OHSU Presentation Template - White

1
Post-traumatic Stress Disorder in the Primary
Care Setting
Presented by Jonathan Betlinski, MD
Date 01/22/2014
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Disclosures and Learning Objectives

• Learning Objectives
• Be familiar with the Criteria for PTSD
• Know two screening tools for PTSD
• Know at least three ways to decrease
  retraumatization during clinic visits
• Know two psychotherapies helpful for PTSD
• Know the two classes of medications most helpful
  for PTSD
• Disclosures Dr. Jonathan Betlinski has nothing
  to disclose.

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PTSD in the Primary Care Setting

• Review epidemiology of PTSD
• Review the diagnostic criteria for PTSD
• Discuss first steps in treatment of PTSD
• Screening
• Avoiding re-traumatization
• Psychotherapy
• Indicated Medications
• Topic for next time

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PTSD in the Primary Care Setting

• PTSD present in 8.6 of primary care patients
• Trauma is common
• - 25-30 of trauma survivors develop PTSD
• - For women, sexual assault is the most likely
  precursor
• - For men, its witnessing injury or death in
  combat
• Trauma leads to health problems
• - Traumatized patients make 4x more PCP visits
• - CSA survivors have more somatic complaints,
• pain disorders, general medical diagnoses
• http//www.ncbi.nlm.nih.gov/pubmed/17339617
  http//www.ncbi.nlm.nih.gov/pubmed/10795604
• https//www.wisconsinmedicalsociety.org/_WMS/publi
  cations/wmj/pdf/103/6/73.pdf

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PTSD in the Primary Care Setting

• Most trauma victims
• do not seek mental health services
• seek help in the primary care setting
• do not disclose personal trauma histories
• will provide trauma history if asked
• do not object to being asked about their trauma
  history in a primary care setting
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf

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PTSD Risk Factors

• Personal or Family history of psychiatric
  disorder
• Involvement of interpersonal violence
• Severity of trauma
• Chronicity of the traumatic experience
• Whether it involves fear of dying
• Stressors in the recovery environment
• http//www.unioviedo.es/psiquiatria/publicaciones/
  documentos/1998/1998_Ballenger_Consensus.pdf
• http//www.aafp.org/afp/2003/1215/p2401.pdf

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DSM-5 PTSD Diagnostic Criterion A Stressor

• The person was exposed to death, threatened
  death, actual or threatened serious injury, or
  actual or threatened sexual violence, as follows
  (one required)
• 1.Direct exposure.
• 2.Witnessing, in person.
• 3.Indirectly, by learning that a close relative
  or close friend was exposed to trauma. If the
  event involved actual or threatened death, it
  must have been violent or accidental.
• 4.Repeated or extreme indirect exposure to
  aversive details of the event(s), usually in the
  course of professional duties (e.g., first
  responders, collecting body parts professionals
  repeatedly exposed to details of child abuse).
  This does not include indirect non-professional
  exposure through electronic media, television,
  movies, or pictures. http//www.ptsd.va.gov/profe
  ssional/PTSD-overview/dsm5_criteria_ptsd.asp

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DSM-5 PTSD Diagnostic Criterion B Intrusion
Symptoms

• The traumatic event is persistently
  re-experienced in the following way(s) (one
  required)
• 1.Recurrent, involuntary, and intrusive memories.
  Note Children older than six may express this
  symptom in repetitive play.
• 2.Traumatic nightmares. Note Children may have
  frightening dreams without content related to the
  trauma(s).
• 3.Dissociative reactions (e.g., flashbacks) which
  may occur on a continuum from brief episodes to
  complete loss of consciousness. Note Children
  may reenact the event in play.
• 4.Intense or prolonged distress after exposure to
  traumatic reminders.
• 5.Marked physiologic reactivity after exposure to
  trauma-related stimuli.
• http//www.ptsd.va.gov/professional/PTSD-overview/
  dsm5_criteria_ptsd.asp

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DSM-5 PTSD Diagnostic Criterion C Avoidance

• Persistent effortful avoidance of distressing
  trauma-related stimuli after the event (one
  required)
• 1.Trauma-related thoughts or feelings.
• 2.Trauma-related external reminders (e.g.,
  people, places, conversations, activities,
  objects, or situations).
• http//www.ptsd.va.gov/professional/PTSD-overview/
  dsm5_criteria_ptsd.asp

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DSM-5 PTSD Diagnostic Criterion D Negative
Alterations in Cognition and Mood

• Negative alterations in cognitions and mood that
  began or worsened after the traumatic event (two
  required)
• 1.Inability to recall key features of the
  traumatic event
• 2.Persistent (and often distorted) negative
  beliefs and expectations about oneself or the
  world (e.g., I am bad, World is dangerous,)
• 3.Persistent distorted blame of self or others
  for causing the traumatic event or for resulting
  consequences.
• 4.Persistent negative trauma-related emotions
  (e.g., fear, horror, anger, guilt, or shame).
• 5.Markedly diminished interest in (pre-traumatic)
  significant activities.
• 6.Feeling alienated from others (e.g., detachment
  or estrangement).
• 7.Constricted affect persistent inability to
  experience positive emotions. http//www.ptsd.va.g
  ov/professional/PTSD-overview/dsm5_criteria_ptsd.a
  sp

