Post-Traumatic Stress Disorder

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right amygdala, decreased blood flow to Broca's area in the left temporal lobe Sympathetic nervous system activation Autonomic hyperresponsiveness to both neutral and trauma-related stimuli Elevated urinary catecholamine levels Downregulation of beta- and alpha-2 adrenergic receptors Increased reactivity to the alpha-2 antagonist, yohimbine Hypothalamic-Pituitary-Adrenocortical mobilization Lower urinary cortisol levels Elevated lymphocyte glucocorticoid receptor levels Dexamethasone supersuppression Other theories of causation Acoustic startle-response Shorter latency and increased amplitude of the acoustic-startle-eyeblink reflex Significant loss of the normal inhibitory modulation of the startle reflex Resistance to habituation of the startle response Fear conditioning Appraisal DSM-IV-TR The person experienced or witnessed an event that involved death or serious injury, or the threat of death or serious injury; response to the event involved intense fear, horror, or a sense of helplessness Relived experiences of the event, such as having distressing images and memories, upsetting dreams, flashbacks, or physical reactions DSM-IV-TR Cont'd Persistent avoidance of situations or things that remind the person of the traumatic event or feeling of emotional numbness Feeling as if constantly on guard or alert for signs of danger, which may cause difficulty sleeping or concentrating Symptoms last longer than one month Acute: duration less than 3 months Chronic: duration 3 months or more Delayed: onset of symptoms is at least 6 months after stress Course of PTSD Signs and symptoms typically begin within three months of a traumatic event May be delayed for more than six months or even years later Severity and duration varies Symptoms may come and go?may have more symptoms during times of higher stress Some people recover within six months, others may not do so for much longer Longitudinal Course PTSD can persist for decades Symptoms may worsen rather than improve over time Approximately 40% of patients with lifetime PTSD are unlikely to recover whether or not they have ever received treatment Series of remissions and relapses Some people able to lead productive and fulfilling lives; others may develop a persistent incapacitating mental illness Prognosis of PTSD Best prognosis depends on how soon the symptoms develop after the trauma, and on early diagnosis and treatment Some individuals who do not receive care recover over a period of years More than 1/3 of patients never fully recover Rarely, individuals may have worsening symptoms and kill themselves Consequences of PTSD Physiological outcomes Physical complaints Depression Other anxiety disorders Conduct disorders Dissociation Eating disorders Consequences of PTSD Cont'd Social outcomes Interpersonal problems Low self-esteem Alcohol and substance use Employment problems Homelessness Trouble with the law Consequences of PTSD Cont'd Self-destructive behaviors Substance abuse Suicidal attempts Risky sexual behaviors leading to unplanned pregnancy or STD's, including HIV Reckless driving Self-injury Treatment Three major approaches Cognitive-behavioral therapy Pharmacotherapy Individual and group dynamic psychotherapy Cognitive-behavioral therapy The most successful treatment for PTSD Consists of exposure therapy and anxiety management strategies May be provided in individual or group therapy Pharmacotherapy No particular drug is a definitive treatment, although medication is clearly useful for symptom relief Antidepressants most commonly used Anti-adrenergic agents Anticonvulsants Management: Medications Dissociative flashbacks or intrusive memories Propranolol (Inderal) 10-20 mg PO qid prn Blocks stimulation of beta-1 (myocardial) and beta-2 (pulmonary, vascular, and uterine) adrenergic receptor sites SE: fatigue, weakness, arrhythmias, bradycardia, CHF Must monitor blood pressure and pulse, I & O Management: Medications Cont'd Nightmares of trauma Cyproheptadine (Periactin) 4 mg PO qhs Blocks the effects of serotonin SE: drowsiness, blurred vision, dry mouth Assess for adverse anticholinergic effects Benzodiazepines prn at bedtime Management: Medications Cont'd Hallucinations of the trauma Olanzapine (Zyprexa) 2...