PTSD is a disease first introduced into the diagnostic and statistical manual of mental disorders (DSM) in 1980
With the world experiencing an unprecedented onslaught of disasters and traumas, it is imperative that health workers are aware of the disease and the factors that affect it
2. Post-traumatic stress disorder (PTSD)
Post traumatic stress disorder is a mental disorder in which an individual's normal response to fear is
changed. When a person without this disorder is faced with a frightening situation, a “fight-or-flight”
response normally occurs in the body. This response causes the reactions that many associate with being
afraid or stressed including an increased heart rate and a hyper-awareness of one's surroundings. This
response occurs so that one would be able to fight or run away from the stimulus that originally caused
this response. However, when individuals have post-traumatic stress disorder, this fight or flight response
happens even when the individuals are not actually in danger (Post-Traumatic Stress Disorder (PTSD)). It
as if the switch that “turns on” this response is broken, turning on the stress response even when it is not
needed.
Mental Health After Traumatic Events and Violence; UCMUN 2014 World Health Organization
It is a problem in which the human brain continues to react with nervousness after the horrific trauma
even though the original trauma is over. Brain can react by staying in "overdrive" and being hyperalert
in preparation for the next possible trauma. Sometimes the brain continues to "remember" the trauma
by having "flashbacks" about the event or nightmares even though the trauma was in the past.
As an effect of psychological trauma, PTSD is less frequent but more enduring than the more commonly
seen acute stress response. Post-traumatic Stress Disorder (PTSD) is a persistent and sometimes
crippling condition and develops in a significant proportion of individuals exposed to trauma, and untreated,
can continue for years. Its symptoms can affect every life domain – physiological, psychological,
occupational, and social
3. Post-traumatic stress disorder (PTSD) is a severe and complex disorder precipitated by exposure to a psychologically
distressing event.
• It is an Anxiety disorder characterized by aversive anxiety-related experiences, behaviors, and physiological
responses that develop after exposure to a psychologically traumatic event (sometimes months after).
• Its features persist for longer than 30 days, which distinguishes it from the briefer acute stress disorder.
• These persisting posttraumatic stress symptoms cause significant disruptions in one or more important areas of
life function.
It has three sub-forms:
– Acute: onset of symptoms < 1 month after the traumatic event
– Chronic: onset of symptoms < 1-3 months after the traumatic event
– Delayed-onset: onset of symptoms < more than 3 months after the traumatic event
Triggered by trauma
• Any traumatic event i.e. such as “mugging, rape, torture, being kidnapped or held captive, child abuse, car
accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes” can trigger
the disease (Post-Traumatic Stress Disorder (PTSD)).
• Chance of developing PTSD after trauma : 8%
• No direct experience of the event necessary
Mental Health After Traumatic Events and Violence; UCMUN 2014 World Health Organization
Post-traumatic stress disorder (PTSD)
4. First introduced into the diagnostic and statistical manual of mental
disorders (DSM) in 1980
One of the few DSM diagnoses to have a recognizable etiologic
agent, in that it must develop in direct response to a severe
(sudden, terrifying, or shocking) life event (American Psychiatric
Association 2000)
Since the introduction of PTSD into DSM-III (American Psychiatric
Association 1980), the disorder has been documented in children
exposed to traumas such as domestic violence, natural disasters,
medical trauma (such as hospitalization or medical procedures
performed on children), war, terrorism, and community violence
DSM-IV-TR Criteria for PTSD
5. DSM-IV-TR Criteria for PTSD
• A:The person has been exposed to a traumatic event in which both of the following were present:
– (1) The person experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
– (2) The person’s response involved intense fear, helplessness, or horror. Note: In children, this
may be expressed instead by disorganized or agitated behavior.
• B:the traumatic event is persistently reexperienced in one (or more) of the following ways:
– (3) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or
perceptions. Note: In young children, repetitive play may occur in which themes or aspects of
the trauma are expressed.
– (4) Recurrent distressing dreams of the event. Note: In children, there may be frightening
dreams without recognizable content.