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DSM-5 PTSD Diagnostic Criterion E Alterations in
Arousal and Reactivity

• Trauma-related alterations in arousal and
  reactivity that began or worsened after the
  traumatic event (two required)
• 1.Irritable or aggressive behavior
• 2.Self-destructive or reckless behavior
• 3.Hypervigilance
• 4.Exaggerated startle response
• 5.Problems in concentration
• 6.Sleep disturbance
• http//www.ptsd.va.gov/professional/PTSD-overview/
  dsm5_criteria_ptsd.asp

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DSM-5 PTSD Diagnostic Criteria

• Criterion F Duration
• Persistence of symptoms for more than one month.
• Full diagnosis is not made until at least 6
  months after the trauma, although onset of
  symptoms may begin immediately
• Criterion G Functional Significance
• Significant symptom-related distress or
  functional impairment
• Criterion H Exclusion
• Disturbance is not due to medication, substance
  use, or other illness.
• Specify if With dissociative symptoms
• Depersonalization and/or Derealization
• Specify if With delayed expression.
• http//www.ptsd.va.gov/professional/PTSD-overview/
  dsm5_criteria_ptsd.asp

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DSM-5 PTSD Diagnostic Criteria Summary

• T - Trauma exposure
• R - Re-experiencing
• A - Avoidance of reminders
• U - Undermined cognition and mood
• M - Magnified arousal and reactivity
• A - Active symptoms for 1 month

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Better than nothing screening GAD-7

• PTSD
• 66 sensitivity
• 81 specificity
• http//www.ncbi.nlm.nih.gov/books/NBK126694/

• http//wiki.galenhealthcare.com/index.php/Galen_eC
  alcs_-_Calculator_GAD-7_Gen._Anxiety_Disorder
• http//www.integration.samhsa.gov/clinical-practic
  e/GAD708.19.08Cartwright.pdf

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Better Screening for PTSD in Primary Care

• PC-PTSD (currently used by VA), cut off score of
  3
• - 77 sensitive, 85 specific, PLR 5.1, NLR 0.27
• http//www.integration.samhsa.gov/clinical-practic
  e/PC-PTSD.pdf
• PCL-C (endorsed by SAMHSA), cut off score of 30
• - 98 sensitive, specificity gt80
• http//www.ncbi.nlm.nih.gov/pmc/articles/PMC338393
  6/pdf/nihms-357066.pdf
• http//www.integration.samhsa.gov/clinical-practic
  e/Abbreviated_PCL.pdf
• http//www.istss.org/PosttraumaticStressDisorderCh
  ecklist.htm
• SPAN and Breslau have reasonable evidence
• Very short screens are less useful
• http//www.hsrd.research.va.gov/publications/esp/p
  tsd-screening-EXEC.pdf

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Treatment of PTSD in Primary Care
Avoid re-traumatizing or re-victimizing patients

• Greet patient while he or she is still fully
  dressed
• Avoid positioning yourself between patient and
  exit
• Ask what you can do to make exams easier and less
  scary
• Explain plans and reasons for procedures before
  starting
• Ask permission to touch
• Keep patient informed while exam progresses
• Check in regularly

• Move at the patients pace
• Take breaks as necessary
• Use grounding techniques if patient seems
  disconnected or distressed
• Remind patient where they are
• Remind patient they are safe
• Remind patient abuse isnt currently happening
• Restore a sense of control by providing patient
  as much choice as possible

https//www.wisconsinmedicalsociety.org/_WMS/publi
cations/wmj/pdf/103/6/73.pdf
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Treatment of PTSD in Primary Care

• NICE 2005 Guideline (reviewed 2011)
• Debriefing should NOT be routine practice
• For mild symptoms of lt4wks, wait watch
• For severe symptoms, offer individual CBT within
  one month of the trauma
• Offer individual CBT or EMDR to all PTSD
• Meds are not routine first line treatment
• though consider if therapy declined
• http//www.nice.org.uk/guidance/cg26/resources/gui
  dance-posttraumatic-stress-disorder-ptsd-pdf

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Treatment of PTSD in Primary Care CBT

• CBT effective in more than 30 studies
• Exposure Therapy repeated descriptions of the
  trauma reduce arousal and distress
• Cognitive Therapy identifying trauma-related
  negative beliefs and changing them
• Stress-Inoculation Training learning skills for
  managing anxiety
• Belly Breathing Progressive Muscle Relaxation
• Likely 60-80 reduction in symptoms
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• https//depts.washington.edu/hcsats/PDF/TF-20CBT/
  pages/420Emotion20Regulation20Skills/Client20H
  andouts/Relaxation/Ways20to20Relax20by20Using
  20breathing.pdf

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Treatment of PTSD in Primary Care EMDR

