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