– (5) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience; illusions, hallucinations, and dissociative flashback episodes, including those that
occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment
may occur.
– (6) Intense psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
– (7) Physiological reactivity on exposure to internal or external cues that symbolize or resemble
an aspect of the traumatic event.
6. DSM-IV-TR Criteria for PTSD
• C:Persistent avoidance of stimuli associated with the trauma and numbing
of general responsiveness (not present before the trauma), as indicated by
three (or more) of the following:
– (8) Efforts to avoid thoughts, feelings, or conversations associated with the trauma
– (9) Efforts to avoid activities, places, or people that arouse recollections of the trauma
– (10) Inability to recall an important aspect of the trauma
– (11) Markedly diminished interest or participation in significant activities
– (12) Feeling of detachment or estrangement from others
– (13) Restricted range of affect (e.g., unable to have loving feelings)
– (14) Sense of a foreshortened future (e.g., does not expect to have a career, marriage,
children, or a normal lifespan)
• D. Persistent symptoms of increased arousal (not present before the
trauma), as indicated by two (or more) of the following:
– (1) Difficulty falling or staying asleep
– (2) Irritability or outbursts of anger
– (3) Difficulty concentrating
– (4) Hypervigilance
– (5) Exaggerated startle response
7. • Duration of the disturbance (symptoms in Criteria B, C, and D) is
more than 1 month.
• The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
• Acute: if duration of symptoms is less than 3 months
• Chronic: if duration of symptoms is 3 months or more
• Specify if:
• With Delayed Onset: if onset of symptoms is at least 6 months after
the stressor.
DSM-IV-TR Criteria for PTSD
8. The age-standardised disability adjusted
life-year (DALY) rates for PTSD
The United Nations' World Health Organization’s estimates of PTSD impact for
each of its member states(2004): per 100,000 inhabitants, in 10 most ranking
countries
9. The age-standardised disability adjusted life-year (DALY) rates for PTSD,
per 100,000 inhabitants, in 10 most ranking countries
10. Incidence of psychiatric disorders
after disasters in India
Psychiatric
morbidity
PTSD Major
depression
Generalised
anxiety
Panic
disorders
1 Latur earthquake (1) 74% 89% 42% 28%
2 Odissa
supercyclone(8)
80.4% 44.3% 52.7% 57.5%
3 Tsunami(post
tsunami)13
79.7% 1.25%* √√√ √√√
4 Tsunami A and N 3.7%* √√√ √√√ √√√
*Psychological symptoms get taken care of by the informal social mechanism and counselors working with non-
governmental organizations (NGO) and that the specialist psychiatric services are required for a smaller proportion of
populations D
11. International research: Factors
leading to Vulnerability (1)
• Biological diathesis
• Early childhood developmental experiences
• Trauma severity.
• Proximity to, duration of, and severity of the trauma
• Interpersonal traumas
• Genetic factors
• Women develop PTSD at about twice the rate as men
• Prior trauma history/multiple traumas
• A premorbid psychiatric history
• Fewer support
• Limited inter-personal coping skills
• Trauma intensity
• Personal perception of event as life threatening
• Hereditary
Amarendra Narayan Prasad (2012). Post Traumatic Stress Disorder – An Overview, Post Traumatic Stress
Disorders in a Global Context, Prof. Emilio Ovuga, Md, PhD (Ed.), ISBN: 978-953-307-825-0, InTech, Available
from: http://www.intechopen.com/books/post-traumatic-stress-disorders-in-a-global-context/post-traumaticstress-
disorder-an-overview
12. • Demographic factors:
– Females vs males,
– older age
• Biological factors:
– Moderate hereditary factors / though no single gene identified.
