PTSD Pri Med Lecture - Institute for Health & Healing News

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Transcript PTSD Pri Med Lecture - Institute for Health & Healing News

Recovery from Traumatic Stress

Thomas C. Neylan, M.D.

University of California, San Francisco

History of Posttraumatic Stress Disorder Homer: Trojan War Veterans Civil War: Soldier’s Heart 19th Century Europe: Railroad Spine WW I: Shell Shock Vietnam War: Vietnam Syndrome 1976 Horowitz: Stress Response Syndromes 1980 DSM III: PTSD

Case Study

 29-year-old single women  Combat helicopter pilot from Iraq War  Shot down, and R shoulder rotator tear, and upper arm laceration  Recovered quickly from injury, but insisted on early retirement  Seeks help for poor sleep and irritability

Case Study (cont.)

What additional information would you want to obtain to evaluate her?

PTSD DSM-IV Criteria

Exposure to traumatic event with  Actual or threatened death or serious injury

and

 Response involving intense fear, helplessness, or horror American Psychiatric Association.

DSM-IV.

1994.

PTSD DSM-IV Criteria (cont.)

 Re-experiencing the traumatic event  Persistent avoidance of stimuli associated with event  Numbing of general responsiveness   Symptoms of increased arousal At least 1 month’s duration (otherwise can diagnose Acute Stress Disorder)  Significant distress or impairment in social, occupational, or other functioning American Psychiatric Association.

DSM-IV.

1994.

 7

PTSD

Associated Features  Alcohol/drug problems  Aggression/violence  Suicidal ideation, intent, attempts  Dissociation  Distancing  Problems at work  Marital problems  Homelessness

Epidemiology of PTSD National Comorbidity Study

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)  1/3 of cases have duration of many years  88% of cases have psychiatric comorbidity Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.

Combat-Related PTSD: Epidemiology Lifetime Prevalence:  30% in Vietnam veterans  5-10% of Gulf War I deployed veterans  10-20% in Operation Enduring Freedom and Operation Iraqi Freedom VIETNAM: Kulka RA, et al. Trauma and the Vietnam war generation: Report of the findings from the National Vietnam Veterans Readjustment Study. 1990, New York: Brunner/Mazel.

GULF WAR: Stretch RH et al. Military Medicine. 1996;161:407-410. IRAQ WAR: Hoge, C.W., et al. R.L. N Engl J Med. 2004;351:13-22.

Primary Psychiatric Disorder 6 Months Following Trauma

Responses to Trauma Are Heterogeneous 80 70 60 50 40 30 20 10 0

McFarlane, et al. Ann N Y Acad Sci. 1997;821:437-441

Longitudinal Course of PTSD Symptoms

94% 47% 42% ?

W 3m 9m

Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.

30% Years

Twelve-Month Prevalence of DSM-IV Major Psychiatric Disorders

% Mood Disorders

Major depressive episode Dysthymia Manic episode

Anxiety Disorders

Social Phobia Simple Phobia PTSD Agoraphobia without panic GAD Panic disorder

Substance Use Disorders

Alcohol abuse/dependence Drug abuse/dependence 6.7

1.5

2.6

4.4

1.8

6.8

8.7

3.5

0.8

3.1

2.7

Adapted from Kessler RC, et al. Arch Gen Psychiatry. 2005;62:617-627.

Prevalence of Trauma and Probability of PTSD

40 % 30 20 Prevalence of Trauma 1 10 0 % 70 60 50 40 30 20 10 0 Witness Accident Threat w/ Weapon Probability of PTSD Witness Accident Threat w/ Weapon

1. Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14. 2. Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060.

Physical Attack Physical Attack Molestation 2 Molestation Combat Combat Male Female Rape Rape

Risk Factors for PTSD

 Severity of trauma (ie, threat, duration, injury, loss)  Prior traumatization  Gender  Ethnicity  Prior mood and/or anxiety disorders  Family history of mood or anxiety disorders  Education

Screening Questions for PTSD

“What’s the worst thing that ever happened to you?” “How did you react when it happened?” “Do memories of _______ still bother you? Did you get over it?” “Do you avoid situations that might remind you of ____? Have your relationships suffered because of ____?” “Have you become more nervous since ___? Is it hard for you to relax because of ____?”

Functional Neuroanatomy of Traumatic Stress

Stress Parietal Cortex Orbitofrontal Cortex Prefrontal Cortex Extinction to fear through amygdala inhibition Hypothalamus Amygdala Conditioned fear Hippocampus Glutamate CRF Pituitary ACTH NE Cerebral Cortex Long-term storage of traumatic memories Attention and vigilance - fear behavior Dose response effect on metabolism Locus Coeruleus Output to cardiovascular system Adrenal Cortisol

PTSD Treatment Options

 Psychotherapy  Pharmacotherapy  Complementary Alternative Interventions – Yoga – Exercise – Meditation  Multimodal treatment

Early Post-Trauma Interventions

Crisis Interventions —Short cognitive behavioral therapy (CBT):  Psychological Debriefing —equivocal or harmful Cognitive Behavioral Prevention Programs:  Prolonged Exposure (PE)  Prolonged Exposure + Stress Inoculation Training (PE/SIT) Psychotherapy  Brief dynamic psychotherapy for traumatic grief   Supportive counseling Spiritual counseling Pharmacotherapy  Propranolol Foa EB, et al.

J Clin Psychiatry.

1999;60(suppl 16):1-34. Mitchell JT. JEMS. 1983;8:36-9.

Psychological Treatments for Chronic PTSD

Psychotherapy  Exposure therapy   Cognitive processing therapy Anxiety management Additional treatments  Eye Movement Desensitization and Reprocessing (EMDR)    Hypnotherapy Psychodynamic therapy Expressive therapies

Meta-analysis of Pharmacotherapy for PTSD 35 RCTS with 17 positive placebo-controlled trials Medication response in 59.1% Placebo response in 38.5% SSRIs most effective Medication effects greater for co-morbid depression and disability 3 maintenance trials suggest long-term medication

Adrenergic-Inhibiting Agents:

Alpha

1

-Adrenergic Blockers

Prazosin* 7 to 15 mg qhs Alpha 1 - post-synaptic adrenoceptor receptor antagonist Alpha 1 receptors widely distributed in the brain, including the amygdala and hippocampus Alpha 1 receptors modulate sleep and startle responses Double-blind RCT in 40 veterans, 13.3 +/- 3 mg –

1

Robust improvement in sleep quality and distressing dreams – Medium to large effect size in each PTSD Sx cluster – Adverse reactions include: syncope, dizziness, drowsiness, decreased energy, headache *Not FDA approved for the treatment of PTSD 1. Raskind, et al. Biol Psychiatry. 2007; 61: 928-34.

Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami.

Descilo T , Vedamurtachar A , Gerbarg PL , Nagaraja D , Gangadhar BN , Damodaran B , Adelson B , Braslow LH , Marcus S , Brown RP .

The Trauma Resolution Center of Miami, Miami, FL, USA Acta Psychiatr Scand. 2009 Aug 19. [Epub ahead of print]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(1), 17--33 (2010)

Exercise and Neurogenesis?

Growth factor signaling genes Growth factor signaling genes upregulated by exercise VGF involved in energy balance & synaptic activity; increased by ECS Sedentary Exercise Exercise increases VGF mRNA in the hippocampus

Slide adapted from D. Shin

Summary:

Recommendations for Immediate Management

Move to safety and reduce terrifying arousal Psychological First Aid – Low arousal, facilitate cognitive processing Education and support Emphasize need to sustain interpersonal connections Screening for risk factors and follow up