Post Traumatic Stress Disorder Dr Linda McCarthy Senior Specialist Psychiatrist Director, PTSD Program RGH Daw Park

Post Traumatic Stress Post Traumatic Stress DisorderDisorder

Dr Linda McCarthyDr Linda McCarthySenior Specialist Senior Specialist

PsychiatristPsychiatristDirector, PTSD ProgramDirector, PTSD ProgramRGH Daw ParkRGH Daw Park

History of PTSDHistory of PTSD

Symptoms of traumatic syndromes Symptoms of traumatic syndromes date back over centuriesdate back over centuries– Ancient RomeAncient Rome– Soldiers HeartSoldiers Heart– Shell ShockShell Shock– PTSDPTSD


Consistent description of features, but a Consistent description of features, but a lack of effective treatments for traumatic lack of effective treatments for traumatic syndromessyndromes

–Battle fatigue after WW2Battle fatigue after WW2–Battle shockBattle shock–Implications about relationship to Implications about relationship to mental disorders (compensation)mental disorders (compensation)


PTSD first described as such in DSM III in PTSD first described as such in DSM III in 19801980

Prototype for environmentally induced Prototype for environmentally induced disorder triggered by an external eventdisorder triggered by an external event

Involved emotional deregulation and Involved emotional deregulation and memory disturbancememory disturbance

Concept essentially the same, empirically Concept essentially the same, empirically validated, consensus achievedvalidated, consensus achieved

Born from Vietnam warBorn from Vietnam war

Diagnostic criteria for Diagnostic criteria for PTSDPTSDDSM - 5DSM - 5

Criterion A: Criterion A: stressorstressor– Person exposed death, threatened death, actual or Person exposed death, threatened death, actual or

threatened serious injury, or actual or threatened threatened serious injury, or actual or threatened sexual violence, as follows: (one required)sexual violence, as follows: (one required)

– Direct exposureDirect exposure– Witnessing, in person.Witnessing, in person.– Indirectly, learning that close relative or friend Indirectly, learning that close relative or friend

exposed to trauma. Must have been violent or exposed to trauma. Must have been violent or accidental.accidental.


Criterion A: Criterion A: stressorstressor– Repeated or extreme indirect exposure to Repeated or extreme indirect exposure to

aversive details of the event(s), usually in the aversive details of the event(s), usually in the course of professional duties (e.g., first course of professional duties (e.g., first responders, collecting body parts; professionals responders, collecting body parts; professionals repeatedly exposed to details of child abuse). repeatedly exposed to details of child abuse).

– Does not include indirect non-professional Does not include indirect non-professional exposure through electronic media, television, exposure through electronic media, television, movies, or pictures.movies, or pictures.


Criterion B:Criterion B:– Traumatic event persistently re-experienced in Traumatic event persistently re-experienced in

the following way(s): (one required)the following way(s): (one required) Recurrent, involuntary, and intrusive memoriesRecurrent, involuntary, and intrusive memories Traumatic nightmaresTraumatic nightmares Dissociative reactions (e.g., flashbacks) which may Dissociative reactions (e.g., flashbacks) which may

occur on a continuum from brief episodes to complete occur on a continuum from brief episodes to complete loss of consciousnessloss of consciousness

Intense or prolonged distress after exposure to Intense or prolonged distress after exposure to traumatic reminderstraumatic reminders

Marked physiologic reactivity after exposure to Marked physiologic reactivity after exposure to trauma-related stimuli.trauma-related stimuli.


Criterion C: Avoidance symptomsCriterion C: Avoidance symptoms

– Persistent effortful avoidance of distressing Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one trauma-related stimuli after the event: (one required)required)

– Trauma-related thoughts or feelings.Trauma-related thoughts or feelings.– Trauma-related external reminders (e.g., Trauma-related external reminders (e.g.,

people, places, conversations, activities, people, places, conversations, activities, objects, or situations).objects, or situations).