• Psychological factors and psychiatric symptoms:
– certain personality traits , such as neuroticism and introversion,
• Post-trauma social resource factors:
– inadequate social support
– economic or marital issues
– disruption of one’s daily life- relocation the death of an intimate partner, or other
significant loss problems
Frank Huang-Chih Chou and Chao-Yueh Su (2012). Risk Factors and Hypothesis for Posttraumatic Stress Disorder (PTSD) in Post Disaster Survivors, Post Traumatic Stress
Disorders in a Global Context, Prof. Emilio Ovuga, Md, PhD (Ed.), ISBN: 978-953-307-825-0, InTech, Available from: http://www.intechopen.com/books/post-traumatic-stress-
disorders-in-a-global-context/risk-factors-andhypothesis-
for-posttraumatic-stress-disorder-ptsd-in-post-disaster-survivors
International research: Factors
leading to Vulnerability (2)
13. Pre trauma
factors
Trauma and post
trauma factors
Trauma severity
Lack of social support
Additional life stress
Psychiatric
illness (PTSD)
Hypothesis for PTSD
Hobfoll’s conservation of resources (COR) model
deprivation of
internal or
external
resources
According to Hobfoll’s conservation of resources
theory, resource loss is an important determinant of
individual stress and physical and mental health,
including PTSD.
When faced with stress, frustration (e.g., life events), or traumatic events (e.g., brain damage or deprivation of internal or
external resources) individuals, either suddenly or gradually, become more vulnerable to psychiatric impairment and diseases
such as PTSD .An individual might reach a sub-threshold of PTSD and then develop the illness due to a decreased availability of
resources, an accumulation of risk factors (personality traits, poor social interactions, etc.) or a major stressful event. Furthermore,
unresolved, subclinical psychiatric symptoms caused by a disaster may increase a survivor’s sensitivity to future stresses.
Frank Huang-Chih Chou and Chao-Yueh Su (2012). Risk Factors and Hypothesis for Posttraumatic Stress Disorder (PTSD) in Post Disaster Survivors, Post Traumatic Stress
Disorders in a Global Context, Prof. Emilio Ovuga, Md, PhD (Ed.), ISBN: 978-953-307-825-0, InTech, Available from: http://www.intechopen.com/books/post-traumatic-stress-
disorders-in-a-global-context/risk-factors-andhypothesis-for-posttraumatic-stress-disorder-ptsd-in-post-disaster-survivors
14. WHO: factors for PTSD
Negative factors
• History of mental illness
• Become physical harmed
• See others physically harmed
• Experience ongoing stress
after the traumatic event.
Positive factors
• Social support system
• Have a coping strategy to
deal with the after effects
of the trauma
Topic B Mental health after traumatic events and violence UCMUN 2014 World Health Organization
15. Meta-analysis for strengths of risk
factors for PTSD
Factors
1. Gender
2. Age at trauma
3. Socioeconomic status (SES)
4. Education
5. Intelligence
6. Race
7. Previous psychiatric history
8. Reported abuse in childhood
9. Reports of other previous traumatization
10. Reports of other adverse childhood
factors (excluding abuse)
11. Family history of psychiatric disorder
12. Trauma severity,
13. Post-trauma life stress,
14. And post-trauma social support.
Chris Brewin, Bernice Andrews, John Valentine; Meta-analysis of risk factors for post traumatic
stress disorders in trauma exposed adults; Journal of Consulting and clinical psychology 2000, vol.
