Posttraumatic Stress Disorder

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of posttraumatic stress disorder (PTSD) and manage­ment of the effects of trauma on women’s mental health. After hearing and assimilating this program, the clinician will be better able to:

1.   Diagnose PTSD.

2.   Describe some of the instruments available for assessing trauma and PTSD.

3.   Discuss the instruments available for assessing psychotherapy for PTSD.

4.   Identify women who have been victims of violence.

5.   List symptoms associated with borderline personality disorder.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In her lecture, Dr. Fretwell presents information related to the off-label or investigational use of therapy, product, or device.

Acknowledgements

Dr. Rauch was recorded at 20th Annual Advances in Psychiatry: Trauma, Stress, and Anxiety: Bringing Science into the Clinic, held November 7, 2008, in Ann Arbor, MI, and sponsored by the University of Michigan Medical School, the Mich­igan Psychiatric Society, the Depression and Bipolar Alliance, and the Veterans Affairs Ann Arbor Healthcare System. Dr. Fretwell was recorded at Psychiatric Aspects of Women’s Health Care, held September 26, 2009, in Indianapolis, IN, and sponsored by Indiana University School of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Assessment of PTSD and Psychotherapy

Sheila A. M. Rauch, PhD, Assistant Professor, Department of Psychiatry, University of Michigan Medical School; Director, Serving Returning Veterans’ Mental Health Program, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI

Posttraumatic stress disorder (PTSD): Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) requires (criterion A) 1) individual experienced, witnessed, or confronted by events involving actual or threatened death or serious injury, or threat to physical integrity of self or others, and 2) individual responded to that event with sense of fear, horror, or helplessness; responses typically occur at time of event, but can be delayed; symptoms  —  divided into clus­ter B (re-experiencing; 1 of 5 required for diagnosis), cluster C (avoidance and numbing; 3 of 7 required), and cluster D (hyperarousal or hypervigilance; 3 of 7 required)

Assessment of PTSD: assure rapport with patient by establishing relaxed, interested, nonjudgmental, and safe environ­ment; gather information (ideally, from multiple sources); assess behavior; select instrument according to purpose of assessment; trauma  —  assess type, life history, frequency, and duration of exposure, and reactions at time of oc­currence and shortly thereafter; determine age of exposures (including those occurring during childhood)

Trauma measures: self-report measures include Life Events Checklist, Posttraumatic Diagnostic Scale, Traumatic Events Questionnaire, and Traumatic Life Events Questionnaire; interview measures (more accurate) include Clini­cian Administered PTSD Scale (CAPS), Traumatic Experience Inventory (TEI), National Women’s Studies Event History, and National Comorbidity Survey trauma assessment

Issues in assessment of PTSD symptoms: need to select measure with appropriate timeframe (not all instruments de­signed for trauma that occurred, eg, several years ago); ensure that symptoms represent change from pretrauma function; cue symptom assessment to particular traumatic event exposure; PTSD symptoms overlap with those of other mental disorders (eg, depression), and need to be sorted out as much as possible

Interview instruments: those not specific to PTSD include Structured Clinical Interview (SCID) for DSM-IV, Anxiety Disorders Interview Schedule (ADIS), Mini International Neuropsychiatric Interview (MINI), and Primary Care Evaluation of Mental Disorders (PRIME-MD); those specific to PTSD include CAPS, Posttraumatic Symptom Scale Interview (PSS-I), and Structured Interview for PTSD (SI-PTSD)

Self-report instruments: PTSD Checklist has civilian and military versions (PCL-C and PCL-M); others include Posttrau­matic Diagnostic Scale, and Davidson Trauma Scale; others not specific to PTSD include Impact of Events Scale and Revised Impact of Events Scale

Interview vs self-report: interviews require significant training and expertise in PTSD and DSM-IV nomenclature; self-report measures more susceptible to biased (over- and under-) reporting

Comorbidity: rule (not exception) with PTSD; most common comorbidities include depression, alcohol and substance abuse and dependence, and anxiety disorders

Other symptoms requiring assessment: guilt; marital, relationship, and interpersonal problems; anger; self-destructive or reckless behavior; dissociation

Validity of assessment: patient may be trying to avoid deployment by overreporting or seeking redeployment by under­reporting; may overreport to get service-related disability; may be trying to avoid stigma by underreporting; consider brief assessment for malingering; study found mixed results on influence of compensation-seeking on over- or under­reporting, but concluded that veterans in midst of process more likely to report more symptoms and to have exagger­ated symptom profile on Minnesota Multiphasic Personality Inventory (MMPI); various non–self-report, noninterview techniques under investigation for measuring PTSD severity without bias

Assessment of psychotherapy guidelines: all guidelines developed by panels of experts in field of PTSD and have con­vergence of conclusions about outcomes of therapies

Prolonged exposure therapy: includes education about common reactions to trauma; breathing retraining; prolonged imaginal exposure to trauma memory; repeated in vivo exposures to situations that patient avoids because of assault-related, combat-related, or other fear; processing meaning of the trauma

