post-traumatic stress disorder in the primary care setting presented by: jonathan betlinski, md...

Post-traumatic Stress Disorderin the Primary Care Setting

Presented by: Jonathan Betlinski, MDDate: 01/22/2014

Disclosures and Learning Objectives

Learning Objectives:•Be familiar with the Criteria for PTSD•Know two screening tools for PTSD•Know at least three ways to decrease retraumatization during clinic visits•Know two psychotherapies helpful for PTSD•Know the two classes of medications most helpful for PTSDDisclosures: Dr. Jonathan Betlinski has nothing to disclose.

PTSD in the Primary Care Setting

• Review epidemiology of PTSD

• Review the diagnostic criteria for PTSD

• Discuss first steps in treatment of PTSD

• Screening

• Avoiding re-traumatization

• Psychotherapy

• Indicated Medications

• Topic for next time


PTSD present in 8.6% of primary care patients

Trauma is common- 25-30% of trauma survivors develop PTSD

- For women, sexual assault is the most likely precursor

- For men, it’s witnessing injury or death in combat

Trauma leads to health problems- Traumatized patients make 4x more PCP visits

- CSA survivors have more somatic complaints,

pain disorders, general medical diagnoseshttp://www.ncbi.nlm.nih.gov/pubmed/17339617; http://www.ncbi.nlm.nih.gov/pubmed/10795604

https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/103/6/73.pdf


Most trauma victims

•do not seek mental health services

•seek help in the primary care setting

•do not disclose personal trauma histories

•will provide trauma history if asked

•do not object to being asked about their trauma history in a primary care setting

http://www.publichealth.va.gov/docs/vhi/posttraumatic.pdf

PTSD Risk Factors

• Personal or Family history of psychiatric disorder

• Involvement of interpersonal violence• Severity of trauma• Chronicity of the traumatic experience• Whether it involves fear of dying• Stressors in the recovery environment

http://www.unioviedo.es/psiquiatria/publicaciones/documentos/1998/1998_Ballenger_Consensus.pdf

http://www.aafp.org/afp/2003/1215/p2401.pdf

DSM-5 PTSD Diagnostic Criterion A: Stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)

1.Direct exposure.

2.Witnessing, in person.

3.Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.

4.Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures. http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

DSM-5 PTSD Diagnostic Criterion B: Intrusion Symptoms

The traumatic event is persistently re-experienced in the following way(s): (one required)

1.Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play.

2.Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).

3.Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.

4.Intense or prolonged distress after exposure to traumatic reminders.

5.Marked physiologic reactivity after exposure to trauma-related stimuli.

http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

DSM-5 PTSD Diagnostic Criterion C: Avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)

1.Trauma-related thoughts or feelings.

2.Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).


DSM-5 PTSD Diagnostic Criterion D: Negative Alterations in Cognition and Mood

Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)

1.Inability to recall key features of the traumatic event

2.Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “World is dangerous,”)

3.Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.

4.Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).

5.Markedly diminished interest in (pre-traumatic) significant activities.

6.Feeling alienated from others (e.g., detachment or estrangement).

7.Constricted affect: persistent inability to experience positive emotions. http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

DSM-5 PTSD Diagnostic Criterion E: Alterations in Arousal and Reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

1.Irritable or aggressive behavior

2.Self-destructive or reckless behavior

3.Hypervigilance

4.Exaggerated startle response

5.Problems in concentration

6.Sleep disturbance


DSM-5 PTSD Diagnostic Criteria

Criterion F: Duration

Persistence of symptoms for more than one month.

*Full diagnosis is not made until at least 6 months after the trauma, although onset of symptoms may begin immediately

Criterion G: Functional Significance Significant symptom-related distress or functional impairment

Criterion H: Exclusion

Disturbance is not due to medication, substance use, or other illness.

Specify if: With dissociative symptoms

Depersonalization and/or Derealization

Specify if: With delayed expression.http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

DSM-5 PTSD Diagnostic Criteria: Summary

T - Trauma exposure

R - Re-experiencing

A - Avoidance of reminders

U - Undermined cognition and mood

M - Magnified arousal and reactivity

A - Active symptoms for 1 month

Better than nothing screening: GAD-7

http://wiki.galenhealthcare.com/index.php/Galen_eCalcs_-_Calculator:_GAD-7_Gen._Anxiety_Disorder

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf

PTSD

66% sensitivity

81% specificityhttp://www.ncbi.nlm.nih.gov/books/NBK126694/

Better Screening for PTSD in Primary Care

PC-PTSD (currently used by VA), cut off score of 3

- 77% sensitive, 85% specific, PLR 5.1, NLR 0.27http://www.integration.samhsa.gov/clinical-practice/PC-PTSD.pdf

PCL-C (endorsed by SAMHSA), cut off score of 30

- 98% sensitive, specificity >80% http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383936/pdf/nihms-357066.pdf

http://www.integration.samhsa.gov/clinical-practice/Abbreviated_PCL.pdf

http://www.istss.org/PosttraumaticStressDisorderChecklist.htm

SPAN and Breslau have reasonable evidence

Very short screens are less usefulhttp://www.hsrd.research.va.gov/publications/esp/ptsd-screening-EXEC.pdf

Treatment of PTSD in Primary Care

•Greet patient while he or she is still fully dressed

•Avoid positioning yourself between patient and exit

•Ask what you can do to make exams easier and less scary

•Explain plans and reasons for procedures before starting

•Ask permission to touch

•Keep patient informed while exam progresses

•Check in regularly

•Move at the patient’s pace

•Take breaks as necessary

•Use grounding techniques if patient seems disconnected or distressed

•Remind patient where they are

•Remind patient they are safe

•Remind patient abuse isn’t currently happening

•Restore a sense of control by providing patient as much choice as possible

Avoid re-traumatizing or re-victimizing patients

https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/103/6/73.pdf

Treatment of PTSD in Primary Care

NICE 2005 Guideline (reviewed 2011)

