Transcript TAKE TIME TO TALK” - Virginia Commonwealth University

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
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
Diagnosis
• Exposure of self or others to an “extreme”
stressor (“the trauma”)
– Avoidance
– Re-experiences
– Hyperarousal
Avoidance or Numbing
• Avoidance of associated thoughts, feelings,
activities, or places
• Diminished interest
• Detachment
• Restricted range of affect
Re-experience the trauma
• Flashbacks
• Nightmares
• Intrusive thoughts
• Intense reaction when exposed to “triggers”
Hyperarousal
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Sleep problems
Irritability
Hypervigilance
Exaggerated startle
Difficulty concentrating
Progression of symptoms - Blank
• Acute stress disorder
• Acute PTSD
• Chronic PTSD
• Delayed PTSD
• Intermittent
• Residual
• Reactivated
Areas of focus tonight
• Stressor Criterion & Non-Assaultive Trauma
• The “Great Imposter”
• Management Update
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 DSMIIIR)
Trauma and PTSD in the community,
The 1996 Detroit area survey of trauma
Breslau N, Kessler RC, et. al.
Arch Gen Psychiatry, July 1998;55:626-632
• A representative sample (2181) persons aged 1845 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%
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%
Conditional Risk
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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%
Bullets
• PTSD is a civilian disease
• Non-assaultive trauma is a common and
real stressor in the genesis of PTSD
The “Great Imposter”
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Depression
Panic attacks
Substance abuse
Personality
Physical symptoms (somatization)
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
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
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
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%
Personality and PTSD
• PTSD is very common but not universal in
Borderline Personality Disorder
• Early trauma associated
• Repeated or chronic trauma associated
“Complex” PTSD - Herman
• Occurs after prolonged and repeated
trauma
• Three broad areas of disturbance
– Multiplicity of symptoms
– Characterological changes
– Repetition of harm
Bullet
The most common diagnosis missed is
the second diagnosisSir William Osler
Management
• Treatments
– Psychopharmacology
– Psychotherapy
• Setting
– Specialty Mental Health
– Primary Care
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
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
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
Psychotherapies
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Education and supportive
Cognitive therapy
Behavioral therapy (relaxation techniques)
Exposure therapy
EMDR (eye movement desensitization
reprocessing)
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
Management Bullets
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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
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
Questions
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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?