new approaches to posttraumatic stress disorder robert k. schneider, md assistant professor...

New Approaches to Posttraumatic Stress Disorder

Robert K. Schneider, MD

Assistant ProfessorDepartments of Psychiatry and Internal Medicine

The Medical College of Virginia of

the Virginia Commonwealth University

Epidemiology

• Epidemiological Catchment Area Study (1987)– Lifetime prevalence: 1-2%

• Urban sample of HMO enrollees (1991)– 11.3% of women

• National Comorbidity Study (1995)– 7.8% of responders

Diagnosis

• Exposure of self or others to an “extreme”

stressor (“the trauma”)

– Avoidance

– Re-experiences

– Hyperarousal

Avoidance or Numbing

• Avoidance of associated thoughts, feelings, activities, or places

• Diminished interest

• Detachment

• Restricted range of affect

Re-experience the trauma

• Flashbacks

• Nightmares

• Intrusive thoughts

• Intense reaction when exposed to “triggers”

Hyperarousal

• Sleep problems

• Irritability

• Hypervigilance

• Exaggerated startle

• Difficulty concentrating

Progression of symptoms - Blank

• Acute stress disorder

• Acute PTSD

• Chronic PTSD

• Delayed PTSD

• Intermittent

• Residual

• Reactivated

Areas of focus tonight

• Stressor Criterion & Non-Assaultive Trauma

• The “Great Imposter”

• Management Update

Stressor Criteria

• Exposed to event that involved serious

injury, or a threat to the physical integrity of

self or others

• The person’s response involved intense

fear, helplessness or horror (change from

DSM-IIIR)

Trauma and PTSD in the community,

The 1996 Detroit area survey of trauma

Breslau N, Kessler RC, et. al. Arch Gen Psychiatry, July

1998;55:626-632• A representative sample (2181) persons aged 18-45 years old in the Detroit metropolitan area screened for traumatic events

• 90% of respondents had experienced one or more traumas

• Most prevalent trauma: the unexpected death of a loved one

• Contingent risk for PTSD (all traumas)– women: 13% men: 6.2%

Categories of traumatic events

• Personally experienced assaultive violence – 37.7%

• Other personally experience injury or shocking experience – 59.8%

• Learning about traumas to others– 62.4%

• Sudden unexpected death of a loved one – 60.0%

Conditional Risk

• Rape 40-60%

• Combat 35%

• Violent Assault 20%

• Sudden death of a loved one 14%

• Witnessing a traumatic event 7%

• Learning about trauma to others 1-2%

Bullets

• PTSD is a civilian disease

• Non-assaultive trauma is a common and

real stressor in the genesis of PTSD

The “Great Imposter”

• Depression

• Panic attacks

• Substance abuse

• Personality

• Physical symptoms (somatization)

Concurrent Psychiatric Illness in Inpatients with PTSD

• 374 inpatients at a VA Medical Center

• 16.8% have PTSD diagnosis

• Mean number of diagnoses– 1.4 diagnoses non-PTSD– 2.9 diagnoses PTSD

• Alcohol abuse; unipolar depression; atypical psychosis and intermittent explosive disorder

Depression and PTSD

• Significantly associated

• Posttraumatic depression may occur without PTSD

• Depression more likely later in the course of PTSD

• Later in the course the patient may no longer meet criteria for PTSD but may still have major depression

Panic and PTSD

• Panic attack may be a marker for PTSD– Incidence is 69%

• PTSD more common in patients with Major Depression and Panic disorder

• Benzodiazepines are effective in Panic but not in PTSD

Substance Abuse and PTSD

• At least 2 possible courses:– PTSD before the Substance Abuse– PTSD after the Substance Abuse

• Substance Abuse and PTSD likely to be hospitalized more than Substance Abuse alone

• In veterans the incidence of concurrent substance abuse is 60-80%

Personality and PTSD

• PTSD is very common but not universal in

Borderline Personality Disorder

• Early trauma associated

• Repeated or chronic trauma associated

“Complex” PTSD - Herman

• Occurs after prolonged and repeated trauma

• Three broad areas of disturbance– Multiplicity of symptoms

– Characterological changes

– Repetition of harm

Bullet

The most common diagnosis missed is the second diagnosis-

Sir William Osler

Management

• Treatments

– Psychopharmacology

– Psychotherapy

• Setting

– Specialty Mental Health

– Primary Care

Psychopharmacology

• SSRIs (e.g. sertraline)

• Tetracyclics (i.e. trazadone and nafazadone)

• Tricyclics (i.e.imipramine and amitriptyline)

• MAOIs (e.g. phenelzine)

• Benzodiazepines

• Mood stabilizers

• Antipsychotics

Which to choose?

SSRIs are first line treatment

• TCAD: side effects and lethal in suicide

• Benzodiazapines: no RCT showing efficacy and some evidence that PTSD deteriorates with treatment.

• MAOIs: only second line

• Neuroleptics: no RCT to support, the newer novel antipsychotics would be used first and found to have unique clinical application

Medication trail

• 8-12 weeks of SSRI

• If no response then another antidepressant

• If partial response and:– Sleep disturbance then tetracyclic– Irritability then mood stabilizer– Peripsychosis then antipsychotic

Psychotherapies

• Education and supportive

• Cognitive therapy

• Behavioral therapy (relaxation techniques)

• Exposure therapy

• EMDR (eye movement desensitization reprocessing)

Primary Care Setting

• Only 38% of cases receive treatment

• 28% of cases and 75% in treatment are seen in the

primary care setting

– 10% of all PTSD and 25% of those treated are in

the specialty mental health sector

• “did not have a problem requiring treatment” was

the most common reason of the 62% of PTSD

patients not receiving treatment

Management Bullets

• Screen for “worst traumas”

• Suggest and use psychotherapies early

• SSRIs are the first line treatment

• Start low and go slow

• Combine other medications if symptoms persist

Conclusions

• A civilian disease

• The “trauma” may be non-assaultive

• Often masquerades as another illness

• SSRIs are the treatment of choice

• Combine psychotherapy and medications

• Most PTSD is treated in primary care

Questions

• How much PTSD do you see?

• How do you screen for PTSD?

• What traumas do you see?

• What treatments do you use?

• What are you doing to treat PTSD in primary care?