
Being exposed to traumatic event is not an uncommon, so I guess it is a common event in the general population. When we do surveys we find that anywhere between 50 and 90% of the people have actually experienced an event that would qualify to be a traumatic event over their lifetime, and the wide variability there in the prevalence is really dependent on how we define traumatic events. So if you ask your patients you are likely to find that many have had different kinds of experiences and traumatic experiences Now I want to focus on PTSD today but I want also to remind you that traumatic events are known precipitants of a variety of psychiatric disorders and I’ve listed some of them here including other anxiety disorders, mood disorder, depression being the most common one, but also some of the other addictive disorders, alcohol and substance use, eating disorders and there is some indication in the literature that psychotic episodes are oftentimes triggered by stressors or full blown traumatic experiences. So even though PTSD is the only psychiatric disorder that requires as the name says an exposure to traumatic event there are other kind of psychiatric outcomes that are common following trauma exposure.
Currently in the DSM4 we define PTSD with 3 symptom clusters. The first set of symptoms refer to reexperiencing symptoms and those include flashbacks, nightmares or intrusive thoughts or images about the event. Another cluster of symptoms include avoidance, and those refer to either purposeful efforts to avoid thinking about the traumatic event or any kind of effort that is made to avoid people, places or any reminder of the trauma. And in that cluster is also where you’ll find this emotional numbing where people will report that they can’t experience any emotion anymore, not fear, not sadness, not happiness and they have a restricted range of affect. But it’s not necessarily sadness as you would see in depression, it’s this completely flat affect or inappropriate affect. And finally there are symptoms of hyperarousal, insomnia is one of them, hypervigilance, exaggerated startle, and irritability is the one that is oftentimes the most acceptable to express for a lot of people.
For a diagnosis of PTSD these symptoms even though they are all normal – normal as stress reactions following exposure to a traumatic event, if they persist for more than a month is when we consider that the diagnostic criteria for PTSD have been met. And of course they have to be associated with impairments and significant distress during the daytime. Now all of my work focuses on returning veterans, people that are coming back from Iraq and Afghanistan right now, and if we only relied on functional impairments we would not make the diagnosis of PTSD as often as we do because people who are exposed to trauma through occupational responsibilities generally speaking tend to be highly functional. And we have to dig a little bit more in terms of what exactly they avoid or what it is that they don’t do anymore that gets in their way.
I’m not going to go through all of this, there are 17 symptoms of PTSD in those clusters. You have them in your slide for your references, for your reference if you want to go through these. And 17 symptoms may be quite a bit to ask when we see a patient and we have little time to evaluate whether or not we need to dig a little bit further into PTSD. There are screening instruments, this is one that performs actually very well in primary care clinics or other kinds of clinics where we’ve used it and it’s basically asking 4 simple questions to patients, whether or not they’ve experienced – they are willing to talk about traumatic experience. But if in the past month they have experienced nightmares or try to avoid thinking about or unwanted thoughts, try really hard not to think about different events or avoided some situations that are related to the event, if people report being on guard, watchful, easily startled, so this is the hyperarousal, hypervigilance aspect and feeling emotionally detached or numb, and if they answer 3 of these 4 questions positively there is a very high likelihood that they will meet diagnostic criteria for PTSD and it may be worth digging a little bit further.
Just as an FYI very quickly as you probably know the DSM is under – is going through a major revision right now, the DSM5 is expected next year and those are some of the aspects that are currently under review to modify recurrent diagnostic symptoms. So what I’m saying right now may actually not apply directly at the same time next year. But it’s mostly expanding the kind of emotional and cognitive disturbances that people with PTSD might actually experience. And maybe clarifying a little bit some of the behaviors that may not be easily recognized as part of PTSD like having irritable, irritable mood but also aggressive behaviors.
