Post traumatic stress disorder Jeff Clothier, M.D.
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Transcript of Post traumatic stress disorder Jeff Clothier, M.D.
Post traumatic stress disorder
Jeff Clothier, M.D.
PTSD
Overview
Epidemiology Diagnosis Psychiatric Comorbidity Treatment
PTSD DSM-IV Criteria
Exposure to traumatic event withActual or threatened death or serious injury
andResponse involving intense fear, helplessness, or horror
American Psychiatric Association. American Psychiatric Association. DSM-IV.DSM-IV. 1994. 1994.
PTSD DSM-IV Criteria (cont.)
Re-experiencing the traumatic eventPersistent avoidance of stimuli associated with eventNumbing of general responsivenessSymptoms of increased arousalAt least 1 month’s duration (otherwise can diagnose
Acute Stress Disorder)Significant distress or impairment in social,
occupational, or other functioning
American Psychiatric Association. American Psychiatric Association. DSM-IV.DSM-IV. 1994. 1994.
PTSDAssociated Features
Alcohol/drug problemsAggression/violenceSuicidal ideation, intent, attemptsDissociationDistancingProblems at workMarital problemsHomelessness
Lifetime Prevalence of DSM-III-RMajor Psychiatric DisordersNCS Data
Mood Disorders
Major depressive episode 17.1Dysthymia 6.4Manic episode 1.6
Anxiety DisordersSocial Phobia 13.3Simple Phobia 11.3PTSD 7.8Agoraphobia without panic 5.3GAD 5.1Panic disorder 3.5
Substance Use DisordersAlcohol abuse/dependence 23.5Drug abuse/dependence 11.9
Adapted from Kessler et al. 1994, 1995.Adapted from Kessler et al. 1994, 1995.
%%
Function and Quality of Life In Vietnam Veterans With and Without PTSD
Pe
rcen
t
Not Working
PhysicalLimitation
ReducedWell-Being
Fair orPoor
Health
Zatzick DF et al. Zatzick DF et al. Am J PsychiatryAm J Psychiatry. 1997;154:1690–1695.. 1997;154:1690–1695.
Violent BehaviorPast Year
PTSDPTSD
Non-PTSDNon-PTSD
PTSD
Risk Factors for PTSD
Severity of trauma (ie, threat, duration, injury, loss)Prior traumatizationGenderPrior mood and/or anxiety disordersFamily history of mood or anxiety disordersEducation
PTSD risks
Epidemiologically, there are two other risk The risk of having a trauma exposure The risk for developing PTSD from that
exposure Has implications for public health policies
Risks of Specific Traumasin the US Population
Pe
rcen
tag
e
Natural Disaster
RapeCombatCriminalAssault
MenMen
WomenWomen
Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1048–1060.. 1995;52:1048–1060.
About 30% of people exposed to trauma developed PTSD
PTSD
Rates Related to Specific Traumas
Pe
rce
nta
ge
Natural Disaster
RapeCombatCriminalAssault
MenMen
WomenWomen
Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1048–1060.. 1995;52:1048–1060.
0
25
50
75
100
1 2 3 4 5 6 7 10
PTSD
Persistence Over Time
Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1048–1060.. 1995;52:1048–1060.
Years
% W
ith
ou
t R
eco
very
(Untreated Group)
PTSD
Impact of Treatment on Recovery
Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1057.. 1995;52:1057.
640 36
Treated
Untreated
Median Months to Recovery
(N = 459)
Biological Correlates of Chronic PTSD
Increased sympathetic responses to trauma reminders Normal resting catecholamines with increased responses
to trauma stimuli Decreased cortisol. Excessive feedback inhibition. Increased free T3 and T4 Insomnia and increased # of rapid eye movements during
REM sleep Possible reduction in hippocampal volume?
Epidemiology of PTSD
7.8% of adults in the U.S. (lifetime) Type of trauma most often the basis for
PTSD - rape in women (46% risk) combat in men (39% risk)
one third of cases have duration of many years
88% of cases have psychiatric comorbidity
Kessler et al., 1995
Depression 48 12 48 19
Mania 12 1 6 1
Panic Disorder 7 2 13 4
Social Phobia 28 11 28 14
GAD 17 3 15 6
Alcohol Abuse/Dependency 52 34 28 13
Substance Abuse/Dependency 34 15 27 8
Any Diagnosis 88 55 79 46
Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995. 1995
Lifetime Rates (%)
Men Women
PTSD Non-PTSD PTSD Non-PTSD
PTSD
Psychiatric Comorbidity
PTSD comorbidity
Patient usually has other psychiatric disorders
“Ticks and fleas”
Makes treatment difficult More deadly
0
20
40
60
80
Impact of Comorbid PTSD in Subjects With Other Anxiety Disorders
(%)
Ra
tes
38
48
30
6
30
21
AlcoholProblems
HospitalizedAttemptedSuicide
Anxiety DisorderAnxiety DisorderWith PTSDWith PTSD
Anxiety DisorderAnxiety DisorderWithout PTSDWithout PTSD
Warshaw MG et al. Warshaw MG et al. Am J PsychiatryAm J Psychiatry. 1993;150:1512–1516.. 1993;150:1512–1516.
