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PTSD: its antecedents and sequelae

A Psychiatric Case Presentation

Boacon, Hanny Mae


Tamonan, Grazle Ann
This case illustrates the factors
precipitating PTSD and the dilemma
suffered by the patient's family.
Objectives:
We aim that at the end of this presentation, we will be able to:
1. Define PTSD
2. Identify factors that may precipitate PTSD
3. Describe a case with PTSD
4. Enumerate the management strategies for patients with PTSD
Patient History:
Date of Interview: February 9, 2018
Informant: Patient and Mother
Reliability: 98%

General Data:
J.T., 12 years old, female, Filipino, Roman Catholic, residing
at Jaro, Leyte, Grade 6 pupil admitted for the 2nd time at EVRMC
with a chief complaint of “Magpapatambal ako kay masakit an
akon tiyan”.
History of Present Illness:
• August 4, 2017 - rape incident

• August 5, 2017 - culprit was arrested and detained


History of Present Illness:
• August 7, 2017 - changes in behavior began

• August 26, 2017 - patient was accused of stealing their


neighbor's piglet

• September, 2018
• Stopped doing her usual household chores
• Stayed outside their house late
• Had 3 episodes of nightmares
• Stares blankly to space for long periods of time
• Persistently irritable
History of Present Illness:
• September 20, 2017 - stabbed a classmate with a ballpen and
was suspended

• September 22, 2017 - the patient was brought to EVRMC


Psychiatric Department for consultatation

• December 4, 2017 - patient was allowed to go back to school


History of Present Illness:
• January 1, 2018 - they celebrated New Year as a family; her
sisters were also there

• January 3, 2017 - patient had increasing violent behavior; she


put her niece into the muddy ground naked and acted as if
nothing happened

• January 4, 2018 - the patient was brought to EVRMC


Psychiatric Department and was admitted
Past Psychiatric and Medical History:
No history of emotional or mental disturbance
No history of Psychosomatic disorder

Medical Conditions:
Admitted at Calubian Distric Hospital due to seizure.
Discharged improved with unrecalled home medications
allegedly for seizure.
March 2017: admitted at EVRMC due to seizure. Discharged
after 1 week improved with Phenobarbital as maintenance. She
was advised to follow-up monthly.
Family History:
 Patient was born last April 13, 2005. She is the 4th child in a
brood of 5.
 Mother, 43 years old., apparently well
 Siblings:
 1st: 21 years old female, married and apparently well
 2nd: 20 years old female, married and apparently well
 3rd: 18 years old male, working and apparently well
 5th: 8 years old, female, student and apparently well

 With family history of CA (liver), Hypertension, Asthma


relevant data:

Prenatal History:
 31 y/o G4P4 (4-0-0-4)
 Non-alcoholic beverage drinker
 Non-smoker
 Had prenatal visits at the BHS
 No vitamins taken
 Received TT5
relevant data:

Birth:
 Term, Cephalic presentation, NSVD
 At Home in Jaro, Leyte, attended by Midwife
 Pinkish and vigorous, with a loud cry immediately at birth
 Sucking was noted to be good
 No newborn screening done
relevant data:

Neonatal:
No jaundice, cyanosis, dyspnea and congenital defects noted.
Meconium stools and urine were passed out within the first 24
hours of life.
Umbilical stump was cleaned daily with alcohol and water
 It sloughed off 7 days after birth.
relevant data:
HEADSS:
Home:
 The patient is living with her family in a one bedroom house
made from light materials. The parents were separated since
the child was 3 years old. She is currently living with her
mother and her younger sister. Her 2 older sisters were already
married and her older brother works in a poultry house in
Ormoc City.

Education:
 The patient is an average grade 6 pupil. She is diligent in
writing notes and always earns check marks on her notebook.
She is participative in class and playful at school. She has a lot
of friends at school. She dreams to become a policewoman
someday.
relevant data:
HEADSS:
Activities:
 She enjoys doing household chores like cooking, washing the
dishes, doing the laundry and fetching water. She is described
as an obedient child before the incident happened.

