PTSD and its

management
Prepared by:
Dr. Prabidhi Adhikari

Moderator:
Dr. Md. Ainuddin
Bagban
Contents
• Introduction
• Epidemiology
• Neurobiology
• Comorbidities
• Symptoms
• PTSD in children and adolescents
• Subtypes
• Diagnosis
• Course and prognosis
• Management
Introduction

• The link between acute mental syndromes and traumatic events

has been recognized for more than 200 years.

• Early psychoanalytic writers, including Sigmund Freud, noted a

relationship between neurosis and trauma.

• The psychological effects of trauma have been described

throughout military history.

• Da Costa syndrome (“soldier's heart”), which is characterized

by cardiac symptoms associated with irritability and increased
arousal, was described in veterans of the American Civil War.
Introduction

• During World War I, it was hypothesized that “shell shock”

resulted from brain trauma caused by exploding shells.

• During World War II, terms such as “combat neurosis” and

“operational fatigue” were used to describe combat-related
symptoms.

• The Vietnam War significantly influenced the current concept of

PTSD.

• In 1980, the APA added PTSD to DSM-III nosological classification

scheme.
Introduction
• Posttraumatic stress disorder (PTSD) : "the complex somatic, cognitive,
affective, and behavioral effects of psychological trauma"

• Trauma :
• A traumatic event is a catastrophic stressor that is outside the range
of usual human experience.

• Traumatic events are clearly different from the very painful stressors
that constitute the normal vicissitudes of life such as divorce, failure,
rejection, serious illness, financial reverses.

• Although most individuals have ability to cope with ordinary stress,

their adaptive capacities are likely to be overwhelmed when confronted
by a traumatic stressor.
Introduction
• May be due to :
Direct exposure:
• Experiencing a violent accident or crime involving actual or threatened
death or injury, or a threat to the physical integrity of him/herself or
others such as :
• military combat, assault, being kidnapped, being involved in a natural
disaster, being diagnosed with a life-threatening illness, or experiencing
systematic physical or sexual abuse

 Indirect exposure:
• learning about the violent or accidental death or perpetration of sexual
violence to a loved one.
• Repeated exposure to the gruesome and horrific consequences of a
traumatic event usually as part of one's professional responsibilities(e.g.
police personnel, body handlers, etc.)
Epidemiology
• Around 70% of people globally will experience a potentially traumatic
event during their lifetime

• Minority (5.6%) will go on to develop PTSD.

• ~ 3.9% of world population has experienced PTSD at some point in

their lives .

• The prevalence of PTSD in Nepal varies depending on the study and

population, with rates ranging from 5% to 59.7%

• Post-Earthquake: 5.2%
• Civil War:9.6%
• Nepali Army Personnel:9%
Epidemiology
• Sexual relationship violence – 33 percent (rape, childhood sexual
abuse,).

• Interpersonal-network traumatic experiences – 30 percent (unexpected

death of a loved one, life-threatening illness of a child).

• Interpersonal violence – 12 percent (childhood physical abuse or

witnessing interpersonal violence or threatened by violence).

• Exposure to organized violence – 3 percent ( refugee, kidnap, war zone).

• Participation in organized violence – 11 percent (combat exposure).

• Other life-threatening events – 11 percent (motor vehicle collision, ND,

toxic chemical exposure).
Risk factors
Epidemiology

Other:
• Gender, Race, Physical
injury (including TBI) as
part of the traumatic
event, and type of
traumatic event.

• For example, rates of

PTSD are higher among
people exposed to violent
conflict or war and
following sexual violence.
Genetics
• account for about 30 percent of the variance in the risk for PTSD.

• A study of Vietnam veteran twin pairs reported that monozygotic

twins of veterans with combat-related PTSD had more significant
mood disorder symptoms than their controls

• Findings suggest a shared genetic vulnerability to PTSD and

mood disorders.

• remaining vulnerability account to unique environmental

experiences.
Genetics
• Several common genetic variants are associated with PTSD

• polymorphisms in FKBP5, PACAP1, COMT, DRD2, GABA alpha-2

receptor, G-protein signaling 2 (RSG2)

• An estrogen response element on ADCYAP R1.

• the s/s genotype of the serotonin transporter gene may interact

with childhood adversity to increase PTSD risk
Neurobiology

• Patients with chronic PTSD have increased circulating levels of

norepinephrine and increased reactivity of a 2 -adrenergic receptors
along with increased thyroid hormone levels- are may help
explain some of the somatic symptoms of the disorder.

• Cortisol levels are lower than normal in patients with PTSD,

even decades after a traumatic event.

