Medical Management Considerations
Post Traumatic Stress Disorder or PTSD is an anxiety syndrome with symptoms that develop after a person has been directly exposed to a highly traumatic event. Examples of trauma include being physically or sexually assaulted or the witnessing of a violent event. The severity of the symptoms are in part related to the severity of the trauma, the closeness of the individual to the event, and whether it is a single event or has been repeated over time (e.g. recurrent sexual abuse). The traumatic event may be re-experienced in a variety of distressing ways including intrusive and recurrent memories and dreams. The individual often withdraws or attempts to numb himself to the emotions involved. Symptoms of increased arousal including irritability, startle responses, and sleep disturbance, are also common. It is important to remember that the full syndrome of PTSD is at the most severe end of a continuum of symptoms of exposure to stress. Symptoms persisting less than a month are diagnosed as Acute Stress Disorder.
Unfortunately, exposure to extreme violence in our society is a common occurrence and every primary care clinician should be aware of its psychological impact. Preliminary evidence indicates that persons with developmental disabilities are much more likely to be victimized by violence and are more vulnerable to the experiencing of PTSD. This is in part related to the extraordinary high rates of abuse, especially sexual abuse, among individuals with developmental disabilities.
PTSD is a common and serious problem in our society. It is estimated that 9% of individuals experience PTSD and many more have sub-threshold symptoms. There is growing evidence that persons with developmental disabilities may be at special risk. Interpretation of crime statistics suggests that persons with developmental disabilities are more likely to be victims of crime of all types. Although accurate statistics are difficult to obtain, persons with disabilities may be at special risk for sexual abuse. It has been estimated that persons with disabilities are 2-4 times more likely to be sexually abused than individuals without disabilities. Several reasons have been proposed why the disabled segment of the population may be at higher risk:
Studies of adults in the general population suggest that as many as 25% of individuals exposed to significant trauma will develop PTSD; one study specifically indicated that 5 to 6% of adult men and 10 to 14% of adult women had experienced PTSD at some time in their lives. With the increased likelihood of exposure to abuse, it follows that PTSD and related anxiety and depressive symptoms are important and common problems in individuals with disabilities and are important considerations for clinicians as part of a differential diagnosis.
Condensation of DSM-IV criteria for PTSD:
Exposure to trauma might suggest diagnostic consideration of PTSD if there is an acute change in an individual’s behavior combined with symptoms of anxiety, for example:
Many of the above PTSD symptoms may be difficult to elicit in individuals with developmental delays and the clinician will need to rely on observation and careful interviews of caregivers. However, in individuals with even basic verbal skills, the clinician should interview the patient alone and ask about potential abuse and trauma in a gentle and non-leading manner. Missed diagnoses are most commonly related to not asking about “sensitive” issues such as sexuality.
In any clinical evaluation where abuse and neglect is suspected, a report must be made to the appropriate authorities. Every clinician should be aware of the reporting requirements for child, dependent adult, or elder abuse. Such reporting is mandatory. If the clinician has any questions about need to report or procedures the appropriate agency should be immediately consulted.
If a recent sexual assault is suspected the person should be referred to an emergency room or specialized evaluation unit for a specialized examination. In other situations the primary care physician should perform a careful physical examination.
In an abuse and neglect situation the safety of others in the home or living situation should be considered.
There is a serious lack of empirical research related to the treatment of PTSD in persons with developmental disabilities. Extending work with other groups and clinical experience suggest the following:
A variety of medication strategies have been employed in the treatment of PTSD. The general goal is to target core symptoms of PTSD and associated symptoms of depression or anxiety, allowing the person to utilize effective coping strategies and process the traumatic event rather than using avoidance behaviors.
Probably the first choice is treatment with an SSRI antidepressant, for example:
Nefazodone (Serzone) has been effective in open trials and also may aid in sleep disturbance; Trazodone (Desyrel) and Clonidine (Catapres) have also been used successfully for sleep disturbance
Sedation with neuroleptics should be avoided
Benzodiazepines should be avoided, and Xanax was shown to be no more effective than a placebo
American Academy of Child and Adolescent Psychiatry. (1998). Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 37(10), 4-26.
American Academy of Child and Adolescent Psychiatry. (1999). Your Adolescent: Emotional, Behavioral, and Cognitive
Development from Early Adolescence through the Teen Years, Pruitt D.B., (Ed.) New York: Harper Collins.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV). Washington DC: American Psychiatric Association
Borus, N. (1999). (Ed.) Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental
Retardation. Cambridge: Cambridge University.
Breslau, N. (2001). The Epidemiology of Posttraumatic Stress Disorder: What is the Extent of the Problem? Journal of
Clinical Psychiatry, 16(17), 16-22.
Dosen, A., Day, K. (2001). (Eds.) Treating Mental Illness and Behavior Disorders in Children and Adults with Mental
Retardation. Washington: American Psychiatric.