Drugs:
 She is not taking any illicit drugs or any alcoholic beverages.
 She does not smoke.
relevant data:

HEADSS:
Sexuality:
 She is not involved in a romantic relationship but she gets
along well with her classmates and friends of both sexes.

Suicide:
 No suicidal ideation.
 There were no attempts to hurt herself.
Physical Examination:
• Ectomorphic; skin is moist and warm
• Wears clean clothes but had unkempt hair
• Her hair has equal distribution with lice
• Pulse rate was 92 beats per minute
• Respiratory rate was 25 breaths per minute
• She is left handed
• No other significant findings upon brief examination.
mental status examination:
General Description
• The patient is talkative and hyperactive. Her speech is rapid with
some incoherent words.
• She is non-combative during the interview and was conversant.
However, she was restless and has short attention span.
• She easily gets distracted by other people talking or crying.
mental status examination:
Mood and Affect
• The patient looks happy and playful.
• She smiles to everyone and laughs to almost everything.
• When asked about what happened to her, she states it vividly
without any emotion evident.
mental status examination:
Thinking
• There are flight of ideas and some loose associations with her
statements. There was no disturbance in the thought content
such as delusions, preoccupation about her illness, or any
compulsion and/or obsession.
mental status examination:
Perception
• There was no hallucinations or illusions during the time of
examination.
mental status examination:
Sensorium and Cognition
• The patient is alert and oriented to place and person. She has
intact remote and recent memory. She remembers well the rape
incident. She recalls all her teachers from Grade 1 to present.
She recalls her meal the past night. She repeats after the
examiner a series of numbers up to 7 digits. She spells some
words correctly like “butterfly” and “bag”.
mental status examination:
Judgment and Insight
• The patient does not understand her condition, she only keeps
on telling that she was admitted because of her abdominal pain.
• She remembered being restrained on bed and she hated it. She
said she hates those people who restrained her. When asked
about it, she said that she was restrained because she was
naughty (“Gingapus ako kay nagpipinasaway man ako”).
Salient Features:
• 12 years old
• Female
• Rape victim 5 months PTA
• Had 3 episodes of nightmares related to the incident
• Changes in behavior noted after the incident:
• Loss of interest in school activities
• Irritability
• Violent behavior
Differential Diagnosis:
Acute Stress Disorder
Is a mental disorder that can occur in the first month following
a trauma.
The symptoms that define ASD overlap with those for PTSD.
One difference, though, is that a PTSD diagnosis cannot be
given until symptoms have lasted for one month.
Also, compared to PTSD, ASD is more likely to involve feelings
such as not knowing where you are, or feeling as if you are
outside of your body.
Panic or Generalized Anxiety
Disorder
May develop in response to traumatic event.
Associated with prominent anxiety and autonomic arousal.
PTSD is associated with reexperiencing and avoidance of a
trauma, features typically not present in panic or generalized
anxiety disorder
impression:

Post - Traumatic Stress Disorder


Posttraumatic stress disorder
(PTSD)
is a debilitating and often chronic mental disorder that
develops in some children and adolescents following exposure
to a traumatic event.
Traumatic events are experiences that involve serious harm or
threat of harm to oneself or others, such as exposure to
interpersonal violence, accidents, natural disasters, and injuries.
Epidemiology:
Trauma exposure:
Studies have found high but varying rates internationally in the
proportion of children and adolescents experiencing a traumatic
event before the age of 18
Epidemiology:
Subsequent PTSD
A substantial minority of children and adolescents exposed to
trauma develops PTSD.
A meta-analysis of 43 studies of child PTSD conducted
cross-nationally indicates that 15.9 percent of children who have
experienced a traumatic event will develop PTSD.
Epidemiology:
Risk factors:
Risk factors for PTSD in children can be grouped into several
clusters: characteristics of the trauma, the child, and family, as
well as responses to the traumatic event.