Criteria D: Negative alterations, cognition and mood:Criteria D: Negative alterations, cognition and mood:– Inability to recall key features of the traumatic Inability to recall key features of the traumatic

event (dissociative amnesia).event (dissociative amnesia).– Persistent (and often distorted) negative beliefs Persistent (and often distorted) negative beliefs

and expectations about oneself or the world (e.g., and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous")."I am bad," "The world is completely dangerous").

– Persistent distorted blame of self or others for Persistent distorted blame of self or others for causing the traumatic event or resulting causing the traumatic event or resulting consequencesconsequences


Criteria D: (cont.)Criteria D: (cont.)–Persistent negative trauma-related emotions Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).(e.g., fear, horror, anger, guilt, or shame).–Markedly diminished interest in (pre-Markedly diminished interest in (pre-traumatic) significant activities.traumatic) significant activities.–Feeling alienated from others (e.g., Feeling alienated from others (e.g., detachment or estrangement).detachment or estrangement).–Constricted affect: persistent inability to Constricted affect: persistent inability to experience positive emotions.experience positive emotions.


– Criterion E: alterations in arousal and Criterion E: alterations in arousal and reactivity (two required):reactivity (two required):

Irritable or aggressive behaviour (angry Irritable or aggressive behaviour (angry outbursts, little or no provocation)outbursts, little or no provocation)

Self-destructive or reckless behaviourSelf-destructive or reckless behaviour HypervigilanceHypervigilance Exaggerated startle responseExaggerated startle response Problems in concentrationProblems in concentration Sleep disturbanceSleep disturbance


– Specify if: With dissociative symptoms.Specify if: With dissociative symptoms. Depersonalization: experience of being an outside Depersonalization: experience of being an outside

observer of or detached from oneself (e.g., feeling as if observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream)"this is not happening to me" or one were in a dream)

Derealization: experience of unreality, distance, or Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").distortion (e.g., "things are not real").

– Specify if: With delayed expressionSpecify if: With delayed expression Full diagnosis is not met until at least six months after Full diagnosis is not met until at least six months after

the trauma(s), although onset of symptoms may occur the trauma(s), although onset of symptoms may occur immediately.immediately.


– Criterion F: durationCriterion F: duration Persistence of symptoms for more than one monthPersistence of symptoms for more than one month

– Criterion G: functional significanceCriterion G: functional significance Clinically significant functional impairment (e.g., Clinically significant functional impairment (e.g.,

social, occupational, other).social, occupational, other).

– Criterion H: exclusionCriterion H: exclusion Disturbance not due to medication, substance use, or Disturbance not due to medication, substance use, or

other illnessother illness

PTSDPTSD

Complex PTSDComplex PTSD

Major causes: trauma in childhood – Major causes: trauma in childhood – abuse, neglectabuse, neglect

Sx of PTSD also accompanied by Sx of PTSD also accompanied by personality changes – c.f. borderline personality changes – c.f. borderline traitstraits– EmptinessEmptiness– Emotional dysregulationEmotional dysregulation– HostilityHostility

DSM has not been adequate so far…DSM has not been adequate so far…

Post-Traumatic Stress Post-Traumatic Stress DisorderDisorder

Estimates suggests that up to 90% of Estimates suggests that up to 90% of people will be exposed to a significant people will be exposed to a significant traumatic event during their lifetimetraumatic event during their lifetime

20% of ♀ and 8% ♂ will go on to PTSD20% of ♀ and 8% ♂ will go on to PTSD Lifetime prevalence 10% ♀ and 5% ♂ Lifetime prevalence 10% ♀ and 5% ♂ Lifetime prevalence amongst Australian Lifetime prevalence amongst Australian

Vietnam veterans > 17%Vietnam veterans > 17%

Risk factors for PTSDRisk factors for PTSD

Male genderMale gender::– AssaultAssault– MVAMVA– CombatCombat

Female gender:Female gender:– Sexual assaultSexual assault

Others – low socio-economic status, high Others – low socio-economic status, high risk occupationsrisk occupations