So I’ve said already that exposure to a traumatic event is common in the general population between 50 and 90% of the people will report one. There is only a significant minority of people exposed to traumatic events who will go on and develop PTSD. It tends to be twice as prevalent in women as it is in men and the general estimate for the populations vary between 5 and 10%. The prevalence of PTSD however is much higher when we look at the types of trauma that people have experienced with different groups of individuals and it can go as high as 30% if you look in the literature for people who have been exposed to interpersonal violence, so physical and sexual assault, also include combat exposures. And when we take a closer look at military samples, especially cohorts that have deployed in different conflicts and been exposed to combat again depending on the definition of PTSD over the years the prevalence estimates vary between 7 and 30%. Now currently in people that are coming back from Iraq and Afghanistan the estimate is closer to 30%. A few years ago we were estimating it between 11 and 18%, but that was only after one deployment to those theaters. And many people now have deployed 2, 3, 4, 5, 6, 7, 8, 9 times and for some people even more. So with greater exposure to potentially traumatic event you increase the risk of developing PTSD. So if you have patients who have served recently or in previous conflicts it might be – keep some level of alertness regarding PTSD.
Now we are not sure why some people develop PTSD following trauma exposure and some don’t. But there are known risk factors that have been identified and they are pretty robust and replicated across different studies across different populations. I’ve already mentioned that being a woman tends to be associated with higher rates of PTSD, having a family history of mental disorder, prior exposure to traumatic event, there is like this cumulative load that develops. Again if you work with people who are at high risk of being exposed to traumatic events through their work lines, be it firefighters, police officers, military personnel tend to entertain the belief, and actually I would say medical professionals as well, tend to entertain the belief that you’ve seen it all and you are developing this – you are desensitizing, you are developing this tolerance to traumatic events and that doesn’t bother you anymore. Well that’s when people become at a higher risk because we do sensitize over time. We may not react the same way but eventually we may have a bad surprise and it’s not necessarily going to be following the worst event that we’ve been exposed to. So that’s for repeated exposure to trauma.
I’ve already mentioned interpersonal violence and because I’m a sleep researcher I had to put it there but it is also a fact that people who don’t sleep well before or start having problems, sleep problems immediately after trauma exposure at much – are at much, much higher risk of developing PTSD chronically and have chronic PTSD symptoms. And that is one of the very few modifiable risk factor of PTSD that we have at the current time.
A little bit about the neurobiology of PTSD and let me see if I can get this to move. So currently we are thinking of PTSD really as a disorder of the fear response system. And I won’t go into much detail but I will say that there are 3 components to the fear response – the brain fear response system and those include the amygdala, but in the upper left corner there you have the amygdala that is depicted, usually the brain rotates, it’s easier to see in red. In the middle picture the red section depicts the hippocampus or the center for memory in the brain whereas the amygdala is really the threat detection center or the center of the brain that really identifies the emotional salience of experiences and different stimuli. And finally in the right bottom corner is a white area that we generally call the medial prefrontal cortex or PMFC that basically regulates our fear responses. And I can go into a lot of complicated brain graphs but I thought the best way to depict how this all works together is to think of the fear response system as this chariot driven by horses which is really – really the effector systems that will drive behavior. And when we are exposed to something that is scary or uncomfortable the amygdala becomes activated but fortunately the hippocampus can go back to previous experience and determine how bad this current experience is, and the medial prefrontal cortex can make sense of it and kind of inhibit the amygdala response, the knee-jerk reaction if you want of the amygdala.
And that’s how things work in a healthy fear system. There is an immediate detection, that’s a good thing for survival, and very soon after drawing from memories, drawing from experience in our brains the higher centers of the brain’s medial prefrontal cortex, interpreting this information and saying oh, that’s all right, it’s just a plastic snake, it’s not a real threat. Now in the case of PTSD you have this complete exhaustion of these regulatory centers or inhibitory centers of the amygdala, where the amygdala is consistently hyper-activated to the point where the medial prefrontal cortex and the hippocampus for different reasons become much less efficient at inhibiting the amygdala and slowing down basically the horses. So you have this perpetual fear reaction that is activated.
Now some of the treatments that we have currently are thought to – I’m not sure they are, but they are thought to really target these brain centers to try to rebalance the relationship between the amygdala, the fear response center, the detection center and the inhibitory and control centers of the hippocampus and medial prefrontal cortex. There are two, like in everything else in psychiatry, kind of approaches for the treatment of PTSD. There are pharmacological treatments and there are cognitive behavioral or psychological treatments that are available.
