POST TRAUMATIC STRESS DISORDER LIFE AFTER TRAUMA IN THE 21ST CENTURY

POST TRAUMATIC STRESS DISORDER

LIFE AFTER TRAUMA IN THE 21ST CENTURY

Mark S. Skillan, MD VP & Medical Director

ANXIETY: An unpleasant emotional state consisting

of psycho-physiologic responses to the anticipation

of real or imagined danger.

Origin of Anxiety Disorders

Unique human survival requirements include:

ƒ Ability to predict circumstances

ƒ Ability to respond to threats

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Inability to predict or

DSM-IV Classification of Anxiety Disorders

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Panic Disorder

PTSD

Specific Phobia

Social Phobia

Generalized Anxiety

Disorder

OCD

POST TRAUMATIC STRESS DISORDER

The complex somatic, cognitive, affective, and

behavioral effects of psychological trauma.

Diagnosis: DSM IV Essential Criteria

Criterion A:

Exposure to traumatic event that included both:

ƒ Actual or threatened death or serious injury to self or others AND

ƒ Response involved intense fear, helplessness or horror

Diagnosis: DSM IV Essential Criteria

Criterion B:

Traumatic event persistently re-experienced by one or more of

ƒ Recurring intrusive thoughts

ƒ Recurring disturbing dreams

ƒ Recurrent re-living the event (flashbacks, etc)

Diagnosis: DSM IV Essential Criteria

Criterion C:

Avoidance of reminder stimuli plus new numbing of general responsiveness by three or more of

ƒ Avoiding thoughts, feelings or conversations

ƒ Avoiding activities, places or persons

ƒ Inability to recall important aspects of the trauma

ƒ Feeling detached or estranged from others

ƒ Restricted range of affect (e.g., unable to have loving feelings)

ƒ Sense of foreshortened future

Diagnosis: DSM IV Essential Criteria

Criterion D:

Persistent symptoms of increased arousal

ƒ Sleep difficulty

ƒ Irritability or anger outbursts

ƒ Hypervigilance

ƒ Exaggerated startle response

Diagnosis: DSM IV Essential Criteria

Criterion E:

Duration of Disturbance > 1 month

ƒ Acute: < 3 months duration

ƒ Chronic: 3 months or longer

ƒ Delayed onset – onset 6 months or more after stressor

Diagnosis: DSM IV Essential Criteria

Criterion F:

Disturbance causes clinically significant distress in social, occupational or other important areas of function.

PTSD - Defining Characteristics

Exposure to extreme traumatic stressor

ƒ Actual or threatened death or serious injury

ƒ Learning about the unexpected or violent death or injury of a loved one or close associate

PTSD - Defining Characteristics

Stressor causes intense fear, horror or sense of

helplessness

ƒ Persistent avoidance of stimuli reminiscent of the event

ƒ Persistent re-experiencing of the event

ƒ Numbing of normal emotions

ƒ Persistent hyper-arousal

Full symptom picture lasting >1 month and associated with distress, social or occupational dysfunction

1 month

1-3 months

3+ months

Onset after

6 months

PTSD Subtypes

15 Acute Stress Disorder Passage of Time Acute PTSD Chronic PTSD Delayed Onset PTSD Trauma occurs

Violent Assault

Rape, Incest, Childhood Abuse Kidnapping

Military Combat Exposure Natural & Man-made Disasters

Severe MVA

Diagnosis of Life Threatening Illness

Classic PTSD Precipitating Events

Special Risk Populations

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POW’s

Refugees from war torn areas Adults living in high crime areas

Victims of terrorist actions

? Some individuals linked to major events by the media

Lifetime Prevalence for PTSD (NCS)

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Overall: 6-12%

Incidence / Prevalence

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Life Time Risk: 1-14% of general population 3-58% for high risk groups

• 3% initially with 8% at two year follow up Gulf War • 30% + Oklahoma City 1995 • 20% + NYC 9/11

Incidence After an Event by Gender

20 6.3% 3.7% 12.6% 1.8% 12.2% 65.0% 8.8% 5.4% 16.2% 21.3% 26.5% 46.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

MVA Disaster Sudden Death

Assault Molestation Rape

PTSD: Possible Co-Morbidities

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Anxiety

Depression

Psychosis

Anxious Depression

Substance Abuse

Insomnia

Phobias

Self-Destructive Behavior

ƒ Somatic complaints

ƒ Feelings of ineffectiveness , shame, despair, hopelessness, guilt, vulnerability

ƒ Change in previously held beliefs

ƒ Change in personality

ƒ Relationship issues

ƒ Intimate

ƒ Social

ƒ Work, etc.

