William J. Resch, DO, FAPA
Rural Health Scholars Retreat
Athens, Ohio
October 19, 2013
 Off-label
indications will be discussed in
this presentation
I
disclose that I have no relevant financial
or other interest in any commercial
company or entity pertaining to this
educational talk
 Interactive
lecture with multitude of
questions and a brief representative case
study
 Give
brief overview of PTSD
 Look
at diagnosing PTSD
 Review current treatment(s) of PTSD
• On own in Primary Care / Rural Health Area
• Referral to VA
 How
many members of the audience would
feel comfortable diagnosing, and initiating
PTSD treatment to a returning combat vet
from Iraq or Afghanistan?
 How
many members of the audience would
know how to and what the VA has to offer
veterans with PTSD?
 When
was PTSD officially recognized as a
formal diagnosis?
 In
1980 the APA formally codified PTSD in
the DSM-III
 Prior
to 1980 it was documented under
many names…
***


T or F
- People with PTSD are violent and
unpredictable?
False - Beliefs that violence and unpredictability
are associated with serious mental problems are
common, but untrue. This misguided fear is one of
the most prominent barriers to acceptance and
social inclusion. In reality, the presence of PTSD or
a psychological condition does not make someone
prone to violence. Therefore, someone with PTSD
or some other psychological condition should not
be viewed as a threat in the community, office,
workplace, etc.
T
or F
will
 False
- Once people develop PTSD, they
never recover.
- Studies show that most people with
PTSD and other mental illnesses get better,
and many recover completely. Recovery
refers to the process in which people are able
to live, work, learn and participate fully in
their communities. For some individuals,
recovery is the ability to live a fulfilling and
productive life. For others, recovery implies
the reduction or complete remission of
T
or F
of
- Therapy and self-help are a waste
time. Why bother when you can just
take a pill?
 False - Treatment and supports vary
depending on the individual. A lot of people
work with therapists, counselors, friends,
psychologists, psychiatrists, nurses and social
workers during the recovery process. They
also use self-help strategies and community
supports. Some choose medications in
combination with other supports. The best
approach is tailored to meet the specific
 How
many medications are FDA approved
for the treatment of PTSD?
 Only
two! sertraline (Zoloft) and
paroxetine (Paxil). However, many other
medications and classes are used in the
treatment of this condition.
 Post-Traumatic
Stress Disorder (PTSD) is an
anxiety disorder that can develop in
response to a traumatic event(s)
 Typically
involves 3 types of symptoms /
clusters *** lasting > 1 month
 Symptoms
lead to problems in functioning
in social / family life, work, or school
 Normal
to have painful memories after a
traumatic event
 Trauma affects the way people think about
themselves, others, the world, and the
future
 For most, these reactions lessen over time
and thinking returns to normal
 For some, however, reactions continue,
become severe, become disruptive, and
lead to more lasting PTSD symptoms
 Trauma
and Stressor-Related Disorders
(DSM-5)
•
•
•
•
•
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder (aka PTSD)
Acute Stress Disorder
Adjustment Disorders
 Chapter
placed near anxiety disorders,
obsessive-compulsive related disorders,
and dissociative disorders due to close
relationship of all of the diagnoses
A.
Exposure to actual or threatened death,
serious injury, or sexual violence in one
(or more) of the following ways:
1. Directly experiencing the traumatic event(s)
2. Witnessing, in person, the event(s) as it occurred
to others
3. Learning that the traumatic event(s) occurred to a
close family member or close friend. In cases of
actual or threatened death of a family member or
friend, the event(s) must have been violent or
accidental
4. Experiencing repeated or extreme exposure to
aversive details of the traumatic event(s) ***
B.
Presence of one (or more) of the following
intrusion symptoms associated with the traumatic
event(s)
1.
2.
3.
4.
5.
Recurrent, involuntary, and intrusive distressing memories
of the traumatic event
Recurring distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s)
Dissociative reactions (e.g. flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring
Intense or prolonged psychological distress at exposure
to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s)
Marked physiological reactions to internal and external
cues that symbolize or resemble an aspect of the
traumatic event(s)
C.
Persistent avoidance of stimuli associated
with the traumatic event(s), beginning
after the traumatic event(s) occurred, as
evidenced by one or the following:
1. Avoidance of or efforts to avoid distressing
memories, thoughts, or feelings about or closely
associated with the traumatic event(s)
2. Avoidance of or efforts to avoid external
reminders (people, places, conversations,
activities, objects, situations) that arouse
distressing memories, thoughts, or feelings
D.
Negative alterations in cognitions or
mood associated with the traumatic
event(s), beginning or worsening after
the traumatic event(s) occurred, as
evidenced by two or more of the
following: Memory disturbance, negative
beliefs, distorted cognitions, negative
emotional state, anhedonia, detached
feelings, and inability to experience
positive emotions
E.
F.
G.
H.
Marked alterations in arousal or reactivity
associated with the traumatic event(s) as
evidenced by two or more of the
following: irritability/anger,
reckless/destructive behavior,
hypervigilance, exaggerated startle
response, problems concentrating, sleep
disturbance
Duration > 1 month
Significant distress and impairment
Not attributable to substance or other
medical condition
 You
can do a great deal, starting with how
you act and speak to people with mental
illness
 You
can create an environment that builds
on people’s strengths, promotes
understanding, and of acceptance
 Be “Psychiatrically
Minded”! Never say
“that is for your other doctor”!
 “If
you don’t take the temperature, you can’t
find the fever…”
 Know
something about our nation’s military
history and about our present military
conflicts
 Know
 Ask
something about DoD and VA
each and every patient if he/she was a
service member/veteran? If so: ask the
branch, years served, job, rank, combat, and
type of discharge? ***
 Common
themes and problems
•
•
•
Marriage, relationship problems
•
Financial hardships
•
Endless questions from family and friends
•
Guilt, shame, anger
•
Lack of structure
Medical issues
 Common
themes and problems
• Feelings of isolation
•
• Nightmares, sleeplessness
• Lack of motivation
• Forgetfulness
• Anger
• Feeling irritable, anxious, “on edge”
 Don’t
label people with words like “crazy,”
“wacko” or “loony” or define them by their
diagnosis (e.g. PTSD’er)
 It is important to make a distinction
between the person and the illness
 Instead of saying someone is “mentally-ill,”
say he or she “has PTSD”
 Don’t say “a mentally-ill person,” say “a
person with PTSD”
 This is called “people-first” language
 Primary
Care PTSD Screen (PC-PTSD)
 Combat Exposure Scale (CES)
 PTSD Checklist – Civilian Version (PCLC)
 Trauma Symptom Checklist - 40 (TSC-40)
3
Question DVBIC TBI Screening Tool
 Other
measures as appropriate