• Paradoxically, levels of corticotropin-releasing factor in

cerebrospinal fluid appear to be increased
Neurobiology
• In PTSD the sensitivity of the negative-feedback system of the
HPAA is increased, as reflected by the exaggerated
suppression of cortisol in response to dexamethasone
administration and the increased sensitivity of lymphocyte
glucocorticoid receptors

• Decreased cortisol levels at the time of a traumatic event could

prolong the availability of norepinephrine to synapses in
both the periphery and the brain, which in turn might affect the
consolidation of the memory of the incident
 Neurobiology

• The biologic alterations

observed in PTSD do not
uniformly resemble those
associated with other types
of stress.

• brief and sustained periods

of stress and with major
depression, are typically
associated with increased
levels of both cortisol and
corticotropin-releasing factor
Neurobiology :Neuroanatomy
• alterations in two major brain structures — the amygdala and
hippocampus

• PET and fMRI findings:

• Increased reactivity of the amygdala and anterior paralimbic
region to trauma-related stimuli
• Decreased reactivity of the anterior cingulate and orbitofrontal
areas

• Differences in hippocampal function and memory processes

suggesting a substrate for the intrusive recollections and other
cognitive problems
Comorbidities
Symptoms
They typically fall into the following 4 categories:

• Intrusion symptoms

• Avoidance of anything that reminds them of the event

• Negative effects on thinking and mood

• Changes in alertness and reactions

Symptoms
Intrusion symptoms:

• traumatic event may repeatedly reappear in the form of

involuntary, unwanted memories or recurrent nightmares.

• Some people have flashbacks, in which they relive events as if they

were actually happening rather than simply being remembered.

• People may also experience intense reactions to reminders of the

event.
• E.g :A combat veteran's symptoms might be triggered by fireworks
or whereas those of a robbery victim may be triggered by seeing a
gun in a movie.
Symptoms

Avoidance symptoms:

• persistently avoid things—activities, situations, or people—that

are reminders of the trauma.

• E.g, they may avoid entering a park or an office building where

they were assaulted or avoid speaking to people of the same
race as their assailant.

• may even attempt to avoid thoughts, feelings, or conversations

about the traumatic event.
Symptoms
Negative effects on thinking and mood:

• may be unable to remember significant parts of the traumatic event

• may feel emotionally numb or disconnected from other

people. Depression is common.

• How people think about the event may become distorted, leading
them to blame themselves or others for what happened.
• Feelings of guilt. E.g., guilty that they survived when other people
did not.

• feel only negative emotions, such as fear, horror, anger, or shame,

and may be unable to feel happy or satisfied or to love.
Symptoms
Changes in alertness and reactions:

• difficulty falling asleep or concentrating.

• may become excessively vigilant for warning signs of risk.
• may be easily startled.
• may become less able to control their reactions, resulting in
reckless behavior or angry outbursts.

Other symptoms

• Some people develop ritual activities to help reduce their anxiety.

For example, people who were sexually assaulted may bathe
repeatedly to try to remove the sense of being unclean.
Other Clinical features:

• They organize their lives trying to contain and mitigate the

persistent effects of the traumatic experience.

• For those traumatized in a war zone, they often feel as if the war
never ended.

• Victims of rape, assault, or torture describe difficulties engaging

and trusting other humans.

• They scan the environment for threat signals, which they fearfully
expect, and remain on guard, tense, restless, and exhausted.
 PTSD in children and adolescents:

• Symptoms such as repetitive dreams of the event,

nightmares of monsters.
• development of physical symptoms such as
stomachaches and headaches.

• Reenactment and Reexperiencing:

Types of abuse
• “Traumatic play” - a specific form of reexperiencing
seen in young children, consists of repetitive acting •65% neglect
out of the trauma or trauma-related themes in play. •18% physical abuse
•10% sexual abuse

• Older children may incorporate aspects of the trauma •7% psychological

into their lives in a process termed reenactment. (mental) abuse
Diagnostic criteria
Subtypes:
• Dissociative subtype
• Delayed subtype
• Preschool Subtype:
• applies to children six years old and younger; it has fewer symptoms
and also has lower symptom thresholds to meet full PTSD criteria.