Trauma characteristics
— The risk of PTSD varies substantially across different
types of traumatic events:
Events that involve a high degree of life threat are most likely to trigger
PTSD in children
Epidemiology:
Children who experience events involving interpersonal violence,
including rape, sexual assault, and physical abuse by caregivers or
romantic partners, have the highest risk of PTSD onset.
Exposure to war and armed conflict are associated with a high
conditional risk of PTSD in children.
High rates of PTSD have been reported in children who are displaced
and living as refugees.
Epidemiology:
Child characteristics:
 Girls are two to three times as likely to develop PTSD as
compared with boys.
Although females are more likely to experience certain types of
traumatic events that strongly predict the onset of PTSD, such
as rape and sexual assault, females remain more likely than
males to develop PTSD, even after accounting for these types
of differences in traumatic event exposure.
Epidemiology:
Family characteristics:
Family characteristics influence risk for PTSD:
Meta-analysis indicates that poor family functioning is a risk
factor for PTSD in children exposed to trauma.
Parent reactions to trauma are associated with PTSD in their
children. In some cases, parents develop PTSD symptoms,
depression, anxiety, or other mental disorders following a child’s
exposure to a traumatic event.
Epidemiology:
Responses to the traumatic event:
Cognitive and emotional responses to a traumatic event have been
associated with risk for PTSD in children:
Higher levels of anger about the traumatic event.
Higher levels of rumination (ie, passive and repetitive thinking about
the causes and consequences of one’s distress) and catastrophizing
(ie, overestimating the negative consequences of an event).
More negative appraisals about the traumatic event.
Elevated levels of avoidance and suppression of trauma-related
thoughts.
Dissociation during and after the traumatic event
Comorbidity:
Child PTSD frequently presents with psychiatric comorbidity,
Including:
Anxiety disorders
Depression
Externalizing behavior problems
Substance use disorders among adolescents
PATHOGENESIS
The precise pathophysiology of posttraumatic stress disorder
(PTSD) is unknown.
A predominant learning model of PTSD argues that the
disorder reflects a failure to inhibit fear. Traumatic events can
result in fear conditioning, such that sights, sounds, smells,
people, and other stimuli present during the experience become
associated with the intense fear and arousal experienced during
the event.
PTSD is specifically associated with heightened amygdala
activation, reduced activity in the vmPFC and rostral ACC in
response t emotional or threatening cues, and elevated activity
in the dorsal ACC during fear conditioning, extinction learning
recall, and response selection
Reduced hippocampal volume has been consistently observed
among individuals with PTSD.
Atypical medial prefrontal cortex function has been identified
as a potential familial risk factor for PTSD.
Reduced hippocampal volume has been observed among
veterans with PTSD and their monozygotic twins discordant for
trauma exposure, indicating that some of these neural
differences might increase vulnerability to PTSD.
Assessment:
It is critical to determine whether symptoms are the sequelae of
a traumatic event as opposed to another mental disorder.
To determine whether the presentation is most consistent with
PTSD, assessment should focus on intrusion symptoms:
intrusive thoughts
strong reactivity to trauma cues
Nightmares
repetitive play
avoidance of trauma reminders
hypervigilance
Diagnosis:
The posttraumatic stress disorder (PTSD) diagnosis includes four core
clusters of symptoms:
Intrusion
 Avoidance
Negative alterations in cognition and mood
 Hyperarousal

