Post-Traumatic Stress Disorder - Primary Care Network · Post-Traumatic Stress Disorder: It’s Not...

Post-Traumatic Stress Disorder: It’s Not Just Stressed Combat Veterans

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Post-Traumatic Stress DisorderIt’s Not Just Stressed Combat Veterans

Brian Koffman, MDCM, DCFP, DABFM, MS Ed

Chief Medical Officer, CLL Society (CLLSociety.org)

Retired Clinical Professor

Department of Family Medicine

Keck School of Medicine, USC Family Practice

Learning Objectives

▪ Consider PTSD when seeing patients with anxiety,

depression, sleep disorders or substance abuse

especially when there is avoidance behavior,

hyperarousal, nightmares or intrusive thoughts

▪ Choose appropriate pharmacotherapy to match the most

disturbing symptoms

▪ Use psychotherapy to help extinguish the recurring fear

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Normal versus Pathologic Anxiety

▪ Normal anxiety is adaptive. It is an inborn response

to threat or to the absence of people or objects that

signify safety and can result in cognitive (worry) and

somatic (racing heart, sweating, shaking, freezing,

etc.) symptoms

▪ Pathologic anxiety is anxiety that is excessive,

impairs function or in the case of PTSD is unrelated

to the present circumstances

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Anxiety vs. Fear

▪ Anxiety

▪ Apprehension about a future threat

▪ Fear

▪ Response to an immediate threat

▪ Both involve physiological arousal

▪ Sympathetic nervous system

▪ Both can be adaptive

▪ Fear triggers “fight or flight”

▪ May save life

Anxiety vs. Fear

▪ Anxiety increases preparedness

▪ “U-shaped” curve (Yerkes & Dodson, 1908)

▪ Absence of anxiety interferes with performance

▪ Moderate levels of anxiety improve performance

▪ High levels of anxiety are detrimental to performance

Yerkes RM, Dodson JD (1908). "The relation of strength of stimulus to rapidity of habit-formation". Journal of Comparative Neurology and Psychology.

18 (5): 459–482. doi:10.1002/cne.920180503.

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Fear vs. Anxiety

FEAR ANXIETY

Basic Emotion Generalized mood state

Noncognitive or elementary/automatic cognitions Cognitive and complex cognitions

Brief/discrete Long/chronic

Depending on the moment Dependent on the learning experiences

Distinct physiology Diffuse physiology

Instantaneous response necessary for survival Plan and prepare for challenge and threat

Response to imminent threat Response to future threat

Intense autonomic arousal Less autonomic arousal

Visual processing/imagery Verbal processing/worry

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Anxiety Disorders (DSM-5)

▪ Specific Phobia

▪ Social Anxiety Disorder (Social Phobia)

▪ Panic Disorder

▪ Agoraphobia

▪ Generalized Anxiety Disorder

▪ Substance/Medication-Induced Anxiety Disorder

▪ Anxiety Disorder Due to Another Medical Condition

PLEASE NOTE THAT PTSD IS NOT INCLUDED

DSM-5 New Category

Trauma and Stressor - Related Disorders

▪ Post-Traumatic Stress Disorder (> 1 month)

▪ Acute Stress Disorder (< 1 month)

▪ Adjustment Disorders

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Post-Traumatic Stress Disorder

▪ Has experienced or witnessed or was confronted

with an unusually traumatic event that has both of

these elements:

▪ Event involved actual or threatened death or serious

physical injury to the person or others

▪ Felt intense fear, horror or helplessness

Old Problem - New Name

▪ PTSD - known to previous generations as nostalgia, shell

shock, soldier’s heart, battle fatigue or war neurosis

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Case Study - Susan

▪ 29 yr old female seen at the urging of her fiance. A nurse with a local Marine Reserve unit who was honorably discharged in 2018 after serving two tours of duty in Afghanistan

▪ “Not been the same” since her 2nd tour of duty and it is impacting their relationship

▪ Offers few details, but upon questioning she reports that has difficulty sleeping, “sleeps with one eye open” and she has nightmares

▪ She confirms experiencing several traumatic events during her second tour but is unwilling to provide specific details

▪ She has never spoken with anyone about them and she is not sure she ever will

Case Study - Susan

▪ Spends much of her time alone as she’s irritable with friends

▪ Easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home

▪ Intrusive memories about her traumatic experiences on a nearly daily basis but declines to share any details

▪ Avoids seeing friends from her reserve unit because seeing them reminds her of experiences