PTSD: Possible Additional Manifestations

Predictors of PTSD Development

PTSD

Pre-Trauma

Peri-Trauma

FEMALES

ƒ Female gender

ƒ Younger age at trauma

ƒ Low SES, education

ƒ Trauma Hx

ƒ Childhood abuse

ƒ Psychiatric Hx

MALES

ƒ Younger age at trauma

ƒ Low SES, education

ƒ Trauma Hx ƒ Childhood abuse ƒ Psychiatric Hx ƒ Ethnicity

Pre-Trauma Predictors

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Peri-Trauma Predictors

Brewin, CR & al.

2000 J Consul. Clin. Psych., 68:748-766

ƒ Proximity & personal nature of threat

ƒ Severity

ƒ Chronicity

ƒ Dissociation at time of trauma

ƒ Perceived helplessness

ƒ Inadequate social support

ƒ Severity of symptoms

ƒ Lack of early intervention, access to care

ƒ Perceived shame

ƒ Poor coping skills

ƒ Recovery-related stressors, other life stressors

Post-Trauma Predictors

Yehuda, McFarlane & Shalev, 1998, Biol.Psychiatry, 44: 1305

Susceptibility to PTSD

ƒ Nature of inciting event

ƒ Gender (female : male ratio 2-4:1)

ƒ Culture – reaction to event, etc.

ƒ Social – inadequate social support system, coexistent socioeconomic stress

ƒ Genetics: PMH or FH of psychiatric illness

PTSD

Panic 9.9% Major Depression 48.2% GAD 15.9% Agoraphobia 19.25% Social Phobia 29.9% Alcohol Abuse or Dependence 39.9%

Kessler & al.

1995, Arch. Gen. Psychiatry, 52:1048

PTSD Psychiatric Co-Morbidities

ƒ Depressive disorders ƒ Anxiety disorders ƒ Substance abuse ƒ Somatization ƒ TBI

85% have at least one co-morbidity

> 60% have more than one

Impact: PTSD and Co-Morbidities

ƒ Suicide risk: ~20% of PTSD patients may attempt

ƒ Share mortality risks of psychiatric disorders

ƒ Increased accident risk

ƒ Effects of substance abuse, etc.

ƒ Significant medical costs to society

ƒ Lost productivity/disability ($3B in U.S.)

ƒ Similar to depression

ƒ Increased risk of “dropping out”, marital discord, divorce, disability, unemployment, etc.

PTSD – NATURAL HISTORY AND CASE STUDY –

COMBAT TROOPS

Incidence Rates:

Combat Troops Returning from Iraq/Afghanistan

ƒ 11-17% screen positive for PTSD on return

ƒ 60% see improvement at 3-6 months

ƒ c/w Acute Stress Disorder(ASD) or Acute PTSD

ƒ 30-40% longer term effects

ƒ Combat troops surveyed 3-6 months after return

ƒ Larger percentage screen positive for PTSD symptoms than upon return

Incidence Rates: Wounded Combat Troops

ƒ Much higher % screen (+) for PTSD on return than among other returning troops

ƒ Percentage with PTSD increases with severity of injury

ƒ Prevalence increases during rehab process

PTSD Diagnostic Tools

ƒ Targeted interview

ƒ DoD Post Deployment Health Reassessment (PDHRA)

ƒ MMPI

ƒ PTSD checklist (PCL)

ƒ Primary Care PTSD screen (PC-PTSD)

ƒ Clinician administered PTSD scale (CAPS)