Dykens, E.M. (2000). Psychopathology in Children with Intellectual Disabilities. Journal of Child Psychology and
Psychiatry, 41, 407-417.
Easter Seals Superior California. (2000). Technical Assistance Manual for Mandated Reporting of Suspected Crimes Against Victims with Disabilities (
Firth, H., Balogh, R., Berney, T., Bretherton, K., Graham, S., Whibley, S. (2001). Psychopathology of Sexual Abuse in Young People with Intellectual Disability.
Journal of Intellectual Disability Research, 45(3), 244-252.
Hageman, I., Andersen, H.S., Jorgensen, M.B. (2001). Post-traumatic Stress Disorder: A Review of Psychobiology and Phamacotherapy.
Acta Psychiatrica Scandinavica, 104, 411-422.
Lumley, B.A., Miltenberger, R.G. (1997). Sexual Abuse Prevention for Persons with Mental Retardation. American
Journal on Mental Retardation, 101(5), 459-472.
Madrid, A.L., State, M.W. (2000). Pharmacologic Management of Psychiatric and Behavioral Symptoms in Mental Retardation.
Child and Adolescent Psychiatric Clinics of North America, 9, 225-243.
Mansell, S., Sobsey, D., Moskal, R. (1998). Clinical Findings Among Sexually Abused Children with and without Developmental Disabilities.
Mental Retardation, 36(1), 12-22.
Parker, S., Zuckerman, B. (1995). (Eds.) Behavioral and Developmental Pediatrics: A Handbook for Primary
Care. Boston: Little, Brown.
Pine, D.S., Cohen, J. (2002). Trauma in Children and Adolescents: Risk and Treatment of Psychiatric Sequelae. Biological
Psychiatry, 51(7), 519-531
Reiss, S., Aman, M.G., (Eds.) (1998). Psychotropic Medications and Developmental Disabilities: The International
Consensus Handbook. Columbus: Ohio State University.
Rothbaum, B.O., Marshall, R., Foa, E.B., Lindy,J., Mellman, L. (2000). Posttraumatic Stress Disorder. In: Treatments
of Psychiatric Disorders. (pp.1539-1566) 3
rd Ed. Gabbard, (Eds.) American Psychiatric Publishing: Washington, DC,
Rush, J., Frances, A. (Eds.) (2000). Expert Consensus Guideline Series: Treatment of Psychiatric and Behavioral Problems in Mental Retardation.
American Journal of Mental Retardation, 105(3), 159-226.
Ryan, R. (1994). Posttraumatic Stress Disorder in Persons with Developmental Disabilities. Community Mental Health Journal 30(1): 45-54
Sullivan, P.M., Knutson, J.F. (2000). Maltreatment and Disabilities: A Population-based Epidemiological Study. Child
Abuse and Neglect, 24(10), 1257-1273.
Szymanski, L., King, B.H. (1999). Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders.
Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), 5-31.
Szymanski, L., King, B.H., Goldberg, B., et al. (1998). Diagnosis of Mental Disorders in People with Mental Retardation. In:
Psychotropic Medications and Developmental
Disabilities (pp. 3-17)The International Consensus Handbook; Reiss, S., Aman, M.G., (Eds.) Columbus: Ohio State University Press.
Volkmar, F.R., Dykens, E. (2002). Mental Retardation. In: Child and Adolescent Psychiatry: A Comprehensive
Textbook (3rd ed., pp. 603-611) Lewis, M., (Ed.) Philadelphia: Lippincott Williams & Wilkins.
Yehuda, R. (2002). Current Concepts: Post-Traumatic Stress Disorder. New England Journal of Medicine,
American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue N.W.
Washington, D.C. 20016-3007
The Arc (formally Association for Retarded Citizens)
500 East Border Street, Suite 300
Arlington, Texas 76010
California Department of Developmental Services
P.O. Box 944202
Sacramento, CA 94244-2020
California Regional Centers
California Alliance for the Mentally Ill
1111 Howe Avenue, Suite 475
Sacramento, CA 95825-8541
National Mental Health Association Information Center
2001 North Beauregard Street, 12th floor
Alexandria, VA 22311
Association of University Centers on Disabilities
8630 Fenton Street, Suite 410
Silver Spring, MD 20910-3803
The National Association for the Dually Diagnosed
132 Fair Street
Kingston, NY 12401
Project MED (Medical Education for Consumers)
The Tarjan Center for Developmental Disabilities at UCLA
California Mental Health and Developmental Disabilities Center
American Psychiatric Association
1400 K Street N.W.
Washington, DC 20005
Theodore A. Kastner, M.D., M.S.
Leonard Magnani, M.D., Ph.D.
Felice Weber Parisi, M.D., M.P.H.
Terrance D. Wardinsky, M.D.
Funded by a grant from the California Department of Developmental Services
For more information, contact:
Center for Health Improvement
1330 21st Street, Suite 100
Sacramento, CA 95814
This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.