REVIEW OF POSTTRAUMATIC STRESS DISORDER

DAVID EISENMAN, MD MSHSUCLA SCHOOL OF MEDICINE

GRAND ROUNDSPROVIDENCE HOLY CROSS

MEDICAL CENTERSEPTEMBER 17, 2013

What percent of adults in the US patients have experienced serious traumatic events?

% OF US ADULTS WITH AT LEAST ONE DSM3 TRAUMATIC EVENT IN THEIR LIFE% OF US ADULTS WITH AT LEAST ONE DSM3 TRAUMATIC EVENT IN THEIR LIFE

A. 10%

B. 25%

C. 35%

D. 45%

E. 55%

Kessler 2005 Arch Gen Psych

E. 55%

IF YOU GUESSED IF YOU GUESSED

YOU’RE RIGHT!YOU’RE RIGHT!

CONDITIONAL RISK IN MEN

61% have trauma

8% develop PTSD

CONDITIONAL RISK IN WOMEN

51% have trauma

20% develop PTSD

CONDITIONAL RISK OF PTSD (GIVEN A QUALIFYING TRAUMATIC EVENT)CONDITIONAL RISK OF PTSD (GIVEN A QUALIFYING TRAUMATIC EVENT)

• Overall, 20% of exposed women and 8% of exposed men develop PTSD, but

• Rape = 40-65%

• Combat = 35%

• Violent Assault = 20%

• Sudden death of a loved one = 14%

• Witnessing a traumatic event = 7%

PTSD PREVALENCE IN THE U.S.PTSD PREVALENCE IN THE U.S.

Women (%) Men (%)

Population lifetime prevalence 10-14 5-6

Primary care prevalence 6-15

Current or recent PTSD (12mos) 3-5%

Breslau et al., 1991, 2002; Resnick et al., 1993; Kessler et al., 1995, NVVRS, Norris 2013

EPIDEMIOLOGY TAKE HOMES….EPIDEMIOLOGY TAKE HOMES….

• Exposure to potentially traumatic events is exceedingly common

• Only a fraction of people exposed to a trauma develop PTSD

• PTSD is a civilian disease

• Non-assaultive trauma is a common and real stressor in the genesis of PTSD

PTSD CHANGES IN DSM 5PTSD CHANGES IN DSM 5

• Stressor criteria includes sexual assault and recurring exposures to details

• Intense fear, helplessness or horror deleted• 4 clusters instead of 3

DSM 5 POSTTRAUMATIC STRESS DISORDERDSM 5 POSTTRAUMATIC STRESS DISORDER

• Stressor criterion• Intrusion symptoms• Hyperarousal symptoms• Avoidance• Cognition & mood• Duration criterion• Clinically significant impairment/distress

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.

PTSD: STRESSOR CRITERION

• The person witnessed, experienced, or learned about a traumatic event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

PTSD CRITERION: INTRUSION SYMPTOMSPTSD CRITERION: INTRUSION SYMPTOMS• Trauma is persistently experienced in the following

ways (needs only 1):

• Recurrent, involuntary, intrusive memories

• Traumatic nightmares

• Flashbacks

• Intense distress after reminders

• Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

PTSD CRITERION: AVOIDANCE SYMPTOMS

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

Efforts to avoid activities, places, or people that arouse recollections of the trauma

Persistent avoidance of stimuli associated with the trauma (needs only 1):

PTSD CRITERION: NEGATIVE ALTERATIONS IN COGNITIONS AND MOOD (NEEDS 2)PTSD CRITERION: NEGATIVE ALTERATIONS IN COGNITIONS AND MOOD (NEEDS 2)

• Unable to recall key features of trauma (not due to head injury, alcohol or drugs)

• Negative beliefs about oneself or world (distorted/persistent)

• Blame of self or others

• Negative trauma related emotions (anger, shame)

• Diminished interest in activities

• Alienated from others

• Constricted affect

PTSD CRITERION: HYPERAROUSAL SYMPTOMS

1. Sleep disturbance

2. Irritability or aggressive behavior

3. Self-destructive/reckless behavior

4. Difficulty concentrating

5. Exaggerated startle response

6. Exaggerated startle response

Increased arousal (needs 2):

PTSD: ADDITIONAL CRITERIAPTSD: ADDITIONAL CRITERIA

• Duration of the disturbance is more than one month.

• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

PHYSICAL EXAMPHYSICAL EXAM• Evaluate possible medical sequelae of the trauma

• 10-15% of mild TBI develop post-concussive symptoms (somatic, cognitive, and emotional) that overlap with PTSD symptoms

• Rule out medical causes of PTSD symptoms

• No medical illnesses can produce all 4 types of PTSD symptoms simultaneously; Focus the medical H&P on the dominant PTSD symptom, e.g. sympathetic hyperactivity

LABORATORY STUDIESLABORATORY STUDIES

• TSH: Consider for all patients. Restlessness, insomnia, and autonomic hyperactivity are common to both PTSD and hyperthyroid states.

• T3 and T4 levels have been found to be elevated in patients with PTSD. TSH levels are unaffected.

• Drug Screen: Consider for all patients. Substance-related disorders are highly comorbid with PTSD.

LABORATORY STUDIESLABORATORY STUDIES

• CT/MRI of head: Consider for patients with cognitive deficits.

• Sleep Studies: Consider for patients with sleep symptoms predating trauma exposure and patients with other symptoms suggesting a primary sleep disorder (e.g., loud snoring, excessive daytime sleepiness)

PATIENTS WHO HAVE EXPERIENCED A TRAUMA AND HAVE SUFFICIENT SYMPTOMS ARE LIKELY TO HAVE PTSD

PATIENTS WHO HAVE EXPERIENCED A TRAUMA AND HAVE SUFFICIENT SYMPTOMS ARE LIKELY TO HAVE PTSD

• Exposure: “have you had any experience that was so frightening or upsetting that it haunts you still?

• Physical reactions, nightmares, unwanted memories—resembles acute anxiety

• Avoidance—they try not to think about it or go out of their way to avoid reminders

• Numb or detached feeling—resembles depression• Constantly on guard, watchful, startled easily—resembles “paranoi

a” to the patient

PIER, ACP Online http://pier.acponline.org/physicians/public/d251/tables/d251-thp.html

The most common diagnosis missed is the second diagnosis.

Sir William Osler

COMORBIDITY OF PTSDCOMORBIDITY OF PTSD

• Majority w/PTSD have other diagnoses:~80-90%

• Depression

• Panic attacks and GAD

• Substance abuse (mostly men)

• Physical symptoms (somatization)

Brown et al., Journal of Abnormal Psychology, 2001Hamner at al., Journal of Nervous and Mental Disease, 2000

Kessler et al., Archives of General Psychiatry, 1995

DEPRESSION AND PTSDDEPRESSION AND PTSD

• 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

SUBSTANCE ABUSE AND PTSDSUBSTANCE 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%

SUICIDE ASSESSMENT

Module 1: Trauma,

PTSD, and Health-27

• Particularly important in older adults, males, and Veterans

DIAGNOSIS BULLETSDIAGNOSIS BULLETS

• Consider head trauma

• Consider the second diagnosis

• Ask about suicidal thoughts

IF IT APPEARS THAT A PATIENT DOES HAVE PTSD

National Center for PTSD: PTSD Screening and Referral, http://www.ptsd.va.gov/professional/pages/assessments/assessment.a

sp

• Let the patient know that your evaluation does not mean that he or she definitely has PTSD, but that you think further evaluation is needed.

• Encourage the patient to voice any reservations or concerns he or she might have about evaluation or treatment. You may be able to facilitate treatment by listening to these concerns, acknowledging their validity, and addressing some of the patient's questions about what to expect during mental health evaluation and treatment.

• Make sure the patient understands that he or she is not crazy.

• Normalize the idea of treatment. Explain that treatment involves common sense activities that include learning more about PTSD, finding and practicing ways of coping with trauma-related symptoms and problems, taking steps to improve relationships with family and friends, and making contact with other patients who experience similar problems.

• Provide the patient with a written referral to a mental health professional

TREATMENT CHOICES: MEDICATION, PSYCHOTHERAPY, OR BOTH

• Initial treatment can be either pharmacotherapy or psychotherapy

• Both approaches are efficacious, and each has advantages and disadvantages

PSYCHOTHERAPIESPSYCHOTHERAPIES

• Education and supportive• Privacy, confidentiality• Distress from traumas can effect the body, health

and mental health• Caution before eliciting detailed trauma story• Assess current safety

• Cognitive Processing Therapy• Exposure-based treatments• EMDR (eye movement desensitization reprocessing)

Patients with PTSD who are going to be treated with medication should, with few exceptions, be prescribed an SSRI or SNRI as their first medication.