68, no 5, 748-766
Research on factors affecting PTSD since 1980 were studied. After a rigorous selection based on
design, sampling and measurement , 77 original research on PTSD were studied. Meta-analyses
were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the
moderating effects of various sample and study characteristics, including civilian/military status,
were examined
16. Risk factor No. Of Studies Population Size Weighted Average
Gender (female) 25 11,261 0.13
Younger age 29 7,207 0.06
Low SES 18 5,957 0.14
Lack of education 29 11,047 0.1
Low intelligence 6 1,149 0.18
Race (minority status) 22 8,165 0.05
Psychiatric history 22 7,307 0.11
Childhood abuse 9 1,746 0.14
Other previous trauma 14 5,147 0.12
Other adverse childhood 14 6,969 0.19
Family psychiatric history 11 4,792 0.13
Trauma severity 49 13,653 0.23
Lack of social support 11 3,276 0.4
Life stress 8 2,804 0.32
Meta-analysis for strengths of risk factors for
PTSD: Summary of risk factors predicting PTSD
17. Trauma and post trauma events
• Trauma severity
• Social support
• Subsequent life stress
Demographic variable
• Female gender
• Low SES
• Less education
• Lower Intelligence
Prior history variable
• Positive psychiatric history
• Reported history of abuse
• Other trauma
• Childhood adversity
• Family psychiatric history
Younger age of trauma
Race(minority status)
Convey the strongest risk of PTSD,
with effect sizes that are individually
small to moderate
Individual effect
sizes are generally regarded as small
Effect sizes are weaker still, but highly
significant because of the large numbers
involved.
Meta-analysis for strengths of risk factors for
PTSD
Chris Brewin, Bernice Andrews, John Valentine; Meta-analysis of risk factors for post traumatic stress disorders in trauma exposed
adults; Journal of Consulting and clinical psychology 2000, vol. 68, no 5, 748-766
18. • Gender , age , race : predict PTSD in some
populations not others
• Education, previous trauma, general childhood
adversity-predict PTSD more consistently but
varyingly according to populations studied
• Psychiatric history, reported childhood abuse,
family psychiatric history –more uniform predictive
effects
• All the factors had only a modest effect but
trauma and post trauma factors had stronger
effects compared to pretrauma factors
Meta-analysis for strengths of risk factors for
PTSD
Chris Brewin, Bernice Andrews, John Valentine; Meta-analysis of risk factors for post traumatic
stress disorders in trauma exposed adults; Journal of Consulting and clinical psychology 2000, vol.
68, no 5, 748-766
19. Indian research on factors affecting PTSD(1)
• Trauma factors: Moderate increase in psychiatric morbidity
was observed in medium term in the disaster affected group
which for most part had subsided by the follow-up stage five
years post-disaster.
• Socio-demographic factors: as measures of distress and
recovery of the affected community.
• Early phase: importance of primary exposure variables in
genesis of morbidity
• Late phases: while the secondary and mediating factors (life
events and social support)
Indian Council of Medical Research: Centre for Advanced Research on health consequences of earthquake disaster with special
reference to mental health at the Maharashtra Institute of Mental Health, Pune.
20. Indian research on factors affecting PTSD(2)
Negative factors
• Women versus men: 6.35 times higher risk (when adjusted for other variables)
• Residents of urban versus rural
• Areas of maximum destruction
• Effect of all the protective factors against PTSD was low for the residents of urban
area as compared to those in the rural area.
• This reminds that disasters impact whole communities, not selected individuals.
• Low SES had significant risk of PTSD
• Death of a relative and injury to self or family members were significantly associated
with PTSD
Protective factors
• Absence of fear of recurrence of tsunami
• Counseling received more than three times
• Satisfaction of services received
Risk factors of post-traumatic stress disorder in tsunami survivors of Kanyakumari District, Tamil Nadu, India
T. T. Pyari, Raman V. Kutty,1 and P. S. Sarma Indian J Psychiatry. 2012 Jan-Mar; 54(1): 48–53.
doi: 10.4103/0019-5545.94645 ,PMCID: PMC3339219
21. Indian research on factors affecting PTSD
(3)
Co morbidity was found in 39.0% of adolescents with a psychiatric
diagnosis
• Middle socioeconomic status
• Gender differences in the presentation of the symptoms
• Prolonged periods of helplessness
• Lack of adequate post-disaster psychological support
• Severity of the disaster.