If we look at pharmacological treatments all the guidelines that we have and what’s been tested and approved by the FDA is really limited to the SSRIs at the time, at the current time. and if we look at the response rate versus placebo to SSRIs to placebo basically we see that about 60% of our patients respond well to medication, but there is also 40% who respond decently to placebo. You know better than I do that prescribing especially psychotropics is an art as much as a science to try to identify what is the combination of what kind of medication will work for a given patient. And for that reason there are other, many other agents that have been used in the treatment of PTSD but none have shown great efficacy. Now we also talk about treatment response, which relates to a reduction in symptom severity. We are far from talking about remission and recovery here.
We don’t get much more benefits in terms of response and recovery when we look at CBT, or cognitive behavioral therapy, for posttraumatic stress disorder. There was a report from the Institute of Medicine in 2007 that conducted this mega metaanalysis to look at comparing pharmacological and nonpharmacological treatments of PTSD and within the psychological treatments concluded that really only exposure based therapy has gathered enough evidence of efficiency for the treatment of PTSD. But again there is quite a bit of work to do. We are talking about response, again not remission, and full recovery.
And in exposure based therapy, just quickly, the idea is to – is to rebalance if you want the fear system where we ask people to expose themselves to the cues and the reminders that are related to the traumatic event so that we can activate, that’s what we think we do, but there is only some pilot data to back it up, but we think we activate the fear system to kind of retrain the brain in or exercise the inhibitory control of the amygdala, so you ask people to expose themselves either in imagination to the traumatic event or to the actual situations if it’s safe to do so of course, and to tolerate the anxiety that comes with it with the idea that eventually they’ll habituate, anxiety goes up, anxiety goes down, you repeat that several times at home in homework, in sessions and eventually the nonthreatening stimuli or environments or reminders do not produce this hyper-activation of the fear emotional response. I’ll leave it at that for now.
So how does that relate to medical outcomes when we think of PTSD? Well if you do a search of the literature you’ll see that there are many, many papers and different research studies and clinical reports that show that individuals with PTSD just tend to have a higher medical burden than non-PTSD subjects. And it’s true if you look at general medical complaint, different kinds of disorders, diabetes, mortality and increased healthcare utilization and cost and to illustrate that I just wanted to select, I picked 4 of these and I want to go into a little bit more details but I promise not too much just to illustrate that this relationship between PTSD and physical health outcome is quite drastic.
There are a series of studies that I’ve looked at whether or not PTSD could predict medical health or physical health in patients seen in primary care clinics and specialty clinics, but usually they are in primary care. And in this particular study it was in primary care with 502 patients with one or more anxiety disorders and the idea here was to just see if PTSD was a significant predictor of the number of nonpsychiatric complaints endorsed by these patients. And what you may be able to see, what you do see here is that whether you look at the total lifetime medical problems or current medical problems PTSD is right up there following age and recruitment site was a multisite study but the usual suspect if you want. And it’s not just any anxiety disorders but among anxiety disorders PTSD is one of the strongest predictor of how many medical complaints patients seen the primary care clinic will endorse.
If we look a little bit more into what kind of medical complaints people with PTSD endorse you have a long list and you see there some type of problems that are more likely to be endorsed by patients with an anxiety disorder and specifically people with posttraumatic stress disorder. What you see here is that pretty much everything is more common of all the list here if you want, and I don’t know if you can read it, there is anemia, arthritis, back pain, diabetes, eczema, kidney disease, lung disease and ulcers. And these were significantly more frequently endorsed by patients with PTSD. But in this study, in the second set of column there what you can see is that – well actually they looked at 3 groups in the study, people who didn’t respond – didn’t report any exposure to trauma, people who were exposed to traumatic events but did not develop PTSD and those who did develop PTSD. And if you can see the numbers you’ll see that there is this nice linear relationship between no trauma to having been exposed to trauma and having PTSD following to it, whereby the risk of having any of this, these conditions is much higher in those with PTSD compared to those who didn’t have trauma exposure. But even those who are exposed to trauma tend to report higher rates of these conditions compared to nontrauma exposed patients.