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Case Study - Susan

History of trauma

▪ Hypervigilance

▪ Intrusive thoughts

▪ Irritability

▪ Loss of interest

▪ Sleep difficulties with nightmares

A Psycho-Neuro-Endocrine Disorder

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Development of PTSD

psychscene.com; psychscenehub.com

PTSD Myths

1. You have it or you don’t

▪ There are mild and severe cases

2. Almost everyone returning from combat zone has it

▪ Most exposed to combat do not

3. Only affects those in direct combat

▪ Affect noncombat military and civilians

4. Only affects veterans

▪ Any trauma exposure is a potential trigger of PTSD

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http://psychscene.com/

http://psychscenhub.com/


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Vets Consult Civilian PCPs

▪ PTSD in Combat Veterans

▪ 20% of ∼ 5 million or 1,000,000 PTSD patients

▪ Vietnam

▪ Middle East

▪ Others & non-combat

▪ But what about the VA?

▪ Not eligible

▪ No desire to go -- prior experiences, word of mouth/ finances/

appointments/ changes in staff

Ramchand R et al. J Trauma Stress. 2010;23:59-68.

Tanielian T, Jaycox LH, eds. Invisible Wounds of War Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.

Santa Monica, CA: Rand Corp.;2008.

Likelihood of Getting PTSDafter Experiencing Trauma

▪ It depends on the event and the person

▪ Men experience more traumatic events

▪ Women are more likely to develop PTSD

▪ Gender is a factor in who gets PTSD

▪ 20% of women

▪ 8% of men

Kessler RC1, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry.

1995 Dec;52(12):1048-60.

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Likelihood of PTSD (con’t)Gender is important again

▪ Rape

▪ Men 65%

▪ Women 45%

▪ Combat

▪ Men 20% returning from Iraq and Afghanistan

▪ Physical Abuse

▪ Almost 50% of women

▪ 20%+ men

What puts you at risk for PTSD?

▪ Strength or severity of the stressor

▪ Characteristics of the trauma:

▪ Greater perceived life threat

▪ Feeling helpless

▪ Unpredictable, uncontrollable

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Risk for PTSD: After the Trauma

▪ Degree of Social

Support

▪ Degree of Life Stress

More than War Veterans

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Problems in Recognizing PTSD

▪ Patients commonly report only certain symptoms

▪ Insomnia, irritability, pain, sexual dysfunction, GI distress, dizziness,

headaches, hypertension or other cardiovascular symptoms, lack of

concentration, alcohol or other substance abuse related problems...

▪ Often FAIL to report traumatic experience

PTSD: Screening with DSM-5

Description

▪ The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a 5-item screen designed to identify individuals with probable PTSD. Those screening positive require further assessment, preferably with a structured interview.

Scoring

▪ Preliminary results from validation studies suggest that a cut-point of 3 on the PC-PTSD-5 (e.g., respondent answers "yes" to any 3 of 5 questions about how the traumatic event(s) have affected them over the past month) is optimally sensitive to probable PTSD. Optimizing sensitivity minimizes false negative screen results. Using a cut-point of 4 is considered optimally efficient. Optimizing efficiency balances false positive and false negative results. As additional research findings on the PC-PTSD-5 are published, updated recommendations for cut-point scores as well as psychometric data will be made available.

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DSM-5 (con’t) If yes to a traumatic event, then ask:

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Diagnosis (modified DSM-5)

A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:

1. Directly experiencing the traumatic event(s)

2. Witnessing, in person, the event(s) as it occurred to others

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (eg, first responders collecting human remains; police officers repeatedly exposed to details of child abuse)

Note: Criterion A4 does not apply to exposure through electronic media, television,

movies, or pictures, unless this exposure is work related.

Diagnosis (con’t)

B. Presence of one or more of the following intrusive

symptoms associated with the traumatic event(s),

beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories

of the traumatic event(s)

2. Recurrent distressing dreams in which the content and/or

affect of the dream are related to the traumatic event(s)

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Diagnosis (con’t)

B. (con’t)

3. Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

Diagnosis (con’t)

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

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Diagnosis (con’t)

D. Negative thoughts and mood associated with the traumatic event(s),

beginning or worsening after the traumatic event(s) occurred, as

evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to

dissociative amnesia and not to other factors such as head injury, alcohol, or drugs)

2. Persistent and exaggerated negative beliefs or expectations about oneself, others,

or the world, for example:

- "I am bad''

- "The world is completely dangerous"

- "My whole nervous system is permanently ruined"

3. Persistent, distorted cognitions about the cause or consequences of the traumatic

event(s) that lead the individual to blame himself/herself or others

Diagnosis (con’t)

