Treating PTSD: A Multimodal Approach

1
Treating PTSD A Multimodal Approach

• Ari Zaretsky MD FRCP(C)
• Head, Cognitive Behaviour Therapy Clinic
• Sunnybrook Womens College Health Sciences
  Centre
• Assistant Professor, Department of Psychiatry
• University of Toronto
• ari.zaretsky_at_swchsc.on.ca

2
Trauma Associated With PTSD

• Serious physical attack or assault
• Rape or sexual trauma
• Witness to death/murder or serious injury
• Life-threatening accidents
• Threats of injury with a weapon
• Fire or natural disaster
• War

3
PTSD As A Worldwide Problem

• Germany 1.3
• USA 7.8
• Ethiopia 15.8
• Gaza 17.8
• Cambodia 28.4
• Algeria 37.4
• de Jong et al. JAMA 2001286555
• Kessler et al. Arch Gen Psychiatry 1995 521048
• Perkonnig et al. Acta Psychiatr Scand 200010146

4
PTSD in Primary Care

• PTSD is the most commonly undetected anxiety
  disorder in primary care and has a major adverse
  impact on illness severity and increased overall
  costs to the medical system.
• Third National Primary Care/Mental Health
  Conference, October 8, 2002

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Educational Objectives

• to describe two psychological mechanisms involved
  in PTSD
• to describe empirically-validated pharmacotherapy
  and psychotherapy approaches for PTSD
• to sketch a phased multimodal, integrative
  therapeutic approach to treat rape-related PTSD
•  
•  

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Outline

• PTSD demographics and facts
• Outline of case
• Psychological models of PTSD
• Pharmacotherapy for PTSD
• CBT treatment for PTSD

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Ubiquity of Trauma and PTSD

• PTSD lifetime prevalence men 5-6 vs.
  women 14-18
• 60 of men and 51 of women experience at least
  one traumatic event during their lifetime
• 20.4 of women and 8.1 of men develop PTSD
  following exposure to trauma
• Kessler et al., Arch Gen Psych 1995 521048

8
An Epidemic of Assault Against Women

• Study of 4,008 women 12.7 victims of rape,
  14.7 victims of other assault
• Prevalence of childhood sexual abuse/molestation
  27 women, 16 men
• Domestic violence by partner or ex-partner 20-33
• 1972-1991 1.5 million sexual assaults, only 16
  reported
• After rape, 94 have PTSD symptoms 1 week later
  and 47 of women develop PTSD
• After 3 months, PTSD occurs in 42 women (failure
  of recovery)
• Resnick et al. Journal of Consulting and Clinical
  Psychology 1993 61984-991
• Finkelhor et al. Child Abuse and Neglect 1990
  14 19-28
• Rothbaum et al. Journal of Traumatic Stress 1992
  5 455-475

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Longitudinal Course of PTSD Symptoms
6 recovered
53 recovered
58 recovered
15-25
UNRECOVERED
YEARS
3 months
9 months
Weeks
Shalev Yehuda, 1999
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Case Description

• 33 year old married woman
• Absolutely no previous psychiatric history
• Had been living in Boston during the summer of
  1993
• Attending a Harvard Law School summer course
  while a 3rd year student at U of T Law School
• Brutally and sadistically raped by a stranger
  after exiting from the wrong door of a Harvard
  Law School building where she had been attending
  an evening lecture

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Case Description (II)

• Returned home the next day
• Did not initially disclose the rape to supportive
  boyfriend and family
• Determined to not allow rape to affect her life
  and her academic functioning
• Experienced intrusive flashbacks, insomnia,
  nightmares, startle response, numbing, anxiety
  and avoidance about being alone outside,
  preoccupation with safety

12
Case Description (III)

• Clinical depression worsened over time
  anhedonia, diminished appetite, dimished libido,
  poor energy, poor concentration, feelings of
  worthlessness and hopelessness
• Was still able to successfully finish law school
• Completed articling year in a chronically
  depressed state

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Case Presentation (IV)

• Mugged 1 year later- Increased PTSD, emergence of
  psychotic major depression with intense suicidal
  ideation
• Hospitalized and required course of bilateral ECT
• From 1993-1999 treated by 3 psychiatrists
• Required 2 involuntary hospitalizations for
  suicidal and psychotic depression
• Pharmacotherapy Zoloft 100 mg/d Risperdal 0.5
  mg/d clonazepam 0.5 mg tid
• Treated with 24 sessions of EMDR-no benefit

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DSM-IV Diagnostic criteria for PTSD
Intense response after a traumatic event (fear,
horror, helplessness)
Significant distress or impairment acute (lt3mo
dur), chronic (gt3 mo dur) or of delayed onset
(onset after 6 mo)
Persistent intrusion/ re-experiencing of the
event-1Sx
PTSD
Persistent hyperarousal symptoms- 2Sx
Disturbance lasting more than 1 month
Persistent avoidance ornumbing- 3Sx
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Impact of PTSD on Patient (V)