Lower educational achievement, family Lower educational achievement, family dysfunction, family psychiatric hxdysfunction, family psychiatric hx

Biology of PTSDBiology of PTSD

Disturbance of key neurotransmission in Disturbance of key neurotransmission in the brain, and other hormonal axes: the brain, and other hormonal axes: noradrenergic, thyroid, endogenous noradrenergic, thyroid, endogenous opioid, serotonin and HPAopioid, serotonin and HPA– Up-regulated catecholamines Up-regulated catecholamines – Down-regulated adrenergic receptorsDown-regulated adrenergic receptors– Typical fight or flight responseTypical fight or flight response

Reduced regulation of autonomic Reduced regulation of autonomic response to emotional arousal and response to emotional arousal and external stressorsexternal stressors

Disturbed appraisal, learning and memoryDisturbed appraisal, learning and memory

Comorbidities & PTSDComorbidities & PTSD

People with PTSD up to 80% more likely People with PTSD up to 80% more likely to satisfy diagnostic criteria for other to satisfy diagnostic criteria for other psychiatric dx:psychiatric dx:

– Alcohol use problemsAlcohol use problems– Other substance misuseOther substance misuse– DepressionDepression– Other anxiety disordersOther anxiety disorders– Chronic painChronic pain– Medical issues (obesity, diabetes, CV disease, Medical issues (obesity, diabetes, CV disease,

smoking-related illnesses)smoking-related illnesses)– TBITBI

PTSD treatment optionsPTSD treatment options

Psychological therapy (regarded as Psychological therapy (regarded as first line):first line):

PsychoeducationPsychoeducation Cognitive behavioural therapyCognitive behavioural therapy

– Trauma focus therapyTrauma focus therapy– DesensitisationDesensitisation

Little or no role for routine Little or no role for routine “debriefing” after a traumatic event“debriefing” after a traumatic event

Drug therapyDrug therapy

PTSD programme goalsPTSD programme goals

Manage anxietyManage anxiety AngerAnger Nightmares, flashbacksNightmares, flashbacks Reduce impact on QOLReduce impact on QOL Reduce impact on relationships and general functioningReduce impact on relationships and general functioning

PTSD programme elementsPTSD programme elements

PsychoeducationPsychoeducation Anxiety management:Anxiety management:– Physical Physical

Controlled breathing strategiesControlled breathing strategies Progressive muscle relaxationProgressive muscle relaxation Aerobic exerciseAerobic exercise stimulant intake (caffeine, nicotine)stimulant intake (caffeine, nicotine)

– CognitiveCognitive Thought stoppingThought stopping DistractionDistraction

– BehaviouralBehavioural To address avoidance and social withdrawalTo address avoidance and social withdrawal

PTSD programme elementsPTSD programme elements

Exposure treatmentsExposure treatments Imaginal exposure (CBT technique)Imaginal exposure (CBT technique)

Cognitive restructuringCognitive restructuring

Management of comorbid conditionsManagement of comorbid conditions AlcoholAlcohol DepressionDepression

PTSD – Psychological interventionsPTSD – Psychological interventions

Strongest evidence for exposure therapy (Foa & Rothbaum) Strongest evidence for exposure therapy (Foa & Rothbaum) Imaginal exposureImaginal exposure

Trauma emotionally processed or digestedTrauma emotionally processed or digested

Cognitive processing therapyCognitive processing therapy Exposure by writingExposure by writing

PTSD drug treatment PTSD drug treatment optionsoptions

AntidepressantsAntidepressants AntipsychoticsAntipsychotics HypnosedativesHypnosedatives Mood stabilisers such as Mood stabilisers such as

anticonvulsantsanticonvulsants Adjuvant therapies Adjuvant therapies


Many drug treatment options Many drug treatment options have been examined, no have been examined, no treatment universally effectivetreatment universally effective

Many patients need sequential Many patients need sequential trials of drug treatmenttrials of drug treatment

Many require combinations of Many require combinations of drugs, also combined with drugs, also combined with psychological approachpsychological approach