D. (con’t)

4. Persistent negative emotional state (eg, fear, horror, anger, guilt, or shame)

5. Markedly diminished interest or participation in significant activities

6. Feelings of detachment or estrangement from others

7. Persistent inability to experience positive emotions (eg, inability to experience happiness, satisfaction, or loving feelings)

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Diagnosis (con’t)

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects

2. Reckless or self-destructive behavior

3. Hypervigilance

4. Exaggerated startle response

5. Problems with concentration

6. Sleep disturbance (eg, difficulty falling or staying asleep or restless sleep)

Diagnosis (con’t)

F. Duration of the disturbance is > 1 month

G. The disturbance is clinically significant, causes distress

and affects important functions

H. There is no other cause - medical, substance or

psychiatric

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Acute Stress Reaction

▪ Symptoms of post-traumatic stress and functional

impairment after traumatic event(s) are diagnosed

acute stress disorder (ASD) for the first 30 days

▪ Most people fully recover

▪ For those who don’t after 30 days, re-diagnosed

as PTSD

Clinician-Administered PTSD Scale(CAPS-5) for DSM-5

The CAPS is the gold standard, a 30-item structured interview to:

1. Make current (past month) diagnosis of PTSD

2. Make lifetime diagnosis of PTSD

3. Assess PTSD symptoms over the past week

Assesses the 20 DSM-5 PTSD symptoms plus targets

▪ Onset and duration of symptoms

▪ Subjective distress

▪ Impact of symptoms on social and occupational functioning, improvement in symptoms

▪ Overall response validity

▪ Overall PTSD severity

▪ Specifications for the dissociative subtype (depersonalization and derealization)

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Implications of PTSD

▪ Greater unemployment

▪ Relationships

▪ Health problems

▪ Violence

▪ Generally worse quality of life

Common Co-occurring Psychiatric Conditions

▪ 80% of people with PTSD have another diagnosis

▪ Depression

▪ Anxiety disorders

▪ Generalized, panic, social phobia

▪ Substance abuse disorders

▪ OCD variant

OCD, obsessive-compulsive disorder

Kessler R, et al. Arch Gen Psychiatry. 1995;52:1048–1060.

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PTSD and Alcohol

▪ The prevalence of comorbid alcohol misuse in those with

PTSD ranged from 9.8% to 61.3%

▪ The prevalence of comorbid PTSD in those with alcohol

misuse ranged from 2% to 63%

▪ Majority of prevalence rates were over 10%

▪ Alcohol misuse associated with

▪ Avoidance/numbing symptoms

▪ Hyperarousal symptoms

Nicola Fear et al, A systematic review of the comorbidity between PTSD and alcohol misuse, 2014.

Common Comorbid Medical Problems

▪ Cardiovascular

▪ Headaches, chronic pain

▪ Metabolic, immune disorders

▪ Traumatic brain injury (TBI)

Sareen J, et al. Psychosom Med. 2007;69:242-248.

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Suicide Risk Factors

▪ Relationship issues -- feels alone, hopeless, helpless

▪ Seeing no way out and fearing things will get worse --

family, finance, and more

▪ Person is anxious, agitated, and has severe insomnia

▪ Judgment is impaired by use of alcohol or other

substances

▪ Weapons are easily accessible

Suicide Prevention

▪ Ask about suicidal thoughts and plans and ask again

▪ Involve support system

▪ Discontinue substances of abuse

▪ Remove weapons where possible

▪ Suggest Suicide Hotline: 1-800-273-TALK/8255

▪ Written contract no self harm

▪ Refer

▪ Document

U.S. DHHS. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: HHS, September 2012.

https://www.integration.samhsa.gov/health-wellness/wellness-strategies/2012_National_Strategy_for_Suicide_Prevention.pdf Accessed February 18, 2020

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Stepwise Treatment Model:Stage 1 Safety

1. Suicide and homicide prevention

2. Harm reduction for risky behaviors

3. Teach positive coping tools

▪ Anger management

▪ Stress management

Important Reason to Treat: Condition Affects Most Areas of a Person’s Life

▪ Self esteem

▪ Relationships

▪ Employment & education

▪ Finances

▪ Legal status

▪ Health

▪ Others

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Treatment Recommendations

Types of Treatment

▪ Psychotherapy

▪ Pharmacotherapy

Foa EB, Keane TM, Friedman MJ, Cohen JA, eds. Effective treatments for PTSD: Practice guide-lines from the International Society for Traumatic Stress

Studies. 2nd ed. New York, NY: Guilford Press;2008.