Steve is a 29 yo MWM who presents to
your rural primary care office
complaining of chronic insomnia,
nightmares, depression, anxiety, difficulty
concentrating, and inability to tolerate
large crowds. States most of the time “I
feel like I am in a fog”. ***
Reports his wife encouraged him to come
to your office “to get some help” or she
was going to consider moving out?
 What
other questions do you need to ask
Steve?
• Duration
• Impairment / Occupational Functioning
• Military history
• Psych history
• Substance Use / History
• Psychiatry ROS
 What
tests could you administer in your office?
 Who else could you talk to for increased
collateral information?
 What labs would you want to order?
 What
treatment options might you
consider?
• Antidepressant
• Anxiolytic / Benzodiazepine
• Antihypertensive
• Antipsychotic
• Hypnotic
• Mood Stabilizer
 What
non-pharmacological treatment
recommendations could you recommend to
Steve…
• Abstinence from alcohol and other illicit drugs
• Evidence Based Psychotherapy referral
 Cognitive Processing Therapy (CBT)
 Prolonged Exposure Therapy
• Eye Movement Desensitization Reprocessing (EMDR)
 Evidence
Based Medicine exists in all of
medicine… and certainly in Psychiatry!
 Clinical
Practice Guidelines are the “gold
standards” of competent care
 The
best studies and research regarding
PTSD is coming from DoD/VA!
 Assist
clinicians in learning about
available treatments, reviewing their
evidence base and making practical,
patient-specific choices among them
 Provide clinical algorithms that walk
clinicians through the necessary steps
from screening and initial assessment
through treatment and re-assessment
 Most relevant among these is the VA / DoD
Clinical Practice Guideline for the
Management of Posttraumatic Stress
 Created
by a working group of VA and
DoD clinicians and researchers
 Separate
algorithms defined for primary
care providers and mental health
professionals
 Evidence
tables provided for each
recommendation and a substantial
literature review included
 Available
at:
http://www.healthquality.va.gov/
 In
the public domain
VA / DOD Guidelines for Treatment
of PTSD
Washington (DC): Veterans Health Administration, Department of Veterans Affairs. Available at: VHA
Web site. www.guidelines.gov Data reviewed up to 9/10
VA / DOD Guidelines for Treatment of
PTSD
Washington (DC): Veterans Health Administration, Department of Veterans Affairs. Available at: VHA Web
site. www.guidelines.gov