Research Open Access
Post-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: a study
of Comorbidity Nilamadhab Kar*1 and Binaya Kumar Bastia2 Published: 26 July 2006 Clinical Practice and Epidemiology in Mental
Health 2006, 2:17 doi:10.1186/1745-0179-2-17
This article is available from: http://www.cpementalhealth.com/content/2/1/17
Risk of posttraumatic stress disorder and depression in survivors of the floods in Bihar, India
Shirley Telles, Nilkamal Singh, Meesha Joshi Indian Journal of Medical Sciences Year : 2009 | Volume : 63 | Issue : 8 | Page : 330--334
Risk of PTSD higher in people above the age of 60 years
22. Children and PTSD (Medscape)
Negative factors
• Previous exposure to traumatic incidents
• Repeated trauma -
• Personal threat
• Developmental state Older age more at risk
• Type of trauma – abuse worse than disaster/accident
• Relationship with Trauma perpetuator
• Trauma caused by a person rather than resulting from an accident is more likely to lead to PTSD;
in particular,
• Guilt
• A preexisting psychiatric disorder
• Symptoms at the time of the abuse
• Physiologic response - Children who have an elevated heart rate in the period soon after the
trauma (eg, those seen in an emergency department [ED]) are more likely to develop PTSD
Positive factors
• Parental support
• Extra familial support
• Resilience
24. • Males and females differ in their expression of PTSD symptomatology- thus
they may respond differently to treatment.
• Sex differences in the risk and protective factors associated with the
development and maintenance of PTSD may still result in sex differences in
treatment outcome.
• Finally, males and females may differ in how comfortable they feel in
different treatment settings and with different treatment paradigms.
• It has been suggested that gender socialisation plays a role in the
treatment of PTSD, and that males express less affect and are more
cognitively oriented in therapy than females (Cason et al., 2002).
• It could be argued that such behaviour represents problem-focused coping
and is consistent with activation of the fight-or-flight system. Based on the
idea that different pathways lead to PTSD in males and females, and that
different risk factors may thus be important for the development of PTSD in
the two sexes as illustrated in Figure 1, it might be expected that females
will benefit more from therapy, which aims to reduce levels of dissociation
and increase levels of social support. In contrast,a therapeutic approach,
which aims to reduce physiological arousal and dampen anxiety may be
more beneficial to males
Sex difference in pathways to PTSD
27. Treatment strategies
• Psychosocial treatment strategies
– Prolonged Exposure (PE)
– Cognitive Processing Therapy (CPT)
– Stress Inoculation Training (SIT)
– Eye Movement Desensitization and Reprocessing (EMDR)
• Pharmacotherapy of adult PTSD
– Antidepressants: SSRIs (selective serotonin reuptake inhibitors), Atypical
Antidepressants
– Anticonvulsants
– Mood stabilizers
– Major tranquilizers and
– Anti-psychotic medications
– Beta blockers (Propranolol)
28. General treatment components in
children
• Initial stages:
– Establishing rapport with the child and caregiver(s)
– Providing a rationale for treatment.
1st line: Trauma-focused cognitive-behavioral treatment
(CBT) to resolve PTSD
• Teaching stress management techniques
• Relaxation techniques
• Cognitive coping techniques
• Direct exploration/discussion of the traumatic experience
• Exploring and correcting inaccuate attributions
Pharmacotherapy
Editor's Notes
According to the American Psychological Association, posttraumatic stress disorder (PTSD)
is defined as "an anxiety disorder that can develop after exposure to a terrifying event or
ordeal in which grave physical harm occurred or was threatened. Traumatic events that may
trigger PTSD include violent personal assaults, natural or human-caused disasters, such as
terrorist attacks, motor vehicle accidents, rape, physical and sexual abuse, and other crimes,
or military combat
Epidemiological studies have indicated
a lifetime prevalence of exposure to traumatic events of 40% 18 to 90%19 and a lifetime prevalence of PTSD in the community ranging from 1% to 9%.19–21
490 BC, the Greek historian Herodotus described an Athenian soldier with PTSD
Shakespeare:Henry IV is just one of many literary characters who experience he symptoms of PTSD even before it became an official diagnosis (Friedman).
In the 19th century, soldiers in Europe and the United States of America were often diagnosed with “exhaustion” (Amarendra Narayan Prasad)
Vietman war veterans