Basic Principles of Effective Treatment

▪ Understand and ACCEPT they have PTSD

▪ Understand and ACCEPT treatment plan

▪ Actively participate in treatment

▪ Recognize that medication alone is generally not

adequate treatment

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Treatment for PTSD

▪ Cognitive Behavioral Treatments most effective

psychotherapy treatments

▪ Medication can be an effective treatment

▪ Most evidence for Cognitive Processing Therapy (CPT)

and Prolonged Exposure (PE)

▪ Most evidence for SSRIs and prazozin

PTSD Theory Behind Psychotherapy

Most individuals have symptoms of re-experiencing, avoidance, and hyperarousal following severe trauma

For most these symptoms resolve over time

For PTSD they don’t

PTSD is a failure of fear extinction following trauma

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Cognitive Based Therapies

▪ Diminishes the link between

imposed meanings and a fearful

emotional state

▪ Changes patient’s thinking about

the trauma and themselves to be

more rational and realistic

▪ The Socratic method is used to

challenge maladaptive beliefs

and thus reduce symptoms

Exposure Based Therapies

▪ Exposure therapy involves

confronting feared memories

and situations in a safe and

therapeutic setting

▪ Re-experiencing trauma

allows it to be emotionally

processed so that it can

become less painful and

see they are not dangerous

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Virtual Exposure

Prolonged Exposure (PE)

PTSD therapy that works – therapy begins with education on PE, its goals, and what to expect at each treatment stage

▪ Learning to maintain even breathing when dealing with traumatic memories can aid treatment immensely. Deep breaths can reduce distress and anxiety

▪ Talking about traumatic memories repeatedly with a therapist can help make sense of what happened and help control emotions and thoughts linked to that trauma. A therapist might advise easing into traumatic memories by first discussing less troubling ones

▪ Repeated voluntary exposure to real-world situations that might be avoided due to trauma can lessen the distress they cause

▪ Repetitive recall of memories linked to trauma can help change reactions to traumatic memories when done in a safe place. This can help to cope with distressing memories

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CPT & PE PTSD: Long Term Effect in Female Rape Victims

0

20

40

60

80

100

Pre 5+ Years

% M

eet

ing

PTS

D D

iagn

ost

ic C

rite

ria

(CA

PS)

CPT (n=63)PE (n=64)

A Comparison of Cognitive-Processing Therapy With Prolonged Exposure and a Waiting Condition for the Treatment of Chronic Posttraumatic Stress

Disorder in Female Rape Victims Patricia A. Resick,et al.

Eye Movement Desensitization and Reprocessing (EMDR)

▪ Like CBT but also incorporates saccadic eye movements with

substituting more positive link

▪ Patient relives a scene from the trauma while the therapist

repeatedly moves two fingers across the patient’s visual field and

instructs the patient to track the fingers until anxiety decreases

▪ The patient is then instructed to generate a more adaptive thought

COCHRANE REVIEW

No difference in efficacy between CBT and EMDR and both

are effective therapies for PTSD

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Other Psychotherapies for PTSD(less data)

▪ Interpersonal psychotherapy

▪ Deals with relationships affected by PTSD

▪ Mindfulness-based therapy, yoga, stress reduction

▪ Live in the moment

▪ ACT (Acceptance and Commitment Therapy)

▪ Teaching acceptance and accompanying behavioral changes

▪ MDMA

▪ Using MDMA as a catalyst of PTSD-specific psychotherapy

MDMA = methylenedioxy-methylamphetamine

Ecstatic Segue to Pharmacotherapy

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Medications

▪ First line SSRI and SNRI

▪ FDA approved: sertraline and paroxetine

▪ Prazosin – useful for nightmares

▪ Other antidepressants

▪ Atypical antipsychotics (with care)

▪ Mood stabilizers

▪ Propranolol

Avoid Benzodiazepines if possibleMay interfere with learning from other therapies

Jeffreys M, et al. J Rehabil Res Dev. 2012;49:703-715.

SSRIs

▪ Paroxetine start at 10 - 20 mg/day

▪ If little or no response is seen after 4 weeks, increase with 10 to 20 mg/day increments with 2 weeks between increases

▪ Max 60 mg/day

▪ Sertraline start at 25 or 50 mg/day

▪ If little or no response is seen after 4 weeks, increase with 25 to 50 mg/day increments with 2 weeks between increases

▪ Max 250 mg/day

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Second-generation Antipsychotics

▪ Quetiapine may help as monotherapy

▪ Little efficacy as augmentation to SSRIs alone

▪ Serious side effects

▪ Suicidal thoughts and behavior

▪ Neuroleptic malignant syndrome

▪ Tardive dyskinesia: potentially irreversible

▪ Cerebrovascular adverse reactions, including stroke, in elderly

patients with dementia-related psychosis

Villarreal G, Hamner MB, Canive JM, et al. Efficacy of Quetiapine Monotherapy in Posttraumatic Stress Disorder: A Randomized, Placebo-Controlled

Trial. Am J Psychiatry 2016; 173:1205.


