nielsenes ptsd presentation handout

8/6/2019 NielsenES PTSD Presentation Handout

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Post-Traumatic Stress Disorder

Presentation by:

Eric Nielsen

2012 PharmD Candidate

Preceptor: Andrea Mason, PharmD

Presented on Friday March 11, 2011

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Objectives

Introduce Post-Traumatic Stress Disorder:

Signs/symptoms, prevalence, theories of origin

Diagnosis of PTSD:

Criteria according to DSM-IV

Treatment of PTSD Cognitive-Behavioral therapy

Medication therapy

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What is PTSD?

Post-Traumatic Stress Disorder is thought to be a

poorly-contained recovery from stressful events

PTSD is an anxiety disorder that develops after exposureto real or threatened death, killing, violent encounters, or

natural disasters.

The PTSD patient will frequently: re-experience theunpleasant emotions associated the traumatic event, show

signs of hyper-arousal, or display avoidance of situations that

remind them of previous trauma

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More about PTSD

Typical of post-traumatic stress syndrome signs:

Recurrent & intrusive distressing memories of event

Recurring, distressing dreams about the event

Strong feelings that the event is happening again, now

Avoidance behaviors in PTSD:

Avoiding - conversations about, thoughts about, activities

or people who remind patient of the traumatic event

Inability to remember event; loss of pleasure from normal

personal & family activities

Hyperarousal: easily startled, hypervigilant, losing sleep

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Epidemiology of PTSD

Prevalence in the general population = 3.6%

PTSD always associated with traumatic event;

About 50% men and 60% women experience such events

Among those with traumatic experience:

About 8% of men, 20% of women will develop PTSD

Environmental, genetic factors: no strong correlations

Causes vs Effects are still debated among researchers5


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Etiology of PTSD

Physical or emotional trauma (or both): Military service, tsunami, tornado, foster care, child abuse

Abnormalities: in brain function, in levels of

neurotransmitters (NE), in adrenal gland activity Including cortisol, epinephrine output [theory]

Trends found in PTSD patients include: high proportion of

NorEpinephrine to Cortisol; low levels of neuronal DA & NE Thought to contribute to altered recovery from stress

Patients often show low brain-catecholamines, high CRF

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Diagnosis of PTSD

DSM-IV criteria for PTSD (all must be met):

A: Exposure to traumatic event

Risk of serious injury/death AND a response of fear or horror

B: Persistent re-experiencing of traumatic event

Flashbacks, distressing dreams, intense response to reminders

C: Persistent avoidance and numbing of responsiveness

Presence of at least 3/7 avoidance criteria such as avoidance of

people, places, thoughts; selective forgetfulness; low interest

D: Hyperarousal - difficulty sleeping, concentrating; outburst ofanger; excessive vigilance; excessive startle response

E: Duration of Symptoms = more than 1 month

F: Significant Impairment of daily living & activities

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Treatment of PTSD

Current First-line therapy:

Cognitive Behavioral Therapy (CBT), with use of

antidepressants (SSRIs) where indicated

CBT for post-traumatic stress often includes Exposure

Therapy (1st line in US Military and VA)

Mixed evidence for the effectiveness of EMDR:

Eye Movement Desensitization and Reprocessing

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Pharmacotherapy for PTSD

Selective Serotonin Reuptake Inhibitors

1st line med therapy

Mixed-action Antidepressants:

Lowest drop-out rates = Bupropion, Venlafaxine

Pressor agents: Alpha-blocking agents.

Reduction in startle response, hyper-arousal effects

Anti-convulsive and mood agents Evidence for preservation of REM sleep with

reduction in frequency/severity of nightmares

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Pharmacotherapy contd

Some evidence for benefit of B-blocker

propranolol, used during CBT.

Thought to interfere with brains process of

reinforcing (patients traumatic) memory

Given just before Exposure Therapy

Poor evidence for use of benzodiazepines (lorazepam, diazepam, etc)

Proven risk of BDz dependence, withdrawal symptoms

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Treatment: SSRIsMedication Class FCA Indications Dosing Side Effects

citalopram

(Celexa)

SSRI MDD (Rxs for severalanxiety & depressive

disorders, typically)

20-60 mg

per day

Nausea, HA,

somnolence,

sexual sideFx

paroxetine

(Paxil)

SSRI MDD, OCD, panic (Rxs

for anxiety &depressive disorders)

20-50 mg

per day

Nausea, HA,

somnolence,sexual sideFx

fluoxetine

(Prozac)

SSRI MDD, OCD, others(Rxs for anxiety &

depressive disorders)

10-80 mg

per day

Nausea, HA,

somnolence,

sexual sideFx

fluvoxamine

(Luvox)

SSRI OCD (Rxs for several

anxiety & depressivedisorders, typically)

100-250 mg

per day

Nausea, HA,

somnolence,sexual sideFx

sertraline

(Zoloft)

SSRI PTSD, OCD, MDD,panic

50-200 mg

per day

Nausea, HA,

somnolence,

sexual sideFx

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Treatment: SSRIsMedication Class FCA Indications Dosing Side Effects

venlafaxine ER

(Effexor)

SNDRI MDD, GAD, SAD,panic

37-225mg

per day

Nausea, HA, dry

mouth, sexual

sideFx

Amitryptaline

(Elavil)

TCA Depression, chronicpain (common Rx for

mod-severe PTSD)

50-300mg

per day

Dry mouth,

dizziness,

orthostasis

mirtazepine

(Remeron)

tetra-

cyclic

MDD

(common Rx for mod-

severe PTSD)

15-45mg at

bedtime

Dry mouth,

appetite incr,

weight gain

phenelzine

(Nardil)

MAOI Depression, bulimia(Rxs for refractoryPTSD)

15-90mg at

bedtime

Hypotension,

dizziness,headache

prazosin

(Minipress)

alpha-

blocker

Hypertension (Rxs

common for anxiety

& panic disorders)

6-10mg at

bedtime

Hypotension,

nausea, HA,

somnolence,

impotence

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Non-drug Therapy

Cognitive-Behavioral Therapy:

Therapist guides individual to be aware of their

thought patterns , recognize maladaptive thoughts

PTSD therapy emphasizes gradual exposure to

perceived traumatic situation & thoughts (desensitization

EMDR: Eye Movement Desensitization and Reprocessing Used by VA and Military; recent review of research suggests its use of

standard CBT elements may produce most benefits, versus actual

effectiveness of eye-movement elements

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Summary

Post-Traumatic StressDisorder is.

Origins and causes of PTSD are not definitively

known. Correlations between altered stress response

and non-typical levels of neuronal NE & DA, and

altered levels of cortisol have been noted in patients.

Self-treatmentwith drugs and alcohol is widespread,

as is misdiagnosis and under-treatment by clinicians. Research to find definitive causes may result in

more effective treatments in the future.

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References

1.Shad MU, Suris AM, North CS. Novel combination strategy to optimize treatment for

PTSD. Hum Psychopharmacol Clin Exp. Feb 2011 (ePub ahead of publication).

http://onlinelibrary.wiley.com.lp.hscl.ufl.edu/doi/10.1002/hup.1171/pdf

2.Joseph T. DiPiro R, Talbert GC, et al: Pharmacotherapy: A Pathophysiologic Approach,

7e, Chapter 74: Anxiety Disorders II: Posttraumatic Stress Disorder and Obsessive-

Compulsive Disorder

3.Peris J, PhD. Pharmacology lecture notes. University of Florida College of Pharmacy.

Oct 2009

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