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POST TRAUMATIC STRESS DISORDER

Highlights of changes from DSM IV-TR to DSM 5

 New chapter in DSM 5, PTSD and ASD was formerly classified
under anxiety disorders in DSM- IV-TR.
 Reactive attachment and disinhibited social engagement
disorders were classified under ' 'Disorders usually first
diagnosed in infancy, childhood, or adolescence" in DSM-IV-TR.
but is reclassified under Trauma and Stressor-related disorders
in DSM 5 because they are seen as responses to a stressful event.
 Criterion A2 of PTSD in the DSM-IV-TR (subjective reaction) has
been eliminated.
 The avoidance/ numbing cluster (DSM-IV-TR) is now two distinct
clusters in the DSM 5: avoidance and persistent negative
alterations in mood and cognition.

NEW CATEGORY
Under this new category (i) Reactive Attachment Disorder,(ii)
Disinhibited Social Engagement Disorder, (iii)PTSD, (iv) Acute
Stress Disorder, (V)Adjustment Disorders

Typical PTSD stressors are:

Rape or sexual molestation; Combat exposure ; Childhood neglect and
physical abuse ; Physical attack ; Being threatened with a weapon ;
Torture (immigrant populations) ; Natural disasters ; Severe
automobile accidents
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Diagnostic Criteria for Posttraumatic Stress Disorder

A. Exposure to actual or threatened death, serious injury, or sexual
violence:
 Directly experienced
 Witnessed in person
 Learning that it occurred to close family member or friend. In
case of death, must have been violent or accidental
 Experiencing repeated or extreme exposure to aversive details
of traumatic events (e.g. first responders collecting human
remains) * Not through media unless work related

B. One or more of intrusion symptoms

 Recurrent, involuntary, intrusive distressing memories
 Recurrent distressing dreams
 Dissociative reactions such as flashbacks
 Intense distress when exposed to cues
 Marked physiological reactions to cues

C. Persistent avoidance (one or both)

 Avoidance of memories, thoughts or feelings
 Avoidance of external reminders

D. Negative alterations in cognitions and mood (2 or more)

 Inability to remember important aspects of trauma
 Persistent negative beliefs or expectations about oneself,
others or the world
 Persistent distorted cognitions about cause or consequence of
trauma that lead to blame
 Persistent negative emotional state
 Marked diminished interest or participation in significant
activities Feelings of detachment and estrangement fromothers
 Persistent inability to experience positive emotions
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E. Alterations in arousal and reactivity (two or more)

 Irritable behavior and angry outburst
 Reckless or self-destructive behavior
 Hypervigilance
 Exaggerated startle response
 Problems with concentration
 Sleep disturbance

F. Duration (Criteria B,C,D, E) more than 1 month

G. Disturbance causing Distress/impairment in social,
occupational..,areas of functioning
H. Not due to substance or medical condition

I. Post-traumatic Stress Disorder (PTSD)

 Extreme stress and anxiety as consequences of experiencing
extreme stressors, referred as ‘traumas'
 Reexperiencing of the traumatic events (intrusive thoughts,
nightmares, flashbacks)
 The most important risk factors are the severity, duration, and
proximity of a person's exposure to the trauma

2. Acute Stress Disorder (ASD)

 Symptoms similar to PTSD and More emphasis on dissociation
 Duration varies • Short term reaction
• Symptoms occur between 3 days and 1 month after trauma
 As many as 90% of rape victims experience ASD
 More than 2/3 of those with ASD develop PTSD

3. Adjustment Disorders
 Characterized by an emotional response to a stressful event such
as financial issues, medical illness, or relationship problem
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ETIOLOGY
A. NEUROBIOLOGICAL PERSPECTIVE
l. Neuroimaging Technique

Positron-emission tomography (PET) and magnetic resonance imaging

(MRI; see Chapter 3) have shown differences between people with
PTSD and those without. These differences occur in brain areas that
regulate emotion, the fi ght-or-fl ight response, and memory,
including the amygdala, hippocampus, and prefrontal cortex
1. Patients with PTSD have hyperactive amygdala and hippocampus,
and medial prefrontal cortex.
Brain Normal Function PTSD
Amygdala Sets off fight-flight-freeze Activates fight-flight-freeze
Responses to danger responses to memories or
(brains alarm system) thoughts about danger
Hippocampus Transfers and stores Stores memories incorrectly
information into memories and affects memory retrieval
Medial Complex thinking, decision Dysfunctional thought
Prefrontal making and appropriate processes and decision
Cortex behavior (modulator for making; inappropriate
(MPFC) Amygdala activity) responses to situation