Serious side effects (con’t)

▪ Metabolic

▪ Hyperglycemia

▪ Increased cholesterol and triglycerides

▪ Weight gain

▪ Orthostatic hypotension and falls

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Serious side effects (con’t)

▪ Leukopenia, Neutropenia, and Agranulocytosis

▪ Cataracts

▪ Seizures

▪ QT Prolongation

▪ Dysphagia and dysarthria

▪ Anticholinergic (antimuscarinic) effects

Prazozin

▪ Alpha 1 blocker used mainly for sleep and nightmares

▪ Meta-analysis showed benefit effects in reducing overall

PTSD symptoms and nightmares and improving sleep

▪ Start at 1 mg hs and slowly increase

▪ Max 15 mg

▪ Side effects include orthostatic hypotension

▪ Taper off to avoid rebound hypertension

Khachatryan D, Groll D, Booij L, et al. Prazosin for treating sleep disturbances in adults with posttraumatic stress disorder: a systematic review and meta-

analysis of randomized controlled trials. Gen Hosp Psychiatry 2016; 39:46.

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Other Medication (less data)

▪ Propranolol for revived memories

▪ Promising early results

▪ TCAs, trazadone and mirtazapine

▪ Little data

▪ Mood stabilizers

▪ Topiramate or tiagabine or divalproex not better than placebo

▪ Ketamine

▪ Clinically meaningful reduction in PTSD

▪ Cannabis

▪ Associated with worse treatment outcomes

Steenen SA, et al. Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis. J Psychopharmacol 2016; 30:128. Davidson JR, et al.

The efficacy and tolerability of tiagabine in adult patients with post-traumatic stress disorder. J Clin Psychopharmacol 2007; 27:85. Tucker P, et al. Efficacy and safety

of topiramate monotherapy in civilian posttraumatic stress disorder: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry 2007; 68:201. Lindley SE,

Carlson EB, Hill K. A randomized, double-blind, placebo-controlled trial of augmentation topiramate for chronic combat-related posttraumatic stress disorder. J Clin

Psychopharmacol 2007; 27:677.

Possible Causes of Treatment Resistance

▪ Inadequate dosage

▪ Side effects

▪ Poor compliance

▪ Adverse life events

▪ Ongoing or re-traumatization

▪ Loss of social support

▪ Drug interactions

Jackson C, et al. Treatment for complex PTSD. In: Sookman D, Leahy RL, eds. Treatment resistant anxiety disorders. New York, NY:

Taylor & Francis Group;2010.

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VA/DoD PTSD Treatment Guidelines

Pharmacotherapy Interventions for Treatment of PTSD: Balance of Benefit and Harm

SR (Strength of Recommendation Rating)

A(Strong Recommendation)

B (Fair Evidence)

C(No Recommendation)

D(Ineffective or Harmful)

I(Insufficient Evidence)

Significant Benefit

• SSRIs–Fluoxetine

Sertraline

Paroxetine

• SNRI–Venlafaxine

Some Benefit

• Mirtazapine

• Prazosin

(Use For sleep/

nightmares)

• TCAs

• Nefazodone

[Use caution]

• MAOIs

(Phenelzine –

attention to drug-

drug and dietary

interactions)

Some Benefit

• Citalopram

Unknown

• Prazosin

(For global PTSD)

No Benefit

Benzodiazepines

(Harm)

Tiagabine

Guanfacine

Valproate

Topiramate

Risperidone

Unknown

• Olanzapine and

Quetiapine

• Conventional

antipsychotics

• Buspirone

• Non-Benzodiazepine

sedative/hypnotics

• Bupropion

• Trazodone (Adjunctive)

• Gabapentin

• Lamotrigine

• Propranolol

• Clonidine

Dept Veteran Affairs. VA/DoD Clinical Practice Guidelines. http://www.healthquality.va.gov/post_traumatic_stress_disorder_ptsd.asp Accessed February 4, 2020.

“And Finally, I Want You to Know...”

▪ The condition from which you suffer has a name -- PTSD -- and it is as

real as any other injury

▪ It has a biological basis, and is not something about which you should

be ashamed

▪ You were not born with it, nor did you bring it on yourself

▪ You cannot -- think it, self-talk it, or pray it away

▪ But you can recover from it by getting a realistic understanding of what it

is, and by participating fully in valid and effective treatment

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Post-Traumatic Stress Disorder - Primary Care Network · Post-Traumatic Stress Disorder: It’s Not...

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