• Profound sense of loneliness, shame, hopelessness
  and worthlessness
• Inability to experience pleasure or re-engage
  emotionally with the world
• No capacity for intimacy with husband
• Incapacitating anxiety and avoidance

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Impairment With PTSD, Other Psychiatric
Diagnoses, and No Diagnoses ()
Other Diagnosis (n405)
No Diagnosis (n509)
PTSD (n93)
Indicator of impairment

• Current limitations in activities
  18.3 8.9
  4.5
• Missed work last month
  33.3 23.1
  15.5
• Self-assessed health as fair/poor
  29.0 17.3
  6.5
• Ever wanted to die
  28.0 14.6
  2.6
• Ever thought about suicide
  46.2 29.9
  8.7
• Ever attempted suicide
  17.2 7.4
  1.2

All comparisons significant at plt 0.0001
Breslau N J Clin Psychiatry 200162 (suppl 17)55
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Risk of Suicide Attempts for Anxiety Disorders
19 of PTSD patients will attempt suicide
Odds Ratio
PTSD patients are 6 times more likely to attempt
suicide than controls
Kessler et al, Arch of Gen Psychiatry, 1999, 56
617
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Economic Costs of PTSD

• PTSD is a primary cost source for medical and
  psychiatric services
• Average work loss 3.6 days/month
• Annual productivity loss 3 billion (USA)
• Level of lost productivity per case similar to
  levels found in depression

1. Kessler and Frank, Psychol Med 1997 27
861. 2. Breslau et al, Arch Gen Psychiatry,
1998 55626. 3. Solomon and Davidson, J Clin
Psychiatry, 1997 58 suppl 9 5.
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Panic
9.9
Alcohol Abuse/ Dependence
Major Depression
48.2
39.9
PTSD
Social Phobia
GAD
29.9
Agoraphobia
15.9
19.25
Kessler et al, 1995 Arch Gen Psychiatry, 521048
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Neurobiology of PTSD Suggests Ongoing Stress
Response

• Enhanced startle (not present until 1 month
  post-trauma) Orr et al. Biol Psychiatry
  19974119 Shalev et al. Compr
  Psychiatry 199738269
• Increased SNS activation (heart-rate is only
  elevated by 18bpm in those that later develop
  PTSD) Shalev et al. Compr Psychiatry 1997 38269
• increased plasma NE Yehuda et al. Biolog
  Psychiatry 1998 4456
• Alteration in HPA axis
• Alterations of the hippocampus
• Increased activation of the amygdala

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Goals of Pharmacotherapy

• Reduce PTSD symptoms
• Improve resilience to stress
• Improve quality of life
• Reduce disability
• Reduce comorbidity

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Efficacy of Pharmacotherapy for PTSD

• Sertraline A
• Paroxetine A
• Fluoxetine A/B
• Phenelzine A/B
• Meclobemide B
• TCAs(Imipramine/Desipramine) A
• Clonidine/Propranolol C
• Carbamzepine/Valproate B
• Clonazepam C
• Nefazodone B
• International Society for Traumatic Stress
  Studies PTSD Treatment Guideline Task Force, 1997

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Effectiveness of Sertraline in PTSDby Symptom
Cluster (CAPS-2)
CAPS-2 Changefrombaseline(ITT)
40
Sertraline (n 97)
Placebo (n 104)
p 0.02
30
p 0.03
20
10
0
Re-experiencing/intrusion
Avoidance/numbing
Arousal
Brady et al. JAMA 20002831837
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Sertraline Maintenance Therapy for PTSDStudy
Design
Change to placebo
RANDOMISE
Receive sertraline
Continue receiving sertraline
Week 024 acute treatment
Weeks 2452 maintenance treatment
Davidson et al, APA 2000
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Sertraline Prevents Relapse
Patientsrelapsing
30
Sertraline (n46)
Placebo (n50)
25
20
15
10
5
0
Davidson et al, APA 2000
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Paroxetine Fixed Dose Study Change in CAPS-2
Scores at Each Visit (ITT Population)
0
Paroxetine 40 mg
Paroxetine 20mg
-10
Placebo
-20
Change in CAPS-2 Total (Week 12 LOCF)
-30



-40

• Least square means adjusted for treatment,
  center, gender, baseline PTSD and Depressive
  symptoms, trauma type, and time since trauma
• Marshall et al. Am J Psychiatry 20011581982

-50
4
8
12
Week
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SRI Drugs in PTSD

• SSRIs improve all aspects of PTSD
• SSRIs prevent relapse
• SSRIs reduce vulnerability to daily stress
• SSRIs reduce disability
• SSRIs improve quality of life

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Psychodynamic View of Trauma

• Illusion of safe, predictable, non-threatening
  world is shattered
• New representation of the world persistently
  dangerous, unpredictable and threatening
• Self in relation to the world that changes
• Eells, Friedhandler, Stinson Horowitz, 1991

