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
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