If you want to look at MI as an outcome there is this quite incredible study with a lot of people done through the VA because they have medical records and long, it’s easier to track patients over time, and in this particular study they were looking at over 300,000 people over time, and looking at if PTSD could actually predict the risk of MI in this group. And because we know that major depression os such a high robust risk factor for MI they looked at two groups of patients, those with depression and those without depression and controlled for everything from age, sex, race, diabetes, alcohol, substance use, nicotine use and I think there was something like 18 covariates entered in the model. But basically in summary what they found is that among people who are not depressed, PTSD is a risk factor for MI. When they looked at the same relationship, I’m sorry this is this one here, when they looked at people who were depressed PTSD did not remain a significant predictor of MI in this particular study.
If you look at mortality as the ultimate outcome again a study conducted through VA medical record with US Army veterans that were followed up or looking back I guess 30 years of their record, and those were all Vietnam veteran era patients seen through the VA and without going into too much details what you can see from the first column there is that if you look at all cause mortality those in the Vietnam theater which is those people that have a higher risk of trauma exposure and higher load effectively of trauma exposure were at higher risk, slightly but significantly higher risk that veterans who had served during the Vietnam era are a whole group, a comparison group that included all actually the combination of the entire sample for all veterans. And if you wanted to – they also looked at different kinds of causes of mortality, cardiovascular, cancer and external causes and those refereed to car accidents or suicide for example consistently of Vietnam veterans who had served in theater were at higher risk of all for mortality but even when we looked at individual causes of mortality.
So PTSD is bad for your health I guess is the take home message from this.
And then if we want to look at healthcare cost, again those are complicated studies but this one study done with women, one of the very few studies conducted with a large sample of women looking at the impact of PTSD and what they did in the study is that they categorized PTSD symptoms as low, moderate or high using the PCL, the PCL is the PTSD symptom – the PTSD checklist, those 7 items that people endorse whether or not they are bothered by the symptoms that are listed, it takes about a minute and a half to complete and 30 seconds to score if you can add up very quickly. We use it in primary care, we use it in trauma surgery, but anyways then they looked at the cost associated, the 6 months increment in cost for different care, specialty care in those with low, moderate or high PTSD symptom severity. And what you see here again is this linear relationship from low to moderate to high whereby women who had high levels of PTSD were using more healthcare for nonpsychiatric specialty care, both if you look at total cost or again looking at emergency care, pharmacy or outpatient care, inpatient and those are outpatient and inpatient nonpsychiatric care. Much more expensive over 6 months with people with high PTSD, so I think it’s worth considering doing screening among all the other things that we have to do if we are looking for efficient ways to reduce healthcare costs and improve outcomes in our patients.
Now how is that PTSD trauma exposure may be related to physical health and medical outcomes, and that’s really the questions and there are many mechanistic studies that have been done or ongoing to try to understand the mind/body relationships if you want. But generally speaking, actually I’ll go straight to the next one, I think it’s clear we can all agree that there is a central effect of posttraumatic stress disorder as well as a peripheral effect. We know that PTSD is associated with poor cardiovascular outcomes and even preclinical indices of poor cardiovascular outcomes. Those two might very well be related by the kind of behaviors, compensatory behaviors that people take on as a way of managing symptoms and all sorts of symptoms. And that with the combination of all of these we end up having a direct and very adverse, very varied effects on physical health
So the take home message from this really is that stress and trauma do effect not only mental health but physical health. Keep in mind that trauma exposure is a common occurrence in the general population and that between 50 and 90% of your patients have been exposed to trauma. Most people are resilient, most people can bounce back and they will, but stressors and traumas accumulate over a lifetime. PTSD is a common psychiatric disorder but trauma can also be associated with other kinds of mood and anxiety disorders that are frequently seen in all specialties. We have treatments that can be effective but I think that’s still an area that – I think it is an area that needs a lot of work. We can get some treatment response, we can get some good response, alleviation of symptoms but we are not there yet in terms of having a cure.
And finally, PTSD is bad for your health, which also points to opportunities for early detection and prevention and reformatting some of the interventions that we have to be able to do more of the acute management. Typically it takes 20 years for people with PTSD to seek treatment in psychiatry or psychology. They have many, many visits to their doctors before we see them there. And I will take questions if there are any questions. Thank you.