Post-Traumatic Stress Disorder

3. Post-Traumatic Stress Disorder Scott Grogan, DO, MBA, FAAFPMAJ, MC30 Aug 2013

4. Objectives • Applied & interpreted screening • Utilized PTSD diagnostic tool • Developed comfort with initiation of therapy and care plan

5. Take Home Points • “Right tool makes the job easy” • When in doubt, Anxiety d/o NOS • SSRIs are your friends

6. Your Responses • Limited experience with PTSD • Diagnosis challenging • Frustrating because suspect malingering for VA rating • Overall with PTSD: 100% uncomfy

7. Results • Principles of PTSD management • Screening &Dx • Prevention after trauma exposure • Pharmacotherapy • CBT

8. Case #1 • In small groups… • Read case • Discuss and answer questions • Be prepared to share 5Minutes

9. Screening • Who? • OTSG: All soldiers (RESPECT-Mil) • “Ask and you shall receive!” • What? • PC-PTSD (VA/DOD) • 4 questions; 2+ is positive

10. Diagnosis • Multiple inventories • Primary Care: PTSD checklist (PCL) • 19 questions if screen +

11. PTSD Checklist (PCL) ≥ 1 Re-experiencing (intrusion) ≥ 3 Avoiding ≥ 2 Hyperarousal • Score “Moderately” or above is + • Cut points vary; affect sens/spec

12. Timing Matters

13. BEWARE of AD!!!

15. BEWARE of AD!!! • $$ & stigma at stake; need to be sure • 50% VA disability rating • Anxiety d/o NOS • Assess risk, safety net, start treatment • Then REFER to BH!

16. BH Diagnosis • Mississippi Scale for Combat-Related PTSD - 35 questions • Personality Assessment Inventory • Self-report exam (1 hr) – 344 questions • Psych interview

17. Case #1 Revisited • In small groups… • Read case AGAIN • Discuss and answer questions AGAIN • Be prepared to share AGAIN 5Minutes

18. Principles of Therapy • Support • Risk assessment • Support • CBT • Support • Pharmacotherapy • Support

19. Establishing Rapport • Empathetic approach • Elicit preferences, listen reflectively • Emphasize autonomy in decisions • Pros, cons, & barriers to treatment • Support self-efficacy

20. Risk Assessment • TBI? • Substance abuse? • Weapons? • Suicidality/Homocidality? • Enlist help of family/friends

21. Evidence-based CBT • Prolonged exposure therapy (PE) • Cognitive processing therapy (CPT) • Eye movement desensitization and reprocessing (EMDR) • Stress inoculation training (SIT)

22. Pharmacotherapy • SSRIs most studied • Sertraline&paroxitine: FDA indications • Helps all three symptom clusters • DO NOT WAIT FOR PSYCH DX!!!

23. Adjunctive Therapies • Trazodone • Prazosin • Clonidine • Imagery Rehearsal Therapy • Reprogramming dreams

24. Expectation Management • Many get better with support • Frequent follow up • 12 weeks for full med effect • Follow PCL scores • Drop of ≥ 5 is adequate • <11 considered remission

25. Case #2 • In small groups… • Read case • Discuss & answer questions, role play • Be prepared to share 10 Minutes

26. My Challenge • Ask screening questions for BH disorders in clinic • “Ask and you shall receive!” • When precepting, ask about screening

27. Objectives • Applied & interpreted screening • Utilized PTSD diagnostic tool • Developed comfort with initiation of therapy and care plan

28. Take Home Points • “Right tool makes the job easy” • When in doubt, Anxiety d/o NOS • SSRIs are your friends