• Debriefing should NOT be routine practice

• For mild symptoms of <4wks, wait & watch

• For severe symptoms, offer individual CBT within one month of the trauma

• Offer individual CBT or EMDR to all PTSD

• Meds are not routine first line treatment• though consider if therapy declined

http://www.nice.org.uk/guidance/cg26/resources/guidance-posttraumatic-stress-disorder-ptsd-pdf

Treatment of PTSD in Primary Care: CBT

• CBT effective in more than 30 studies• Exposure Therapy – repeated descriptions

of the trauma reduce arousal and distress• Cognitive Therapy – identifying trauma-

related negative beliefs and changing them• Stress-Inoculation Training – learning skills

for managing anxiety• Belly Breathing & Progressive Muscle Relaxation

• Likely 60-80% reduction in symptomshttp://www.publichealth.va.gov/docs/vhi/posttraumatic.pdf

https://depts.washington.edu/hcsats/PDF/TF-%20CBT/pages/4%20Emotion%20Regulation%20Skills/Client%20Handouts/Relaxation/Ways%20to%20Relax%20by%20Using%20breathing.pdf

Treatment of PTSD in Primary Care: EMDR

• EMDR - Eye Movement Desensitization and Reprocessing• Patients bring to mind images of the trauma while

engaging in back-and-forth eye movements

• Also addresses trauma-related negative beliefs

• Less effective and sustained than CBT

• More effective than placebo wait list, or psychodynamic, relaxation or supportive therapies

• Eye movement component may not add any addition treatment effect



Treatment of PTSD in Primary Care: Other

• Psychodynamic Psychotherapy• One study showed 18 sessions of Brief PP reduced

avoidance symptoms by 40%; effect was sustained at 3 months

• Needs more research

• Group Therapy• Clear benefit for psychological distress, depression,

anxiety, and social adjustment

• Possible 18-60% symptom reduction

• Results typically sustained at 6 monthshttp://www.publichealth.va.gov/docs/vhi/posttraumatic.pdf

Pharmacologic Interventions

Psychotherapy (CBT) remains the gold standard treatment for PTSD

Main goal for medication is to minimize symptoms rather than cure PTSD

Hyperarousal symptoms (nightmares, etc) are the most likely to respond to meds

Medications should never replace therapy unless it is ineffective or declined

http://www.thecarlatreport.com/printpdf/5050



Pharmacology for PTSD: Antidepressants

APA and VA recommend SSRIs as the first choice when medications are indicated

Sertraline and Paroxetine remain the only SSRIs with FDA approval for PTSD

Most studies show a modest response

60% response, 40% remission

Dose SSRIs the same as for depressionhttp://www.thecarlatreport.com/printpdf/5050



http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf

Pharmacology: Other Antidepressants

Studies on other antidepressants are mixed• SNRIs may be more likely to be effective

• NICE recommends Mirtazapine, Amitriptyline and Phenelzine first-line

Sleep may be least likely to respond to SSRI• Consider adding Mirtazapine, a sedating TCA like Doxepin,

or perhaps Trazodone

No evidence for use of Bupropionhttp://www.thecarlatreport.com/printpdf/5050




Pharmacology for PTSD: Antipsychotics

Neither a first-line nor a solo treatment

Sedating atypicals most likely to show benefit• Risperidone is the most researched, and may be an helpful

adjunct to SSRIs

• Olanzapine helpful in some studies, esp as adjunct

• Quetiapine supported, though research lags

No studies support the use of typicals

Other medications can help with sedationhttp://www.thecarlatreport.com/printpdf/5050



Pharmacology for PTSD: Mood Stabilizers

Often shown to be ineffective, especially as monotherapy

Trials showing effectiveness are typically open-label

Notably, Valproate no better than placebo.

Topiramate may be helpful for nightmares and flashbacks




Pharmacology for PTSD: Anti-Adrenergics

More helpful in the short run

Typically associated with less stigma

May help with Hypervigilance and Activation

Propranolol 10-40mg po 3-4x/day

Clonidine 0.1-0.3mg po bedtime and PRN

Prazosin 1-3mg po bedtime

Guanfacine not supported in studieshttp://www.thecarlatreport.com/printpdf/5050



Pharmacology for PTSD: Benzodiazepines

May be helpful for sleep, BUT…

Avoid in active or recent substance abuse• SA in 40% of PSTD (75% if combat-related)

Benzos may contribute to emotional numbing• This may interfere with recovery

Scant evidence for actual benefit

Little evidence for or against buspirone



Summary

• PTSD occurs in 8.6% of primary care patients• DSM-V has shifted PTSD diagnostic criteria to 6

categories (think TRAUMA)• Tools like the PC-PTSD and PCL-C accurately

detect PTSD in the primary care setting• Good treatment avoids retraumatization• CBT and EMDR are PTSD’s treatments of choice• Antidepressants (SSRI’s) and anti-adrenergics

are the most supported medications for PTSD

The End!

Obsessive-Compulsive

Disorder

01/29/15

http://proof.nationalgeographic.com/2014/11/05/musings-corey-arnold-looks-wildlife-straight-in-the-eye/?source=photoeditorspicks

post-traumatic stress disorder in the primary care setting presented by: jonathan betlinski, md...

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