Prof c tennant PTSD september

PTSD: UPDATE Prof Chris Tennant RNSH- 2005 PTSDOverview LIFETIME LIFETIME COMMUNITY COMMUNITY BASED BASED ESTIMATES ESTIMATES of of PTSD PTSD USA CRITERIA CANADA DSM IV PTSD Scale 1.2% GERMANY DSM IV CIDI AUSTRALIA* DSM IV ICELAND VIETNAMESE DIS MEN 1-6% WOMEN TOTAL 1-10% 1-7% 2.7% 1.9% 0.4% 2.2% 1.3% 1.2%* 1.4%* 1.3%* 0.6% 0.2% EAST TIMOR 0.4% *12 month prevalence + Frequency of traumatic events similar in Australia and USA PROF C TENNANT RNSH – 2005 - PTSDoverview LIFE LIFE TIME TIME PREVALENCE PREVALENCE OF OF TRAUMA TRAUMA (in (in Australia) Australia) (Creamer (Creamer2001) 2001) Rape Molestation Physical attack Threat (weapon) Shock (other person) Accident (life threat) Witness (injury etc) Natural disaster Other Combat Any trauma PROF C TENNANT RNSH – 2005 - PTSDoverview MEN (%) 0.6 3.5 12.9 16.5 9.8 28.3 37.8 19.9 8.2 6.1 64.5% WOMEN (%) 5.4 10.2 7.6 7.0 12.0 13.6 16.1 12.7 8.3 0.9 49.5% ONE ONE YEAR YEAR RISK RISK OF OF PTSD PTSD with with specific specific traumas traumas (Creamer (Creamer2001) 2001) MEN % WOMEN % Rape 8.4 9.2 Molestation Physical attack 11.8 2.4 5.5 3.7 Threat (weapon) 1.9 4.2 Shock 2.0 1.7 Accident (life threatening) 1.5 1.7 Witness (injury etc) 1.0 1.1 Natural disaster 0.3 1.3 Other 5.0 4.5 Combat 4.7 - (“other person” trauma) Any trauma (causing PTSD) PROF C TENNANT RNSH – 2005 - PTSDoverview * These rates similar to USA 1.9 2.9% SPECIFIC SPECIFIC TRAUMA TRAUMA RISK RISK FACTORS FACTORS IN IN THE THE COMMUNITY COMMUNITY (Breslau (Breslau1991) 1991) Male 1.3 Conduct disorder 2.0 Childhood separation 1.6 FH depression 2.0 Alcohol problems 1.5 Drug problems 1.8 Antisocial behaviour 1.9 Prof Chris Tennant RNSH- 2005 PTSDOverview TRAUMA TRAUMA PROF C TENNANT RNSH – 2005 - PTSDoverview PTSD PTSD PSYCHOLOGICAL SEQUELAE SEQUELAE OF OF PSYCHOLOGICAL TRAUMA TRAUMA • DEPRESSION is far more common than PTSD (Particularly so for Civilian Vs Military Trauma ) •PTSD is “Relatively” uncommon following trauma One year relative risk (Australia] In Men: 1.9% In Women: 2.9% •BRIEF PSYCHOSIS also occurs e.g East Timor: 1.3% •EXPLOSIVE ANGER : follows Human Rights Violations e.g E Timor: 40% (minimum episode per month) (average 2-3 episodes) “SYMPTOM RISK” RISK” WITH WITH SPECIFIC SPECIFIC “SYMPTOM TYPES OF OF TRAUMA TRAUMA TYPES • Acute unpredictable trauma (e.g rape, MVA) “Reliving” is more common Dissociation is also common • Chronic Trauma Depression, anxiety are more common Specific effects on sleep “Administrative” stress – poor global sleep Critical incident stress – broken sleep [nightmares] GENES Depression anxiety, D/A Personality Trauma PTSD Other Life Events PROF C TENNANT RNSH – 2005 - PTSDoverview VARIANCE IN PTSD SYMPTOMS DUE TO COMBAT TWIN STUDIES VARIANCE IN PTSD SYMPTOMS DUE TO COMBAT (McLeod 2001) COMBAT  21% of “re experiencing”  1% of “arousal”/avoidance alcohol use PROF C TENNANT RNSH – 2005 - PTSDoverview  1% of UNDERLYING NEUROBIOLOGY NEUROBIOLOGY AND AND UNDERLYING MEMORY PROBLEMS PROBLEMS IN IN PTSD PTSD MEMORY I Hippocampus and HPA Axis (Corticosteroids) II Prefrontal Cortex, Amygdala and (Catecholamines) COGNITIVE BEHAVIOURAL BEHAVIOURAL COGNITIVE TREATMENTS TREATMENTS  An Aversive (unconditioned) stimulus ie Traumatic Event is paired with a ‘neutral’ stimulus (reminders, recollection)  leading to a conditioned fear response and Cognitive and Behavioural Avoidance “New learning” (extinction) is the basis of CBT COMPONENTS OF OF TREATMENT TREATMENT COMPONENTS  Activation of the feared memory  WITH  Corrective information/experience which is incompatible with the fears II COGNITIVE COGNITIVE and and BEHAVIOURAL BEHAVIOURAL II THERAPY in in PTSD PTSD GENERALLY GENERALLY THERAPY Psycho education Exposure treatments * Anxiety management 1972) Cognitive restructuring Prof Chris Tennant RNSH- 2005 PTSDOverview (Miechenbaum COGNITIVE BEHAVIOUR BEHAVIOUR THERAPIES THERAPIES COGNITIVE COGNITIVE THERAPY Socratic questioning and challenge maladaptive beliefs Efficiency : most studies show some benefit EXPOSURE THERAPY Exposure allows emotional reprocessing/re-learning Efficiency: clinically most effective treatment (Combined) CBT Efficiency: consistently clinically effective EMDR Efficiency: Clinically effective (exposure) [ Value of Eye Movement is uncertain ] COPING SKILLS (Stress treatment ,Assertiveness training exercise, Sleep hygiene) Efficiency: No evidence Relaxation OTHER PSYCHOLOGICAL PSYCHOLOGICAL OTHER THERAPIES THERAPIES PSYCHODYNAMIC THERAPY Efficiency: no evidence “ECLECTIC “ PSYCHOTHERAPY Efficiency: no evidence COMPARISON OF CBT VS SSRIs No evidence SINGLE TREATMENT VS CBT PLUS SSRIs No evidence MDMA (ECSTASY) (ECSTASY) ASSISTED ASSISTED MDMA “EXPOSURE” “EXPOSURE” • RCT: Chronic Refractory PTSD (assault) (n=23) 1)MDMA – hours spontaneous exposure (+ 90 minute follow up at 24 hours) weeks of weekly follow up 2)MDMA session at weeks CAPS PTSD scale scores (baseline 79) - Post first session 38 Vs 74 - Post second session 29 Vs 69 - Two months after 25 Vs 59 EFFECTS OF OF MDMA MDMA (ECSTACY) (ECSTACY) EFFECTS 1) Increases in Serotonin Therapeutic Relationship Improved Reduces: Depression Anxiety, Fear Exposure with minimal Aggression anxiety Increases: Confidence - Improves self efficacy Alters: Perceptions New ways of thinking of experiences EFFECTS OF OF MDMA MDMA (ECSTACY) (ECSTACY) EFFECTS 2) INCREASES IN DOPAMINE AND NORADRENALINE Increases: Alertness/ Arousal - (Improves recall; “Optimal Arousal Zone”) 3)INCREASES IN ALPHA RECEPTOR ACTIVITY Increases: Relaxation - (Improved mental alertness) 4) OXYTOCIN AT HYPOTHALAMUS Increases: Oxytocin - (Improves empathy, closeness) Prof Chris Tennant RNSH- 2005 PTSDOverview OTHER ADJUNCTS ADJUNCTS TO TO THERAPY THERAPY ?? OTHER  D-CYCLOSERINE Enhances learning (Agonist at NMDA receptors (i.e extinction) i.e glutaminergic activity) *Strong Animal Research *Strong Human Research: only in social anxiety/phobia  CORTICOSTEROIDS “Reduces Avoidance” in PTSD (No positive long term effects however) ‘PREVENTATIVE INTERVENTION’ INTERVENTION’ OF OF ‘PREVENTATIVE PTSD PTSD • Critical incident stress debriefing: • Stress Education: • Very early CBT: No value No value No preventative effects IN THE MILITARY • Trauma Risk Management (TRIM (UK) (Symptom identification, structural interview and subject encouraged to access psychological help) Minimal effects • Battlemind (USA) (Normalises reactions to trauma i.e education) Minimal effects HIPPOCAMPUS AND AND HPA HPA HIPPOCAMPUS (GLUCOCORTICOIDS) IN IN PTSD PTSD (GLUCOCORTICOIDS) I Animal Experimental Studies I II III IV Stressors Glucocorticoids Hippocampus Loss Memory Deficits All Correlate HUMAN STUDIES STUDIES OF OF PTSD PTSD AND AND HUMAN THE HIPPOCAMPUS HIPPOCAMPUS THE Have smaller Hippocampal volumes (bilateral) Have poorer Hippocampal blood flow (During memory tasks) (Not at rest) Hippocampal changes are associated with memory problems + Hippocampal Memory Problems are of ‘Retention’ (not “Acquisition”) Have reduced N-Acetyl Aspartate (Which is a marker of neuronal integrity) These changes are not observed in kids with PTSD PREFRONTAL CORTEX CORTEX AND AND CATECHOLAMINES CATECHOLAMINES PREFRONTAL IN PTSD PTSD IN (Function is is ‘Acquisition ‘Acquisition and and Learning’ Learning’ i.e i.e (Function working memory) memory) working • Stress  Glucocorticoid and Catecholamine Released in the PFC • G/C and C/A  Reduced Working memory  Reduced Executive function  Reduced Emotional regulation • Frontal and Prefrontal Cortical Volumes are reduced • Functional studies similarly show “Underactivation” Prefrontally ARE COGNITIVE COGNITIVE CHANGES CHANGES AND AND BRAIN BRAIN ARE CHANGES A A CAUSE CAUSE OR OR EFFECT EFFECT OF OF CHANGES PTSD? PTSD? Does PTSD cause Cognitive and Brain changes? OR Are these impairments a risk factor for PTSD*? * MZ Twins Discordant for Combat trauma or PTSD – Had similar verbal memory impairments – Had similar (smaller) Hippocampi So poorer Neurocognitive function is risk factor for PTSD Seems both cause and effect (i.e “Downward Spiral”) ... 2.0 Alcohol problems 1.5 Drug problems 1.8 Antisocial behaviour 1.9 Prof Chris Tennant RNSH- 2005 PTSDOverview TRAUMA TRAUMA PROF C TENNANT RNSH – 2005 - PTSDoverview PTSD PTSD PSYCHOLOGICAL SEQUELAE... DYSFUNCTION NEUROCOGNITIVE IN PTSD PTSD IN MAJOR PROBLEM IS VERBAL DECLARATIVE MEMORY Greater in combat PTSD than civilian PTSD (probably due to chronic/repetetive trauma or chronicity of PTSD. .. also correlated with Antisocial personality •When personality was controlled : • Combat did not predict PTSD [Gulf war ] PROF C TENNANT RNSH – 2005 - PTSDoverview PREDICTORS PREDICTORS OF OF PTSD