• Complex PTSD:
• commonly seen in victims of prolonged, repeated interpersonal
violence such as domestic or sexual abuse and political torture.
• captivity or entrapment (a situation lacking a viable escape route for
the victim) which results in the lack or loss of control, helplessness
• multiple symptoms, excessive somatization, dissociation,
changes in affect, pathological changes in relationships, and
pathological changes in identity.
Relation to other
trauma and stress
related disorders
Course and prognosis
• Symptoms can
fluctuate over time
and may be most
intense during
periods of stress.
Prognostic Factors for PTSD

Positive Negative
Rapid onset of the symptoms Physical disabilities typical of late life
Short duration of the symptoms (less than Examples :impairments of the nervous
6 months) system and the CVS, such as reduced
cerebral blood flow and arrhythmias.
•

Good premorbid functioning Strong social Pre-existing psychiatric disability

supports

Absence of other psychiatric, medical, or PTSD comorbid with other disorders is

substance-related disorders or other risk often more severe and perhaps more
factors chronic and may be challenging to treat.

Mid life Very young and old

Course and prognosis
• About 80 percent of young children who sustain a burn injury v/s
30 percent of adults who suffer such an injury, have symptoms of
PTSD after 1 year.

• Presumably, young children do not yet have adequate coping

mechanisms to deal with the physical and emotional insults of the
trauma.

• Older persons are likely to have more rigid coping mechanisms

than younger adults and to be less able to muster a flexible
approach to dealing with the effects of trauma.
DIFFERENTIAL DIAGNOSES

• Adjustment disorder

• Specific phobias

• Generalized anxiety disorder

• Obsessive–compulsive disorder (OCD)

• Panic attack

• Depression
SCREENING TOOLS
FOR PTSD
PRIMARY CARE PTSD SCREEN
(PC-PTSD)
• 5 item screen

• To identify people with PTSD

In primary care settings
SCREENING TOOLS
FOR PTSD
• PTSD CHECKLIST FOR DSM 5 ( PCL
5)

• 20 item self report measure that

assesses DSM 5 symptoms of PTSD

• Can be used for : Screening

Monitoring symptoms during
treatment

• cluster B (items 1-5), cluster C

(items 6-7), cluster D (items 8-14),
and cluster E (items 15-20).

• cutoff score between 31-33 is

indicative of probable PTSD
Psychological Interventions
• Shared Decision Making and Collaborative Care (Strong
Recommendation)
• early interventions and collaborative care model Both are important
• First-Line:
• strongly recommended; large effects
• Cognitive Processing Therapy (CPT)
• Prolonged Exposure (PE)
• Trauma-Focused Cognitive Behavioral Therapy (CBT)

• Second line:
• Moderate to large effects
• Cognitive Therapy (CT)
• Eye Movement Desensitization and Reprocessing (EMDR)
• Narrative Exposure Therapy (NET)
Management
• Trauma-Focused Therapy:

• Trauma-focused (TF) psychotherapy uses cognitive, emotional, or

behavioral techniques to help people process traumatic
experiences.

• Some involve visualizing, talking or thinking about the traumatic

memory.
• Others focus on changing unhelpful beliefs about the trauma.

• The trauma-focused psychotherapies with the strongest evidence

from clinical trials are PE, CPT, and EMDR.
Trauma-Focused Therapy
• therapist or psychiatrist uses a guide manual to assist in care
delivery, ensuring that all important trauma related topics are
addressed.

• Use of a manual for trauma therapy is the gold standard for

treatment delivery.

• have shown consistent reduction of symptoms of PTSD with

completion of 12-16, 60-minute weekly individual sessions.

• new subtypes of manualized focused therapy such as cognitive

behavioral therapy for PTSD (CBT for PTSD), Narrative
Exposure Therapy (NET) and Written Exposure have also
shown evidence to support their use in treatment.
Prolonged Exposure

• Duration of treatment: PE usually takes 8-15 weekly sessions, so

treatment lasts about 3 months.
• Sessions are usually 1.5 hours each.
• verbal with imagining retelling of the trauma experience
• PE teaches to gradually approach trauma-related memories, feelings,
and situations that patient have been avoiding since experiencing
trauma.

• By confronting these challenges, he/she can decrease your PTSD

symptoms

• Drop-out rates from PE tend to be higher because verbal with

imagining, and retelling the trauma experience is described as difficult
by patients.
Written exposure therapy

• Of the newer researched therapies, written exposure therapy

has been showing excellent benefit with good treatment
retention.

• Especially for people whose learning style may be more tactile or

experiential,

• It allows for the patient’s written narrative with additional

cognitive therapy to be the mechanism for improvement,

• Emerging data suggest a much-improved retention rate in

therapy when compared to PE.
Cognitive Processing Therapy
• Components:
• Psychoeducation
• Written account about impact of traumatic event in life
• Cognitive restructuring

• Duration of treatment: CPT usually takes about 12-sessions.

Sessions are 60 minutes.