The symptoms must represent a marked difference from the child’s


behavior prior to the traumatic event and cause significant distress or
impairments in role functioning (eg, in social relationships or school
performance).
DSM-5 Criteria: PTSD
Criterion A (One required):
The person was exposed to: death, threatened death, actual or
threatened serious injury, or actual or threatened sexual violence,
in the following way (s):
Direct exposure
Witnessing the trauma
Learning that a relative or close friend was exposed to trauma
Indirect exposure to aversive details of the trauma, usually in
the course of professional duties (e.g. first responders, medics)
DSM-5 Criteria: PTSD
Criterion B (One required)
The traumatic event is persistently re-experienced, in the
following way (s):
Intrusive thoughts
Nightmares
Flashbacks
Emotional distress after exposure to traumatic reminders
Physical reactivity after exposure to traumatic reminders
DSM-5 Criteria: PTSD
Criterion C (one required):
Avoidance of trauma-related stimuli after the trauma, in the
following way(s):
Trauma-related thoughts or feelings
Trauma-related reminders
DSM-5 Criteria: PTSD
Criterion D (two required):
Negative thoughts or feelings that began or worsened after the
trauma, in the following way (s):
Inability to recall key features of the trauma
Overly negative thoughts and assumptions about oneself or the
world
Exagerated blame of self or others for causing the trauma
Negative affect
Decreased interest in activities
Feeling isolated
Difficulty experiencing positive effect
DSM-5 Criteria: PTSD
Criterion E (two required):
Trauma-related arousal and reactivity that began or worsened
after the trauma, in the following way (s):
Irritability or aggression
Risky or destructive behaviour
Hypervigilance
Heightened startled reaction
Difficulty concentrating
Difficulty sleeping
DSM-5 Criteria: PTSD
Criterion F (required)
Symptoms last for more than 1 month

Criterion G (required)
Symptoms create distress of functional impairment (e.g., social and
occupational)

Criterion H (required)
Symptoms are not due to medication, substance abuse, or other
illnesses
DSM-5 Criteria: PTSD
Two specifications:
Dissociative Specification. In addition to meeting criteria for
diagnosis, an individual experiences high levels of either of the
following in reaction to trauma-related stimuli:
Depersonalization: Experience of being an outside observer or
detached from oneself (e.g. feeling as if “this is not happening to me”
or one were in a dream)
Derealization: experience of unreality, distance or distortion (e.g.,
“things are not real”)
Delayed Specification. Full diagnostic criteria are not met until
atleast 6 months after the trauma (s), though onse of symptoms
may occur immediately.
Clinical Manifestation:
Intrusion symptoms reflect persistent and uncontrollable
thoughts, dreams, and emotional reactions about a traumatic
event
These symptoms are the hallmark of posttraumatic stress disorder
(PTSD) and distinguish it from other anxiety and mood disorders.
Intrusive thoughts are frequently triggered by trauma cues:
sights, sounds, smells, people, and places that remind the child
of the traumatic event.
Upsetting dreams and nightmares are common in children with
PTSD.
Severe distress and physiologic reactivity in response to cues
associated with the traumatic event.
Avoidance symptoms often develop in response to distressing
and uncontrollable re-experiencing symptoms. Avoidance of
trauma reminders can manifest in two ways:

Avoidance of thoughts, feelings, and memories of the traumatic


event (ie, internal reminders).
Avoidance of people, places, and activities associated with the
traumatic event (ie, external reminders). In young children,
avoidance can manifest as restricted play or reduced exploration
of their environment.
Course:
Highly variable
Most adolescents who develop PTSD recover from the disorder,
although approximately one-third experience a chronic course
of illness that can last many years
In a longitudinal study of over 2500 adolescents in Germany,
approximately half of those with PTSD recovered three to four
years later. Adolescents who had a low likelihood of recovering
from the disorder included those who had:
Additional traumatic events after developing PTSD
Greater avoidance symptoms
Incident anxiety and somatoform disorders after the onset of
PTSD
In a large study of United States adolescents with PTSD,
characteristics of subjects who were least likely to recover
included those:
Living in poverty
 Having co-occurring bipolar disorder
Experienced additional traumatic events after the trauma that
triggered the onset of PTSD
approach to treatment:
psychotherapy

TRAUMA-FOCUSED PSYCHOTHERAPIES
PTSD is conceptualized as a disorder of fear conditioning that is
both overgeneralized and fails to extinguish normally.

