Post-traumatic Stress Disorder
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 01/22/2014
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.
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
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, it’s 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/publications/wmj/pdf/103/6/73.pdf
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/posttraumatic.pdf
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
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 nonprofessional exposure through electronic media, television,
movies, or pictures. http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp
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
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
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.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp
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
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
DSM-5 PTSD Diagnostic Criteria: Summary
TRAUMA-
Trauma exposure
Re-experiencing
Avoidance of reminders
Undermined cognition and mood
Magnified arousal and reactivity
Active symptoms for 1 month
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_eCalcs_-_Calculator:_GAD-7_Gen._Anxiety_Disorder
http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf
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-practice/PC-PTSD.pdf
PCL-C (endorsed by SAMHSA), cut off score of 30
- 98% sensitive, specificity >80%
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383936/pdf/nihms-357066.pdf
http://www.integration.samhsa.gov/clinical-practice/Abbreviated_PCL.pdf
http://www.istss.org/PosttraumaticStressDisorderChecklist.htm
SPAN and Breslau have reasonable evidence
Very short screens are less useful
http://www.hsrd.research.va.gov/publications/esp/ptsd-screening-EXEC.pdf
Treatment of PTSD in Primary Care
Avoid re-traumatizing or re-victimizing patients
•Greet patient while he or she is
still fully dressed
•Move at the patient’s pace
•Avoid positioning yourself
between patient and exit
•Use grounding techniques if
patient seems disconnected or
distressed
•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
•Take breaks as necessary
•Remind patient where they are
•Remind patient they are safe
•Remind patient abuse isn’t currently
happening
•Restore a sense of control by
providing patient as much
choice as possible
https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/103/6/73.pdf
Treatment of PTSD in Primary Care
NICE 2005 Guideline (reviewed 2011)
• Debriefing should NOT be routine practice
• For mild symptoms of <4wks, 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/guidance-posttraumatic-stress-disorder-ptsd-pdf
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 traumarelated 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/posttraumatic.pdf
https://depts.washington.edu/hcsats/PDF/TF-
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/posttraumatic.pdf
http://www.nice.org.uk/guidance/cg26/resources/guidance-posttraumatic-stress-disorder-ptsd-pdf
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/posttraumatic.pdf
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/posttraumatic.pdf
http://www.nice.org.uk/guidance/cg26/resources/guidance-posttraumatic-stress-disorder-ptsd-pdf
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/posttraumatic.pdf
http://www.nice.org.uk/guidance/cg26/resources/guidance-posttraumatic-stress-disorder-ptsd-pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
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/posttraumatic.pdf
http://www.nice.org.uk/guidance/cg26/resources/guidance-posttraumatic-stress-disorder-ptsd-pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
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/posttraumatic.pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
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/posttraumatic.pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
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/posttraumatic.pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
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/posttraumatic.pdf
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 PTSD’s treatments of choice
• Antidepressants (SSRI’s) and anti-adrenergics
are the most supported medications for
PTSD
The End!
ObsessiveCompulsive
Disorder
01/29/15
http://proof.nationalgeographic.com/2014/11/05/musings-corey-arnold-looks-wildlife-straight-in-theeye/?source=photoeditorspicks