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Freud

• First to observe the brutal reductiveness of
  trauma
• Traumatic incident sat in the soul like a rock
  in the stomach, undigestible
• The mechanism of the ego, including efforts to
  master the trauma in dream work, might not
  succeed
• It is not so much a symptom of the unconscious
  as it is a symptom of history
• Freud, Introductory lectures on psychoanalysis,
  1917
• Freud, Beyond the pleasure principle, 1920

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Mowrers Two Factor Theory of Fear

• Factor I classical conditioning- innocuous cues
  (paired at the time of the trauma) become
  associated with the trauma and accompanying
  emotional reactions
• stimulus generalization- stimuli similar to the
  trauma cues elicit anxiety (e.g. patient fears
  all side exits of buildings)
• higher order conditioning- stimuli unrelated but
  paired to other trauma cues elicit anxiety (e.g.
  patient overwhelmed watching suspense movie)

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Mowrers Two Factor Theory (II)

• Factor II operant conditioning
• Avoidance (cognitive, behavioural, emotional
  numbing, substance use) is reinforced (negative
  reinforcement) because it temporarily reduces
  anxiety
• Fear reaction is maintained because opportunity
  for extinction of the learned associations is
  prevented
• Mowrer, 1960

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Cognitive Conceptualization of PTSD

• We propose that what distinguishes PTSD from
  other anxiety disorders is that the traumatic
  event was of monumental significance and violated
  formerly held basic concepts of safety. That is
  to say, stimuli and responses that previously
  signalled safety, have now become associated with
  danger.
• Foa, 1989

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Efficacy of Psychotherapy for PTSD

• Exposure Therapy A
• Cognitive Therapy A
• Cognitive Processing Therapy B
• EMDR A/B
• Psychodynamic Therapy C/D
• Hypnosis C/D
• Biofeeedback/Relaxation Training NR!
• International Society for Traumatic Stress
  Studies PTSD Treatment Guideline Task Force, 1997

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Gender Issues in PTSD Treatment

• Effectiveness of male therapists with female rape
  victims has not been studied specifically
• It is believed they can be quite effective if
  well trained
• Common mistakes by male therapists viewing rape
  as a sexual crime rather than a crime of violence
• Rape victims are extremely sensitive to
  implications of blame
• Resick et al. Behavior Therapy 198819 385-401
• Koss Harvey. The rape victim Clinical and
  community approaches to treatment. Lexington MA,
  1991

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Cognitive-behavioural treatment of patient

• Psychiatric history- attention to previous
  traumata
• Establish therapeutic alliance
• Psychoeducation about PTSD
• Breathing retraining, relaxation and imagery
  exercises
• Cognitive restructuring (automatic thought
  record)
• Fear hierarchy and in vivo graded exposure

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Prolonged Exposure (PE)

• Written narrative in first person present
  (description of sensory experience, feelings and
  thoughts/beliefs)
• Imaginal exposure increasingly detailed
  description of rape in first person present
  tense- 90 minute sessions (60 minutes of
  exposure)
• Listen to tape of session once per day between
  sessions

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Exposure Homework Recording Form

• Client______________________________Date__________
  __________________
• Description of exposure in imagination Starting
  from the minute I realize he will rape me and
  ending at the time I was taken to the police.
• Date 9/7/2000
• Before imaginal exposure SUDs _45__
• After imaginal exposure SUDs _ 75_
• Comments It was difficult in the beginning and
  then it became easier.
• Date 9/8/2000
• Before imaginal exposure SUDs _25__
• After imaginal exposure SUDs _65__
• Comments It was not as difficult as yesterday.
• Date 9/12/2000
• Before imaginal exposure SUDs _10__
• After Imaginal exposure SUDs _60__
• Comments It is becoming more easy as I continue
  to do it.

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Cognitive Restructuring for PTSD

• I am to blame
• I am weak
• I am vulnerable
• I am damaged
• I am worthless
• I am pathetic
• The world is dangerous
• The world is evil
• Sex is disgusting
• My body is disgusting
• Life is meaningless

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Later Psychotherapy Focus

• Address secondary emotions and conflicts- shame,
  worthlessness, disgust, anger, self-blame and
  hopelessness
• Use of the therapeutic relationship to heal
  interpersonal trauma
• Focus on competence, self-esteem and intimacy
• Couple therapy- sensate focus exercises

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Quantitative Improvement in Patient
CAPS 70
CAPS 55
BDI 28
BDI 21
CAPS 14
BDI 9
Baseline 8 weeks 52 weeks
Baseline 8 weeks 52 weeks
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Conclusions

• Trauma is ubiquitous and has chronic mental
  health consequences. PTSD is a common and often a
  complex and chronic condition.
• SRI pharmacotherapy and various forms of
  cognitive-behavioural therapies are
  evidence-based, efficacious treatments for PTSD.
• Although synergism has not been proven, chronic
  PTSD requires a multimodal approach for
  conceptualization and treatment.