BY: DR.

MEDHA (JR1)
GUIDE: DR. CHINMAY SIR
(ASST. PROF)

POST
TRAUMATIC
STRESS
DISORDER
 Definition:
• PTSD is a trauma and stress-related
disorder, defined by the co-occurrence of
the following in survivors of extreme
adversity.
a) Re-experiencing
b) Avoidance
c) Negative beliefs and hyperarousal
symptoms
• Individuals who suffer from PTSD re-
live distressing instances of the
traumatic event, with high intensity.
• Symptom persistence despite
termination of threat.
• Inability to regain sense of safety.
 Etiology:

• THE STRESSOR: The necessary cause of PTSD is

an exceptionally stressful event.

• GENETIC FACTORS: Studies of twins suggest that

differences in susceptibility to PTSD are in part genetic*.
The genetic liability to PTSD is partly explained by a
genetic effect on personality, which modifies the
propensity of individuals to engage in risky behaviours.
• OTHER PREDISPOSING FACTORS:
• Female gender
• Age at trauma
• Race
• Lower education
• Childhood abuse
• Greater severity of trauma exposure
• Lack of social support,
• and Additional life stress
• NEUROBIOLOGI
CAL FACTORS:
AMYGDALA AND
HIPPOCAMPUS:

• Anxiety and fear symptoms :

regulated by an amygdala-
centered circuit.
• Worry: regulated by a cortico-
striato-thalamo-cortical (CSTC)
circuit.
• Feelings of fear: Overactivation of circuits

connecting amygdala with oritofrontal cortex

(OFC) and anterior cingulate cortex (ACC)

• Fear response: characterized by endocrine

effects such as increases in cortisol,

because of amygdala activation of the

hypothalamic-pituitary-adrenal (HPA) axis.

• Hippocampus plays a major role in
re-experiencing the Traumatic
memories.
• Traumatic memories stored in
hippocampus activates amygdala
which in turn generates fear
response.
PREVALENCE:
• Lifetime trauma exposure in the United States ranging from 50
to 89 percent : physical or sexual assault (52 percent) being
involved in an accident or fire (50 percent).
• Lifetime prevalence of PTSD among adult Americans to be 6.8
percent.
• Current past year PTSD prevalence : 3.5 percent (men was
3.6 percent and women was 9.7 percent)
• Study revealed a low prevalence of PTSD in India at 0.2%.
CLINICAL PICTURE:
• Intrusion (re-experiencing) : flashbacks, distressing
recollections or dreams and stress reactions to exposure to
stimuli that linked to trauma.
• Avoidance : thoughts, activities related to
trauma, anhedonia, blunted affect, Reduced
capacity to remember events related
to trauma, feeling of detachment or
derealisation, and sense of foreshortened
future
• Hyperarousal : insomnia, irritability,
hypervigilence, exaggerated startled
response.
• Alternations of mood and cognition
• Duration :
 >1month :PTSD
 <1 month : acute stress disorder
ICD-10 (F43.1)
1. PTSD- delayed response to a stressful event or situation of
an exceptionally threatening or catastrophic nature.
2. Typical symptoms: Reexperiencing in form of (Intrusive
memories, flashbacks, nightmares), emotional blunting,
unresponsiveness to surroundings, anhedonia,
Avoidance, autonomic hyperarousal, insomnia.
3. Anxiety and depression: commonly present with above
symptoms.
4. Onset follows trauma with latency period with latency
period of a few weeks to months.
DSM-5

1. History of exposure to
(directly experiencing, repeated exposure witnessing in
person, learning of occurrence in close acquaintance)
actual threatened death, severe injury, or sexual trauma
2. Intrusive symptoms :

a)Involuntary intrusive memories

• In children <6 yr, may see reenactment of event
through play
b) Recurrent Nightmares/dreams of the event
• In children <6 yr, frightening dreams without identifiable content
may be present
c)Dissociative responses or reliving of prior experience
(i.e.flashbacks)
• In children <6 yr, may see reenactment of event through play
d)Psychological distress related to exposure to stimuli that are
reminders of prior trauma
e) Presence of physiologic response to stimuli that are
reminders of prior trauma
3. Pattern of avoidance of stimuli associated with prior experience of
trauma
• Avoidance of memories related to trauma
• Avoidance of external reminders of trauma
4. Negative mood or cognitions related to trauma
• Impairment in memories related to event
• Negative perceptions of self and others
• Cognitive distortions related to event
• Excessive guilt, anger or fear
• Diminished interest and social withdrawal
• Subjective detachment from others
• Difficulty experiencing positive feelings in response
• 5. Altered level of arousal
• Irritability and/or anger
• Risk taking
• Hypervigilance
• Increased startle response
• Difficulties with concentration
• Sleep disturbances
Required number of symptoms:
DSM 5 :
In addition to history of exposure to trauma, must have
• at least one symptom of intrusion
• at least one symptom of avoidance
• at least two symptoms of Negative mood/cognition
• at least two symptoms of arousal alterations

ICD 10 :
Any of the above
• Psychosocial consequences of symptoms :
Marked distress and impairment in functioning