SSRI AND SNRI• SSRIs

• Paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac), and citalopram (Celexa)

• Effective for comorbid depression, anxiety, insomnia, social phobias

• SNRIs• Venlafaxine

• May exacerbate hypertension• Duloxetine

SSRI

• Some patients may demonstrate an initial worsening when starting treatment

• In some cases, this may be due to activating/ anxiogenic effects of the SSRIs (e.g., insomnia, agitation, gastrointestinal distress)

• In other instances, it may be related to discussion of the trauma and uncovering heretofore unaddressed feelings and thoughts

MEDICATION TRIAL

• Start low and go slow: Begin with low doses with gradual dose increases in the first few weeks, since initial high doses can exacerbate anxiety/arousal symptoms

• Week 3–4: Increase the dose if excellent response is not achieved

• If only partial response, push to maximal dose tolerated by patient• E.g., sertraline: 25mg increase to 50mg in 1 week, then up by

25/50mg every 1–2 weeks to maximum 200mg• E.g., paroxetine: 10–20mg up by 10–20mg every 2 weeks to

maximum 60mg

MEDICATION TRIAL

• Continue at maximal dose for 4–6 more weeks for a total of 8–12 weeks

• Treat for a minimum of one year

• If no response, then try another antidepressant

• If partial response, add other medications

WHAT TO TELL PATIENTS ABOUT ANTIDEPRESSANTSWHAT TO TELL PATIENTS ABOUT ANTIDEPRESSANTS

• They are not like antibiotics

• They are not addictive

• The response is gradual

• Take the medications daily (don’t double up if you miss a day)

• Keep taking the medications even if you feel better

• Keep track of side effects, and discuss these with health care providers

AVOID BENZODIAZEPINE MONOTHERAPY• They do not control or eliminate the core features

of PTSD

• They can interfere with the cognitive processing of the trauma necessary for psychotherapy to be successful

• No demonstrated benefit over placebo for PTSD-related sleep dysfunction

• Can produce dependence in PTSD patients who are prone to addiction

• Withdrawal may exacerbate PTSD symptoms

• Not recommended by VA/DoD Clinical Practice GuidelineBernardy, N., PTSD Research Quarterly,

2013

MANAGING PTSD-RELATED INSOMNIA

• Sleep hygiene: Decrease caffeine, alcohol, etc.

• Antihistamines: Diphenhydramine (25–50mg)

• Antidepressants: Low dose trazodone 50mg to 100mg after 1 week, up to 200mg

• Alpha-blocker: Prazosin, titrated up from 1–15mg, may reduce nightmares and insomnia; monitor BP and pulse

• Non-BZD: Zolpidem

SIDE EFFECTS AND MANAGEMENT*

Side effect Probability Management

Sedation +/- Bedtime dosing; caffeine

Anticholinergic(dry mouth/eyes, constipation)

+/- Hydration; sugarless gum; artificial tears; fiber

GI distress ++ Improves in 1–2 weeks; take with meals; try antacids or H2 blockers

*Adapted from RESPECT-Mil Primary Care Clinician’s Manual.

SIDE EFFECTS AND MANAGEMENT

Side effect Probability Management

Restlessness/jitters

+ Start low; reduce dose temporarily; propranolol 10mg b.i.d. or t.i.d.

Headache + Lower dose; Tylenol

Sexual dysfunction

++ Reduce dose; Viagra

Insomnia + Take in a.m.; low dose trazodone; zolpidem

MANAGEMENT BULLETSMANAGEMENT BULLETS

• SSRIs are the first line treatment

• Start low and go slow

• Combine other medications as needed

David Eisenman, MD, MSHS Director, UCLA Center for Public Health and DisastersAssociate Professor Medicine/Public Health at UCLARAND Associate Natural Scientist Preparedness Science Officer, Los Angeles County Department of Public Health

deisenman@mednet.ucla.edu

PC-PTSD: 4 ITEM SCREENER USED IN PRIMARY CARE AND AT THE VA

• In your life, have you had any experience that was so frightening, horrible, or upsetting that in the past month you:

• Had nightmares about it or thought about it when you didn’t want to?

• Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

• Were constantly on guard, watchful, or easily startled?

• Felt numb or detached from others or activities or surroundings?

• “Positive” if answers yes to any three.

Prins, Primary Care Psychiatry, 2003