• CPT teaches how to evaluate and change the upsetting thoughts

you have had since experiencing a traumatic event.
• By changing thoughts, patient can change how they feel.
• They will use worksheets in session and at home that help them
learn this strategy.
Cognitive therapy for PTSD

• Derived from CBT Cognitive model for PTSD

• Traumatic event in a way that leads to a feeling of a present and

severe threat

• This happens because of negative evaluations of trauma or

disturbances in the autobiographical memories associated with
the trauma

• Treatment goals- Modify pessimistic evaluations and faulty

memories of the trauma
Eye Movement
Desensitization and
Reprocessing

• Duration of treatment:
EMDR usually takes about
1-3 months of weekly 50-
90-minute sessions.

• EMDR can help process

upsetting memories,
thoughts and feelings
related to the trauma went
through. By processing
these experiences, it can
relief from PTSD
symptoms.
Treatment: Pharmacotherapy

• SSRIs: sertraline and paroxetine, have the most robust evidence for
efficacy.

• SNRI: venlafaxine
• atypical antipsychotic :risperidone,
• anticonvulsant topiramate.

• Finally, the alpha 1-adrenergic antagonist prazosin shows effectiveness

for treating nightmares.

• Insomnia :
• low-dose trazodone preferable to benzodiazepines.
• orexin antagonist suvorexant is also promising for insomnia.
Other treatments
• Brexpiprazole and sertraline – Treatment with a combination of
the sertraline and the second-generation antipsychotic
medication, brexpiprazole, appears to be an effective novel
treatment for PTSD.
• Riluzole augmentation – The glutamatergic modulator riluzole,
has been shown to improve hyperarousal symptoms associated
with PTSD but not overall PTSD symptoms.

• Ketamine – Based on clinical trials, treatment with ketamine

combined with psychotherapy appears to reduce PTSD symptoms

• 3,4 methylenedioxymethamphetamine (MDMA) – MDMA

appears to be effective when combined with a very specific,
intensive form of psychotherapy
Other treatments
• Cannabis and synthetic cannabinoids –cannabis use is associated with
worse treatment outcomes in some naturalistic studies

• Benzodiazepines –Some data suggest that benzodiazepines may impair

the therapeutic effects of treatments, such as exposure therapy that rely
on extinction learning.

• Beta-adrenergic blocking agents (eg, propranolol) –studies have not

supported its use
• Mood stabilizers : not supported

• Other antidepressants – There is insufficient evidence of effectiveness

of antidepressants other than SSRIs or SNRI in PTSD, including TCA,
monoamine oxidase inhibitors, serotonin modulators (eg, trazodone), or
atypical antidepressants (eg, mirtazapine)
Other investigational treatments

•Repetitive transcranial magnetic stimulation (rTMS) –Trials

investigating the efficacy of rTMS have shown some benefits as
compared with sham rTMS when applied to the DLPFC

•Stellate ganglion blockade – Stellate ganglion blockade

involves injection of local anesthetic into the stellate ganglion of
the sympathetic chain in the neck. Randomized trials have shown
mixed results in the treatment of PTSD symptoms

•Acupuncture –Acupuncture appears to be effective for symptom

reduction and enhanced fear extinction in veterans with combat-
related PTSD
Recent advances

• In Israel, Hyperbaric Oxygen Therapy is being explored as a novel

treatment for PTSD. Preliminary studies suggest that about 68% of
patients experience significant improvement, with some achieving long-
term remission

• Use of virtual reality:

• This type of therapy gives the viewers a controlled and immersive
environment where they can safely confront and work through
traumatic events, significantly reducing the emotional response to PTSD
triggers.

• The realistic scenarios generated in VR ensure active and focused

participation from patients, which is critical for the success of exposure
therapy.
Summary

• Trauma and Stress related disorder.

• Clear point of onset.

• Onset may be delayed.

• Occurrence in children and adolescent fairly common.

• Frequently associated with other psychiatric illnesses.

• Pharmacotherapy along with psychotherapy to be instituted.

• 1/3rd cases resolve by the end of a year whereas 1/3rd continue to

be symptomatic even at the end of 10 years.
References
• Kaplan & Sadock’s Comprehensive textbook of Psychiatry,11th edition
• Oxford textbook of psychiatry,3rd edition
• Tasman’s psyhiatry,5th edition
• Post traumatic stress disorder- Mathew J Friedman
• Stahl’s essential psychopharmacology
• TMS Therapy and PTSD - Treatment Without Medication - MHM Group
• Zachary S et.al Family Medicine Institute, Waco, Texas Posttraumatic
Stress Disorder: Evaluation and Treatment. American Family
Physician. Volume 107, Number. March 2023
• POST –Traumatic Stress Disorder. Rachel Yehuda, P H .D. N Engl J Med,
Vol. 346, No. 2 · January 10, 2002