• Biological, learning, and social/environmental factors are


implicated in the development and maintenance of child PTSD,
suggesting the need for nuanced approaches to treatment.
Individual trauma-focused CBT
 Is a parallel child and parent (or primary caregiver) treatment
model that incorporates cognitive-behavioral, developmental,
neurobiological, attachment, family, and empowerment
principles.
Goals include helping children and parents gain resiliency and
coping skills, master learned and over-generalized avoidance of
feared trauma memories, make more adaptive meaning of
traumatic experiences, and resume optimal developmental
trajectories.
Phases and components:
Stabilization phase: Includes psychoeducation, parenting skills,
relaxation skills, affect modulation skills, and cognitive processing
skills.

Trauma narration and processing phase: Includes trauma


narration and processing.

Integration and consolidation phase: Includes in vivo mastery,


conjoint child parent sessions, and enhancing safety.
The components of these phases ("PPRACTICE“):
Psychoeducation
Parenting skills
Relaxation skills
Affect modulation skills
Cognitive processing skills
Trauma narration and processing
In vivo mastery of trauma reminders
Conjoint child-parent sessions
Enhancing safety
Other individual trauma-focused therapies:
Combined parent-child (CPC)-CBT:CPC-CBT differs from TF-
CBT in that it includes parents who perpetrated physical abuse.
Elements:
 A stronger focus on developing noncoercive parenting skills.
 Joint parent-child meetings during every session.
 Abuse clarification
Trauma affect regulation: Guide for education and therapy
(TARGET):
TARGET is a type of TF-CBT developed specifically for teens with
complex trauma.
TARGET may have specific applicability for the juvenile justice
population.
Eye movement desensitization and reprocessing (EMDR)
 EMDR differs from TF-CBT in that: EMDR incorporates saccadic
eye movements during exposure.
The trauma narrative is completed differently in EMDR
Parental involvement is optional in EMDR.
The duration of treatment is generally shorter for EMDR
(approximately eight sessions) than TF-CBT (8 to 24 sessions).
Cognitive-based trauma therapy (CBTT):
CBTT differs from TF-CBT in that:
 it does not include relaxation and has a specific focus on
integrating cognitive restructuring throughout treatment.
Kid narrative exposure therapy (KidNET)
This treatment differs from TF-CBT in that it primarily utilizes
the trauma narration and cognitive processing components,
with relatively little focus on other treatment components.

This treatment is particularly applicable for children exposed to


war, refugee, or migrant conditions
Group therapies

Cognitive-Behavioral Intervention for Trauma in Schools


(CBITS): CBITS incorporates cognitive behavioral principles with
peer support and resiliency modeling to help children overcome
learned trauma avoidance and gain adaptive skills.
Trauma grief components treatment (TGCT)
Includes both trauma-focused and grief-focused treatment
components that aim to address PTSD and maladaptive grief
responses, respectively.

TGCT is particularly appropriate for teens who have PTSD


symptoms and maladaptive grief related to war, terrorism, or
other circumstances of traumatic death.
ERASE-Stress
Extending and enhancing resiliency amongst students
experiencing (ERASE)-Stress
Is a 16-session, teacher-delivered resiliency-building intervention
designed specifically for children and adolescents who have been
exposed to terrorism or war
Group trauma-focused CBT
The trauma narrative TF-CBT treatment phase is provided in
individual “break out” sessions that are provided in addition to
the group sessions.
Therapies for preschool children
• Child-Parent Psychotherapy
• TF-CBT for Preschoolers
• Preschool PTSD treatment (PPT)
Pharmacotherapy:
ANTIDEPRESSANT MEDICATIONS:
• SSRIs

ANTIADRENERGIC MEDICATIONS
• Clonidine and guanfacine
• Prazosin
• Propranolol

SECOND-GENERATION ANTIPSYCHOTICS:
• Risperidone
ANTICONVULSANT MEDICATIONS:
• Carbamazepine
References:
Kaplan and Sadock's Synopsis of Psychiatry 10th ed.
U.S. Department of Veterans Affairs:
PTSD: National Center for PTSD
Up to date journal