2. Stressful/ life-threatening event > triggers fight-flight-or-freeze

system>. stops hippocampus from organizing memory; stops neo-
cortex > memory that is stored is fragmented (traumatic memories)
*even the slightest association with the trauma (e.g. red color)
triggers alarm system
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II. Neurotransmitters
1.Cortisol
• PTSD patients have increased cortisol levels in the brain that is
implicated in hippocampus that results to impaired memory
Stressful/ life-threatening event > amygdala> cortisol is released
through the activation of the Hypothalamus Pituitary Adrenal Axis >
Hypothalamus secretes cortisol-releasing factor/ hormone (CRF/H)
which triggers pituitary gland to release Adreno Corticotropic
hormone (ACTH). In turn ACTH signals adrenal gland to release 30
other hormones cortisol, epinephrine (adrenaline), or
norepinephrine (noradrenaline), necessary for the fight-flight-or-
freeze mechanism (i.e increased blood flow to the muscles, blood
pressure)
Normally, once cortisol reaches the hypothalamus (i.e. when the
stressor is gone). it terminates the production of cortisol (negative
feedback). However, in PTSD, there is less sensitivity to negative
feedback.
One theory is, people with PTSD have lower levels of cortisol prior to
trauma than people who do not have PTSD (not used to stress). Thus,
there is lesser sensitivity to the negative feedback > continuous
production of cortisol > shrinking of hippocampus > memory is
impaired

B. PSYCHOLOGICAL PERSPECTIVE

i. Psychodynamic perspective
1.This perspective hypothesizes that the trauma has reactivated a
previously inactive, yet unresolved psychological conflict.
People already experiencing increased symptoms of anxiety or
depression before a trauma occurs are more likely to develop PTSD
following the trauma
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2. Style of Coping may lead to vulnerability; people who use self-

destructive or avoidant coping strategies, such as drinking and self-
isolation, are more likely to experience PTSD

ii. Cognitive perspective

1. Affected persons cannot process or rationalize the trauma that
precipitated the disorder. They continue to experience the stress
and attempt to avoid experiencing it (avoidance) - since they
only partially process the trauma, they alternate between
acknowledging and blocking the event
Less decline in vividness, emotional intensity, and accuracy of traumatic memories.• Exhibit difficulty
retrieving specific memories• Difficulties of attentional control
2. Dissociation and memory suppression may keep the person from
confronting the trauma

iii. Behavioral perspective

1.First, the traumatic experience (unconditioned stimulus) is paired
with a neutral stimulus (e.g. color& places, odor, etc.) producing
responses through classical conditioning > the conditioned stimulus
(colors, places, etc.) then elicit fear response independent of the
unconditioned stimulus > the person develops a pattern of avoidance
(my experience of fear of death…the smell of incense stick)
2. Another, some people also receive secondary gains such as
monetary compensation, increased attention/ sympathy and
satisfaction of dependency needs.

C. SOCIO-CULTURAL PERSPECTIVE

i.Severity, duration, and proximity to trauma

Strong predictors of people’s reactions to trauma include its severity

and duration and the individual’s proximity t o it (Cardozo, Vergara,
Agani, & Gotway, 2000; Ehlers et al., 1998; Hoge et al., 2004; Kessler
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et al., 1995). People who experience more severe and longer-lasting

traumas and are directly affected by a traumatic event are more prone
to developing PTSD.

ii. Resilience
1.When faced with a traumatic event, some people seem to rise to the
challenge and show resilience

iii. Social support

A nother predictor of vulnerability to PTSD is the available social
support . People who have the emotional support of others after a
trauma recover more quickly than do people who do not

iv. Gender Differences

1.Women may experience more triggers for PTSD since they are more
prone to sexual abuse as opposed to men
2.Men are more likely to report traumas that carry less stigma such as
exposure to war

TREATMENT
A. Pharmacological
a. Selective Serotonin Reuptake Inhibitors (SSR1s)
i. Antidepressants (Sertraline, Fluoxetine)
ii. Antianxiety drugs (Lorazepam)
B. Psychotherapy
a. Psychodynamic therapy
b. Cognitive-behavioral therapy
i. Imaginal exposure through virtual reality (VR) technology
ii. Systematic desensitization
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The client identifies thoughts and situations that create anxiety,

ranking them from most anxiety-provoking to least. The therapist
takes the client through this hierarchy, using relaxation techniques to
quell the anxiety (Resick & Calhoun, 2001). It usually is impossible to
return to the actual traumatic event, so imagining it vividly must
replace actual exposureiii.
iii.EMDR (Eye Movement Desensitization and Reprocessing)
c. Stress management Interventions
those who cannot tolerate exposure to their traumatic memories, is
stress-management interventions. T herapists teach clients skills for
overcoming problems in their lives that increase their stress and may
result from PTSD, such as marital problems or social isolation
d. Group and family therapy
Telling ones story helps to go ahead in life, feels more confident and
able to trust
Help the loved ones to understand what the person undergoes and
everyone in the family can communicate with the person