Many drugs are known to work Many drugs are known to work for PTSDfor PTSD

Methodological difficulties with Methodological difficulties with research, many studies short research, many studies short duration with high drop-out ratesduration with high drop-out rates

Many drugs not examined Many drugs not examined thoroughly because of patent thoroughly because of patent limitationslimitations

Antidepressants for PTSDAntidepressants for PTSD

Almost all antidepressants drugs Almost all antidepressants drugs are known to work for PTSDare known to work for PTSD

First research with TCAs and MAOIsFirst research with TCAs and MAOIs Greatest evidence now for SSRIs, Greatest evidence now for SSRIs,

some with FDA and TGA approvalsome with FDA and TGA approval Anxiolytic effect may be Anxiolytic effect may be

independent of antidepressant independent of antidepressant effectseffects

Antidepressants for PTSDAntidepressants for PTSD

SSRIsSSRIs Mirtazapine Mirtazapine VenlafaxineVenlafaxine TCAsTCAs MAOIsMAOIs Other agents may also be Other agents may also be

effectiveeffective

Antipsychotics for PTSDAntipsychotics for PTSD

Relative lack of controlled researchRelative lack of controlled research Clinical use in situations where there Clinical use in situations where there

is severe agitation, anger or is severe agitation, anger or requirement for sedationrequirement for sedation

Not approved indication, no PBS Not approved indication, no PBS subsidy but may attract RPBS subsidysubsidy but may attract RPBS subsidy

Generally reserved for time limited Generally reserved for time limited course of treatment or prn therapycourse of treatment or prn therapy

Hypnosedatives & PTSDHypnosedatives & PTSD

BZDs play multiple roles:BZDs play multiple roles: SedationSedation AnxiolyticAnxiolytic Substance withdrawal managementSubstance withdrawal management

Care required in view of high Care required in view of high potential for dependence and potential for dependence and known association of PTSD and known association of PTSD and substance use disorderssubstance use disorders

Hypnosedatives & PTSDHypnosedatives & PTSD

Avoid very short acting drugs Avoid very short acting drugs (alprazolam) and favo(alprazolam) and favour longer ur longer acting drugs (e.g. diazepam)acting drugs (e.g. diazepam)

May interact with SSRIsMay interact with SSRIs Can potentiate sedation seen with Can potentiate sedation seen with

other prescribed drugs, will also other prescribed drugs, will also interact with alcoholinteract with alcohol

Mood stabilisers & PTSDMood stabilisers & PTSD

Not regarded as first line therapyNot regarded as first line therapy Valproate and carbamazepine Valproate and carbamazepine

most often usedmost often used Regarded as helpful for severe Regarded as helpful for severe

anger/impulse control issuesanger/impulse control issues Many serious adverse effects, not Many serious adverse effects, not

safe in overdose or pregnancysafe in overdose or pregnancy

Adjuvant therapies for Adjuvant therapies for PTSDPTSD

PrazosinPrazosin PropranololPropranolol BaclofenBaclofen ClonazepamClonazepam BuspironeBuspirone Others under investigationOthers under investigation TopiramateTopiramate

Alcohol & PTSDAlcohol & PTSD

Use of treatments to decrease EtOH Use of treatments to decrease EtOH use:use:

NaltrexoneNaltrexone AcamprosateAcamprosate Disulfiram (last choice)Disulfiram (last choice) Topiramate (strong evidence evolving)Topiramate (strong evidence evolving)

May enhance the effectiveness of May enhance the effectiveness of other interventionsother interventions

In conclusion…In conclusion…

Relatively common, especially amongst specific groupsRelatively common, especially amongst specific groups Unique amongst almost all Dx in DSM5Unique amongst almost all Dx in DSM5 Extreme variability in presentation, course, severity and Extreme variability in presentation, course, severity and

outcome despite consistent core symptomsoutcome despite consistent core symptoms

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Post Traumatic Stress Disorder Dr Linda McCarthy Senior Specialist Psychiatrist Director, PTSD Program RGH Daw Park