Cognitive restructuring: has been used as augmentation to other protocols and as stand-alone therapy; includes identi­fying automatic trauma-related cognitions (eg, “the world is dangerous,” “other people can’t be trusted,” “I’m in­competent”); identifying functional links among those feelings, thoughts, and actions; and systematically evaluating evidence for and against those automatic thoughts

Stress inoculation training: includes relaxation training, thought-stopping, guided self-dialogue, cognitive restructur­ing, and covert modeling and role playing; provides skills for managing PTSD symptoms in that moment (without reviewing trauma memories)

Cognitive processing therapy (CPT): mixes exposure and cognitive techniques; includes psychoeducation; creation of written statement about trauma’s impact on patient’s self-perception and account of trauma itself; examination of problematic thoughts; Socratic questioning and challenging of thoughts; focused review of specific topics related to PTSD using cognitive-therapy techniques

Eye-movement desensitization and reprocessing (EMDR) therapy: includes accessing trauma memories and images and evaluating aversive qualities of those memories; generating and focusing on alternative cognitive appraisals while doing lateral eye movements

International Society for Traumatic Stress Studies (ISTSS): guidelines under revision; in old guidelines, exposure therapy, stress inoculation training, and cognitive therapy recommended as having highest level of evidential sup­port; speaker thinks CPT will have highest level in revised guidelines

Veterans Affairs/Department of Defense guidelines: cognitive therapy, exposure therapy, stress inoculation training, and EMDR recommended as first-line treatments

Australian Center for Posttraumatic Mental Health: concluded that adult PTSD best treated with trauma-focused inter­ventions that include in vivo exposure or EMDR; evidence does not support importance of eye movements (ie, gains more likely due to engagement with memories); alternative treatments should be considered if symptoms do not re­spond to first-line treatments; 8 to 12 sessions of individual therapy should be adequate; group interventions should not be considered as stand-alone treatment for PTSD

Institute for Clinical Excellence: trauma-focused psychological therapy or EMDR should be first-line treatment for PTSD

Institute of Medicine: sufficient evidence exists to establish efficacy of exposure therapies for PTSD, but not for effi­cacy of other modalities

The Effects of Trauma on Women’s Health

Heather M. Fretwell, MD, Psychiatrist, Midtown Mental Health Service and Wishard Memorial Hospital, Indianapolis, IN

Introduction: rape, sexual molestation, childhood neglect and physical abuse most common types of trauma reported by women; >20% of couples affected by partner violence; of women in United States (US), 20% experience physical assault, 20% rape, and 35% intimate-partner violence (>2 million women total) every year; intimate partner violence responsible for 50% of women presenting to emergency departments for treatment; women twice as likely to develop PTSD in response to trauma, perhaps because of higher incidence of interpersonal (ie, related to one-on-one relationship) trauma

Indications for screening for violence: screen any frequently seen patient, especially those with increased utilization of medical services, traumatic injuries, multiple visits for minor concerns, or with chronic pelvic pain, headache, or ir­ritable bowel syndrome

Perioperative screening: patients with history of trauma have rate of surgery twice that of those without; may present as unusually anxious or frightened; studies show that depression and anxiety have negative effect on immunity and wound healing

Obstetrics and gynecology clinic: especially for woman who presents for first visit late in pregnancy; other indicators include low maternal weight gain and frequent infections during pregnancy; women with domestic violence have higher risk for preterm labor and for low-birthweight infants; 29% of perinatal deaths related to domestic violence; domestic violence during pregnancy more common than preeclampsia, gestational diabetes, or placenta previa; in domestically violent relationship, pregnancy or less availability to partner often triggers escalation in violence

Speaker’s one-question screen: all patients asked “do you feel safe in your relationship with your partner?”; survey found no complaints about acceptability of question

Health consequences of sexual assault and rape: pregnancy (5% of rapes result in pregnancy); sexually transmitted diseases; subsequent fear of sex; arousal dysfunction; decreased interest in sex

Health consequences of child abuse and neglect: impairment of normal brain development (especially of cerebellar vermis, which regulates irritability in limbic system; impairment of development in this area is risk factor for sub­stance abuse); lack of immunization; malnutrition; medical underutilization; frequent school absences

Health effects of interpersonal trauma: women with histories of childhood adversity (defined as physical, sexual, or se­vere verbal abuse) at 400% increased risk for depression; more health-risk behaviors (eg, alcohol and drug use, driving while intoxicated, unsafe sex, disordered eating and obesity, self-injurious behaviors, suicide attempts); higher incidence of smoking and decreased willingness to quit smoking; higher incidence of cancer, ischemic heart disease, chronic lung disease, headache, chronic back pain, gastrointestinal disorders, liver disease, skeletal fractures, and chronic pelvic pain

Trauma and chronic pain: trauma can play role in development of chronic pain and have detrimental effect on emo­tional adjustment to chronic pain