• EMDR - Eye Movement Desensitization and
  Reprocessing
• Patients bring to mind images of the trauma while
  engaging in back-and-forth eye movements
• Also addresses trauma-related negative beliefs
• Less effective and sustained than CBT
• More effective than placebo wait list, or
  psychodynamic, relaxation or supportive therapies
• Eye movement component may not add any addition
  treatment effect
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//www.nice.org.uk/guidance/cg26/resources/gui
  dance-posttraumatic-stress-disorder-ptsd-pdf

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Treatment of PTSD in Primary Care Other

• Psychodynamic Psychotherapy
• One study showed 18 sessions of Brief PP reduced
  avoidance symptoms by 40 effect was sustained
  at 3 months
• Needs more research
• Group Therapy
• Clear benefit for psychological distress,
  depression, anxiety, and social adjustment
• Possible 18-60 symptom reduction
• Results typically sustained at 6 months
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf

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Pharmacologic Interventions

• Psychotherapy (CBT) remains the gold standard
  treatment for PTSD
• Main goal for medication is to minimize symptoms
  rather than cure PTSD
• Hyperarousal symptoms (nightmares, etc) are the
  most likely to respond to meds
• Medications should never replace therapy unless
  it is ineffective or declined
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//www.nice.org.uk/guidance/cg26/resources/gui
  dance-posttraumatic-stress-disorder-ptsd-pdf

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Pharmacology for PTSD Antidepressants

• APA and VA recommend SSRIs as the first choice
  when medications are indicated
• Sertraline and Paroxetine remain the only SSRIs
  with FDA approval for PTSD
• Most studies show a modest response
• 60 response, 40 remission
• Dose SSRIs the same as for depression
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//www.nice.org.uk/guidance/cg26/resources/gui
  dance-posttraumatic-stress-disorder-ptsd-pdf
• http//psychiatryonline.org/pb/assets/raw/sitewide
  /practice_guidelines/guidelines/acutestressdisorde
  rptsd-watch.pdf

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Pharmacology Other Antidepressants

• Studies on other antidepressants are mixed
• SNRIs may be more likely to be effective
• NICE recommends Mirtazapine, Amitriptyline and
  Phenelzine first-line
• Sleep may be least likely to respond to SSRI
• Consider adding Mirtazapine, a sedating TCA like
  Doxepin, or perhaps Trazodone
• No evidence for use of Bupropion
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//www.nice.org.uk/guidance/cg26/resources/gui
  dance-posttraumatic-stress-disorder-ptsd-pdf
• http//psychiatryonline.org/pb/assets/raw/sitewide
  /practice_guidelines/guidelines/acutestressdisorde
  rptsd-watch.pdf

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Pharmacology for PTSD Antipsychotics

• Neither a first-line nor a solo treatment
• Sedating atypicals most likely to show benefit
• Risperidone is the most researched, and may be an
  helpful adjunct to SSRIs
• Olanzapine helpful in some studies, esp as
  adjunct
• Quetiapine supported, though research lags
• No studies support the use of typicals
• Other medications can help with sedation
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//psychiatryonline.org/pb/assets/raw/sitewide
  /practice_guidelines/guidelines/acutestressdisorde
  rptsd-watch.pdf

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Pharmacology for PTSD Mood Stabilizers

• Often shown to be ineffective, especially as
  monotherapy
• Trials showing effectiveness are typically
  open-label
• Notably, Valproate no better than placebo.
• Topiramate may be helpful for nightmares and
  flashbacks
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//psychiatryonline.org/pb/assets/raw/sitewide
  /practice_guidelines/guidelines/acutestressdisorde
  rptsd-watch.pdf

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Pharmacology for PTSD Anti-Adrenergics

• More helpful in the short run
• Typically associated with less stigma
• May help with Hypervigilance and Activation
• Propranolol 10-40mg po 3-4x/day
• Clonidine 0.1-0.3mg po bedtime and PRN
• Prazosin 1-3mg po bedtime
• Guanfacine not supported in studies
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf
• http//psychiatryonline.org/pb/assets/raw/sitewide
  /practice_guidelines/guidelines/acutestressdisorde
  rptsd-watch.pdf

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Pharmacology for PTSD Benzodiazepines

• May be helpful for sleep, BUT
• Avoid in active or recent substance abuse
• SA in 40 of PSTD (75 if combat-related)
• Benzos may contribute to emotional numbing
• This may interfere with recovery
• Scant evidence for actual benefit
• Little evidence for or against buspirone
• http//www.thecarlatreport.com/printpdf/5050
• http//www.publichealth.va.gov/docs/vhi/posttrauma
  tic.pdf

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Summary

• PTSD occurs in 8.6 of primary care patients
• DSM-V has shifted PTSD diagnostic criteria to 6
  categories (think TRAUMA)
• Tools like the PC-PTSD and PCL-C accurately
  detect PTSD in the primary care setting
• Good treatment avoids retraumatization
• CBT and EMDR are PTSDs treatments of choice
• Antidepressants (SSRIs) and anti-adrenergics are
  the most supported medications for PTSD

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The End!
Obsessive-Compulsive Disorder 01/29/15

• http//proof.nationalgeographic.com/2014/11/05/mus
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