Treatment Goals

Reduce core symptoms

Improve quality of life

Reduce disability

Improve or resolve co-morbid conditions

Avoid relapse

Reduce morbidity & mortality risk

Treatment Modalities

Early Appropriate Intervention Supportive Therapy Cognitive Behavioral Therapy Virtual Reality Exposure (VRE) therapy Pharmaco-therapy Combined Approach Often Required

Natural History of PTSD

1/3 better in 3-6 months 1/3 better in 2 years 1/3 Long lasting effects Relapse(s) possible

Pharmacotherapy Choices

ƒ

First Line

: SSRI’s

ƒ Fluoxetine, paroxetine, sertaline, venlafaxine (Prozac, Paxil, Zoloft, Effexor)

ƒ

Second Line

:

ƒ Fluvoxamine (SSRI), mirtazipine, moclobemide, phenelzine (MAO) (Luvox, Remeron, Manerix, Nardil)

ƒAdjuncts: anti-psychotics risperidone, olanzapine (Risperdal, Zyprexa)

ƒ

Third Line

:

ƒ Amitryptyline, imipramine (Elavil, Tofranil)

ƒ Adjuncts: carbamazepine, gabapentin, clonidine, trazodone, bupropion (Tegretol, Neurontin, Catapres, Desyrel, Wellbutrin)

ƒ

Not Recommended

: monotherapy with alprazolam, clonazepam, olanzapine, etc (Xanax, Klonopin, Zyprexa, etc)

Underwriting Considerations

ƒ Confirm diagnosis

ƒ DSM criteria

ƒ PTSD morbidity & mortality risks associated with co-morbid conditions

ƒ Depression, suicide, etc

ƒ Other psychiatric disorders

ƒ Substance abuse

PTSD Risk Assessment

Pre-morbid history Type of Trauma

Time since trauma (late onset possible!)

Severity of symptomatology Therapy provided

Compliance with and response to therapy

Likelihood for future trauma exposure

PTSD Risk Assessment

ƒ PMH – trauma(s), ED visits, sleep disorder, substance abuse, prior psych disorders, etc

ƒ Family history – psych, etc.

ƒ Social history – stability, support resources, work history

ƒ Exam – BP, pulse, ROS: weight changes, sleep disorders, flashbacks,

ƒ MVR

ƒ Lab – LFT’s, MCV, lipids, cotinine, drug screen

PTSD Risk Assessment

Don’t forget that late onset can occur…

66% fully recover - time varies, generally 6-24 months

33% never fully recover – persistent increased morbidity and mortality risk

Be aware of predictors for better outcome -Pre-, peri- and post-trauma factors

Summary

PTSD Defining Characteristics Severity, Duration, Proximity At Risk Populations Co-factors Affecting Susceptibility Treatment Options Natural History Underwriting Considerations

THANK YOU

© 2009 M ünchener R ü ckv er si ch er un gs-G esell s c h af t © 2009 M uni ch R e in sur ance C o mpany

PTSD Resources & References

1. 309.81 DSM-IV – Anxiety Disorders, PTSD

2. 309.81 DSM-V – Proposed Revision, American Psychiatric Association, www.dsm5.org

3. Post-Deployment Health Reassessment Program - DD Form 2900, Jan 2008 http://fhp.osd.mil/pdhrainfo/

4. Anxiety Disorders Association of America, PTSD Self Test, etc www.adaa.org

5. Substance Abuse & Mental Health Services Administration www.samhsa.gov/

6. Effects of Repeated Deployment to Iraq and Afghanistan… Kline, et al, Am J Public Health 2010 Feb; 100(@):276-83

7. Increased Framingham 10 Year Risk of CHD…Folsom, et al, Schizophr Res 2010 Nov 18

PTSD Resources (continued)

8. Anxiety Buffer Disruption Theory… Pyszczynski, et al; Anxiety Stress Coping 2011Jan; 24(1):3-6

9. Association of PTSD with Increased Prevalence of Metabolic Syndrome, J Clin Psychopharmacol. 2009 Jun;29(3):215

10. Pharmacotherapy for PTSD; Stein, et al, Cochrane Database Syst Rev 2000;(4):CD002795