• Exclusions
 Exposure through media, electronics,movie, or photo
 Related to substance use
 Related to another medical condition
• Symptom specifiers
• With dissociative symptoms:
• • Depersonalization: perception of feeling outside one’s own body
• • Derealization: perception of surrounding environment being unreal
or distorted

• Course specifiers
• With delayed expression:
• All diagnostic criteria not met until 6 month or more after initial
traumatic event
ICD-11(6B40)
• Syndrome develops following exposure to extremely threatening
or horrific event or characterized by all of the following:
1) Re-experiencing in the form of vivid intrusive memories,
flashbacks, or nightmares, which are typically accompanied by
strong and overwhelming emotions such as fear.
2) Avoidance of thoughts , memories ,activities, situations.
3) Persistent perceptions of heightened current threat,
hypervigilance or an enhanced startle reaction
• Symptoms must persist for at least several weeks, cause
significant impairment in personal, family, social, educational,
occupational or other important areas of functioning.
Complex PTSD (6B41):
• Disorder that may develop following exposure to events ,extremely
threatening or horrific nature, prolonged or repetitive events, escape
is difficult or impossible .
• The disturbance causes significant impairment in personal, family,
social, educational, occupational functioning.
• In addition to core symptoms of PTSD,
Complex PTSD is characterized by:
severe and pervasive problems in affect
regulation
persistent beliefs about oneself as
diminished, defeated or worthless,
accompanied by deep and pervasive
feelings of shame, guilt or failure related
to the traumatic event; and
persistent difficulties in sustaining
relationships and in feeling close to
others.
DIFFERENTIAL DIAGNOSIS:
• Medical causes:
a) Traumatic brain injury
b) Epilepsy
c) Alcohol use disorder
d) Substance-related disorders
e) Acute substance or alcohol withdrawal
• Psychiatric Diagnosis:
a) Panic disorder
b) Generalized anxiety disorder
c) Major depressive disorder
d) Dissociative identity disorder
e) Borderline personality disorder
f) Acute stress disorder
g) Adjustment disorder
h) Obsessive Compulsive Disorder
Course and Prognosis:
• Epidemiological data from the National Comorbidity Study
(NCS) : median time for PTSD to remit is 36 months for
individuals who sought help for any mental health problem
64 months for individuals who never sought help for a
mental health problem.
• Approximately one-third of those who qualify for PTSD had a
chronic course.
Positive Prognostic Factors for
PTSD :
• Rapid onset of the symptoms
• Short duration of the symptoms (less than 6 months)
• Good premorbid functioning
• Strong social supports
• Absence of other psychiatric, medical, or substance-related
disorders or other risk factors
MANAGEMENT:
• NICE Guidelines:

• The routine use of a brief screening instrument for

PTSD at 1 month.
• Where symptoms are mild and have been present for
less than 4 weeks after the trauma, watchful waiting.
• Trauma-focused cognitive behavioural therapy should be
considered for those with severe post-traumatic
symptoms during the first month after the traumatic
event.
• Psychological treatments preferred in the treatment of
PTSD, pharmacotherapy has a role in patients
presenting with significant comorbid depression.
• Where alcohol or substance use disorders coexist with
PTSD, advisable to treat the substance misuse prior to
offering psychological treatment for PTSD
• Pharmacotherapy (NICE Guidelines):
Psychotherapeutic interventions:

• Prolonged exposure (PE) therapy

• Trauma-focused cognitive-behavioral therapy (TFCBT)
• Cognitive processing therapy (CPT)
• Eye movement desensitization and reprocessing therapy
(EMDR)
• Group and family therapy
• Prolonged exposure (PE) therapy:

Completed in 8-15 sessions

Includes psycho education, breathing retraining and 2
types of exposure: in vivo exposure and imaginal
exposure.
In vivo exposure: approaches situation, places, people
that patients avoid.
Imaginal exposure: approach of memories, thoughts,
events related to trauma.
• Trauma-focused cognitive-behavioral therapy:

Includes both behavioral techniques, such as exposure, and cognitive

techniques.
CBT that includes exposure to trauma-related stimuli , practice
discrimination of "then vs. now“
Cognitive restructuring focuses on teaching patients to identify
dysfunctional thoughts and thinking errors.
Kubany et al. (2004) suggest that guilt-associated appraisals may
evoke negative affect, repeatedly recondition memories of the trauma
with distress.
• Cognitive processing therapy (CPT):

Following a traumatic event, survivors attempt to make sense of

what happened- leading to distorted cognitions amongst
themselves, world and others.
An attempt is done to integrate the traumatic event : assimilate,
accommodate, overaccomodate.
Assimilation: "because I didn't fight harder, it is my fault I was
assaulted.“
Accomodation: "I couldn't have prevented them from assaulting
someone“
Over Accomodation: "because this happened, I cannot trust
anyone"
• Eye movement desensitization and reprocessing
(EMDR):

Possibly more effective than others therapies in PTSD.

1st phase: History taking and Treatment Planning.
2nd phase: Preparation
3rd phase: Identifying the target memory
4th phase: Desensitisation phase
5th phase: Installation phase
• Group therapy:
• Sharing of traumatic experiences
• Support from other group members

• Family therapy:
• Helps sustain a family through periods of exacerbated
symptoms.
Thank you!