New Approaches to Posttraumatic Stress Disorder

1. New Approaches to Posttraumatic Stress Disorder Robert K. Schneider, MD Assistant Professor Departments of Psychiatry and Internal Medicine The Medical College of Virginia of the Virginia Commonwealth University

2. 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

3. Diagnosis • Exposure of self or others to an “extreme” stressor (“the trauma”) • Avoidance • Re-experiences • Hyperarousal

4. Avoidance or Numbing • Avoidance of associated thoughts, feelings, activities, or places • Diminished interest • Detachment • Restricted range of affect

5. Re-experience the trauma • Flashbacks • Nightmares • Intrusive thoughts • Intense reaction when exposed to “triggers”

6. Hyperarousal • Sleep problems • Irritability • Hypervigilance • Exaggerated startle • Difficulty concentrating

7. Progression of symptoms - Blank • Acute stress disorder • Acute PTSD • Chronic PTSD • Delayed PTSD • Intermittent • Residual • Reactivated

8. Areas of focus tonight • Stressor Criterion & Non-Assaultive Trauma • The “Great Imposter” • Management Update

9. 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)

10. Trauma and PTSD in the community, The 1996 Detroit area survey of traumaBreslau 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%

11. 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%

12. 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%

13. Bullets • PTSD is a civilian disease • Non-assaultive trauma is a common and real stressor in the genesis of PTSD

14. The “Great Imposter” • Depression • Panic attacks • Substance abuse • Personality • Physical symptoms (somatization)

15. 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

16. 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

17. 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

18. 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%

19. Personality and PTSD • PTSD is very common but not universal in Borderline Personality Disorder • Early trauma associated • Repeated or chronic trauma associated

20. “Complex” PTSD - Herman • Occurs after prolonged and repeated trauma • Three broad areas of disturbance • Multiplicity of symptoms • Characterological changes • Repetition of harm

21. Bullet The most common diagnosis missed is the second diagnosis- Sir William Osler

22. Management • Treatments • Psychopharmacology • Psychotherapy • Setting • Specialty Mental Health • Primary Care

23. 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

24. 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

25. 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

26. Psychotherapies • Education and supportive • Cognitive therapy • Behavioral therapy (relaxation techniques) • Exposure therapy • EMDR (eye movement desensitization reprocessing)

27. 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

28. 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

29. 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

30. 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?