Effects of trauma on pain regulation: patients with history of depression secondary to physical trauma less likely to ex­perience inhibition of pain signals; neuropathic changes occur as direct result of physical injury with sensitization of pain pathways (“pain memory”); neuroanatomic reorganization of pain pathways; hyperexcitability of peripheral and central neurons; dysregulation of immune, endocrine, and other systems

Mutual maintenance of PTSD and chronic pain: both conditions involve - hypervigilance and anxiety; attentional and reasoning biases; sensitivity to anxiety and catastrophizing; sensitization; conditioned fears; avoidance; depression and reduced activity; cognitive demands that interfere with adaptive coping

Treatment options: use integrated treatment; treat PTSD with medications and cognitive therapy; physical therapy and integrative cognitive behavioral therapy (CBT) for PTSD and pain management currently under investigation

Psychological sequelae of trauma: long continuum of effects, ranging from little effect on functioning to large effect (leading to research on resiliency; US military currently conducting study on improving resiliency before deploy­ment to combat areas); sequelae of trauma include acute stress disorder, PTSD, complex PTSD, major depressive disorder, dissociative disorders, and borderline personality disorder

Acute stress disorder: distinguished from PTSD because symptom pattern in acute stress disorder must occur and re­solve within 4 wk of traumatic event

Complex PTSD: controversial diagnosis; associated with severe repetitive abuse, especially during childhood; could be considered PTSD with comorbid borderline personality disorder (PD); symptoms  —  difficulty regulating emo­tions; variations in consciousness (eg, episodes of dissociation); changes in self-perception; variations in perception of perpetrator; alterations in relationships with others, including isolation, distrust, or repeated searching for res­cuer; loss of or changes in system of meanings

Borderline PD: 85% of patients with borderline PD have history of sexual abuse; DSM-IV requires patient meet 5 of 9 cri­teria, which include 1) frantic efforts to avoid real or imagined abandonment; 2) stormy relationships; 3) identity dis­turbance; 4) impulsivity; 5) recurrent suicidal behavior, gestures, threats, or self-injurious behavior; 6) affective instability; 7) chronic feelings of emptiness; 8) inappropriate anger or difficulty controlling anger; 9) transient, stress-related paranoid ideation, delusions, or severe dissociative symptoms

Treatment options: dialectical behavior therapy; transference-focused psychotherapy; Systematic Training for Emo­tional Predictability and Problem Solving (STEPPS); mentalization; schema-focused therapy

Schema therapy: incorporates aspects of CBT, attachment theory, gestalt therapy, and self-psychology; developed for treatment-resistant depression and personality disorders

Schema: pervasive maladaptive theme (trait present at all times); consists of cognitive core belief (eg, “I am worth­less”); includes childhood memories and emotional and physical flashbacks; 18 schemas identified, including de­fectiveness, abandonment, self-sacrifice, unrelenting standards, punitiveness

Schema mode: somewhat dissociated way of operating; defined as state (ie, moment-to-moment way individual in­teracts with world); includes feelings, thought patterns, and behaviors; examples include detached protector, abandoned child, angry child, punitive parent, and healthy adult

Schema therapy: high rates of retention and recovery in twice-weekly individual study; significant improvement in symptoms with addition of weekly schema-therapy group

Editor’s Note

The next Indiana Psychiatric Society Fall Symposium will be held Saturday, September 25, 2010, in Indianapolis.

Suggested Reading

Deckersbach T et al: Functional imaging of mood and anxiety disorders. J Neuroimaging 16:1, 2006; Gill JM et al: Experiences of traumatic events and associations with PTSD and depression development in urban health care-seeking women. J Urban Health 85:693, 2008; Hegadoren KM et al: Posttraumatic stress disorder Part III: health effects of interpersonal violence among women. Perspect Psychiatr Care 42:163, 2006; Herman J: Trauma and recovery: The Aftermath of Violence – From Domestic Abuse to Po­litical Terror. New York: Basic Books, 1997; Kendall-Tackett K, ed: Health Consequences of Abuse in the Family: A Clinical Guide for Evidence-based Practice. Washington, DC: American Psychological Association, 2004; Milad MR et al: Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder. Biol Psychiatry 66:1075, 2009; Rauch SA et al: Posttraumatic stress, depression, and health among older adults in primary care. Am J Geriatr Psychiatry 14:316, 2006; Rauch SA et al: Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic. J Trauma Stress 22:60, 2009; Shin LM et al: Dorsal anterior cingulate function in posttraumatic stress disorder. J Trauma Stress 20:701, 2007; Shin LM et al: Amygdala, medial prefrontal cor­tex, and hippocampal function in PTSD. Ann N Y Acad Sci 1071:67, 2006; Simon NM et al: Paroxetine CR augmentation for post­traumatic stress disorder refractory to prolonged exposure therapy. J Clin Psychiatry 69:400, 2008; Young JE et al: Schema Therapy: A Practitioner’s Guide. New York: The Guilford Press, 2003; Zanarini MC: Psychotherapy of borderline personality disorder. Acta Psychiatr Scand 120:373, 2009.