PTSD
Treatment Options
PsychotherapyPharmacotherapyMultimodal treatment
Expert Consensus Guidelines
J Clin Psychiatry, ‘99
Noncomorbid children, adults, geriatric patients
Psychotherapy first
Comorbidpopulation
Psychotherapy firstor combine
meds/psychotherapy
Mild PTSD
More severe
Combine meds/psychotherapy
from start
Considerations for psychotherapy
Capacity to tolerate distress with exposureMotivation/preferenceAbility to participate and follow structureProblems with interpersonal adjustment
Treatment of PTSD by Exposureand/or Cognitive Restructuring
Marks I et al. Marks I et al. Arch Gen PsychiatryArch Gen Psychiatry. 1998;55:317–325.. 1998;55:317–325.
IES
Sco
res
Treatment1 mo 3 mos 6 mos
r = relaxationc = cognitive restructuringe = prolonged exposureec = e + c
rr
cc
ecec
ee
Follow Up
PTSD
Goals of Pharmacotherapy Reduction/amelioration of target symptoms
Improve sleep Affects improvement in other symptoms (eg, irritability, preoccupation,
vigilance, impaired concentration) Decreased risk for development of comorbidity
Reduce re-experiencing and intrusive symptomsImprove mood and numbingReduce phasic and tonic hyperarousalReduce impulsivityReduce psychotic or dissociative symptoms
Davidson and van der Kolk, 1996.Davidson and van der Kolk, 1996.
Pharmacologic treatment
Multiple conditions Medical comorbidities Side effects from one treatment may impact
other symptoms and medications.
PTSD
Medications Studied
BenzodiazepinesAntidepressants
TCAs MAOIs SSRIs 5-HT2 antagonists
Anticonvulsants/antipsychoticsNoradrenergic agents: clonidine, propranolol
4040
100100
00
2020
8080
FluoxetineFluoxetine
Van der Kolk BA et al. Van der Kolk BA et al. Prim CarePrim Care. 1993;20:417–432.. 1993;20:417–432.
CA
PS
T
ota
l Sc
ore
Effect of Trauma Population
PTSD Treatment With SSRIs
Effect of Fluoxetine
PlaceboPlacebo
PrePre PostPost
6060
Trauma Clinic (n = 23)PrePre PostPost PrePre PostPost
VA (n = 24)PrePre PostPost
Sertraline Efficacy in PTSD
-40
-35
-30
-25
-20
-15
-10
-5
0
SertralinePlacebo
(N=187)
*
*
†
*p<0.05; †p=0.07; Brady et al, JAMA, 2000
DTSIESCAPS-2
PTSD and Comorbid Depression: Sertraline Studies
PTSD with No ComorbidDepressive Disorder
PTSD with ComorbidDepressive Disorder
Per
cen
t R
esp
on
der
s*
0
10
20
30
40
50
60
70
80
Sertraline(N=104)
Placebo(N=112)
Sertraline(N=87)
Placebo(N=82)
*Response is defined as CGI=I score of 1 (very much improved) or 2 (much improved) at end point Brady et al., 2000, Davidson et al. , 1998
56.7%
40.2%
60.9%
37.8%
p=0.0034p=0.011
Quality of Life In PTSD
0
2
4
6
8
10
12
14
Total Scores*
Ch
ang
e in
Q-L
ES
-Q
Sertraline
Placebo
Sertraline vs. Placebo• Subscales all p0.05
– Mood – Social relationship – Leisure time – Ability to fix – Living/housing – Physical ability– Work/hobby
*p0.004, Brady et al., 2000
8080
7070
6060
5050
4040
3030
2020
1010
00BaselineBaseline
Sertraline in PTSD: The Effect of Continuation Treatment with Sertraline
Week 12Week 12 Week 20Week 20 Week 28Week 28 Week 36Week 36 Endpoint(LOCF)
Endpoint(LOCF)
Acute Phase Continuation Phase Acute Phase Continuation Phase
CAPS-2Total Score
CAPS-2Total Score
Londborg, APA/CINP 2000
5HT2 antagonists
1. Trazodone – commonly used for sleep, may reduce nightmares
2. Cyproheptadine – reports of improved sleep with decreased nightmares as well, appetite stimulant as well. (Pharmacologically rich compound)
Anti-Psychotic Agents
• Not first-line but often required in difficult cases
• Indications:– Reduce disorganizing hyperarousal, paranoid ideation,
and aggressive impulsivity– Co-morbid psychotic disorder– Low doses are often effective– Atypical agents preferred
Mood Stabilizers
• Carbamazepine– Open clinical trial: decreased intrusions, flashbacks,
insomnia, irritability, impulsivity, and violent behavior (Lipper et al., Psychosomatics, 1986)
• Valproic acid – Open trial: decreased hyperarousal and avoidance (Stein, J
Clin Psych, 1995)
• Lamotrigine– Small controlled trial: decreased re-experiencing,
numbing and avoidance (Hertzberg et al., Biol Psychiatry, 1999)
Immediately after exposure: Normalize distress Educate patient, family and significant others Repeated retelling of the event Provide emotional support Relieve irrational guilt Refer to peer support group or trauma counseling Consider short-term sleep medication for insomnia
Foa, Davidson, Frances, J Clin Psychiatry 1999
Early Intervention and Prevention
Recommendations for Early Intervention and Prevention
PTSD
SummaryPTSD is common Usually chronic Presentations vary Comorbidity is the ruleComprehensive assessment of patients is
critical to develop an individualized treatment planTreatment often involves multiple modalities