The American Psychiatric Association (APA) has
published a Practice Guideline for Patients with
Acute Stress Disorder and Posttraumatic Stress
Disorder
The International Society for Traumatic Stress
Studies, the world’s largest international
multidisciplinary professional organization working
in the field of psychological trauma, provided a
comprehensive set of treatment guidelines in 2000
with an update version in 2008
Both guidelines provide a thoughtful introduction to
available therapies, significant background
information and evidence-based treatment
recommendations.
 aka
CPT
 Identify
and clarify patterns of thinking
 Identify
distressing trauma-related
thoughts
 Convert
these thought patterns into more
accurate thoughts
 Address
core beliefs about self, others,
larger world
 aka
PET
 Reduce the fear associated with traumatic
experience through repetitive, therapistguided confrontation of feared places,
situations, memories, thoughts, and
feelings
 Exposure
 Reduced
can be “imaginal” or “in vivo”
intensity of emotional and
physiological response is achieved
through habituation.


aka SIT
Anxiety management is among the most useful
psychotherapeutic treatments for PTSD clients
(Expert Consensus Guideline Series)

SIT can be thought of as a set of skills for managing
stress and anxiety
• Breathing control, Deep Muscle Relaxation,
Assertiveness Training, Role Playing, Covert Modeling,
Thought Stopping, Positive Thinking, Self Talk
 aka
EMDR
 Accessing
and processing traumatic
memories to bring these to resolution
 The
client focuses on emotionally
disturbing material while at the same time
focusing on an external stimulus (usually
therapist directed bilateral eye
movements, hand tapping, sounds)


Specific serotonin reuptake inhibitors (SSRI’s) and
venlafaxine (Effexor) have the strongest evidence
While many drugs from a wide range of classes have
been studied in PTSD, there is little evidence for their use
except as adjunctive treatment
• Antipsychotics often prescribed in VA/DoD settings


Available research suggests that prazosin reduces the
frequency and intensity of posttraumatic nightmares and
may be effective in managing other symptoms of PTSD
Benzodiazepines are NOT effective as first line agents in
the treatment of PTSD
• Because of potential for dependence and abuse, their use as
single agents is strongly discouraged!!!!!!!!!!!!!!!
 153
medical centers
• at least one in each state, Puerto Rico and the
District of Columbia
 909
ambulatory care and community-based
outpatient clinics (CBOC’s) – in Southern Ohio
alone there are CBOC’s in Marietta,
Cambridge, Athens, Wilmington, Portsmouth,
and Lancaster
 47
residential rehabilitation treatment
programs
 232 Veterans
Centers
 88
4
comprehensive home-care programs
DoD/VA Polytrauma Centers
 My
HealtheVet
http://www.myhealth.va.gov/
 PTSD
Coach Application for Droid/I-phone
 21 Veterans
(VISNs)
Integrated Service Networks
 PTSD Clinic
 Group therapies
 MHRRTP = PRRTP/SATP
 Suboxone Clinic
 Transcranial Magnetic Stimulation (TMS)
 Community Residential Care (CRC) Homes
 TeleBuddy System
 Telepsychiatry
 Acute Inpatient Psychiatry
 Long Term Psychiatry
 Community Living Centers
 Learn
the facts about mental health and
PTSD and share them with others,
especially if you hear something that isn’t
true
 If you treat people with PTSD in your
practice, consider hosting workshops to
educate patients, families, and co-workers
on the facts
 There
should be “No Wrong Door” to
which veterans can come to physicians for
help
 PTSD should be a fairly straightforward
diagnosis when using good history, DSM-5
criteria, screening tests, and sound clinical
judgment
 Multitude of Evidenced Based Therapies to
either initiate or refer to
 The VA has many effective, safe, and
groundbreaking tools to treat its veterans
“who have borne the battle”
1)
2)
3)
4)
5)
6)
7)
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. 5th ed.
Washington, DC: American Psychiatric Association.
2013.
APA Practice Guidelines for PTSD, 2004,
www.psych.org.
Becker ME et el, Journal of Clinical
Psychopharmacology 2007; 27(2):193-197.
Berger et al, Prog Neuropsychopharmacological
Biological Psychiatry 2009;33(2):169-180.
Cukor J et al, Ann. N. Acad. Sci 2010;1208:82-89.
Davis et al, J Clin Psychopharmacology 2008;28(1):8488.
Washington (DC): Veterans Health Administration,
Department of Veterans Affairs. Available at: VHA Web
site. www.guidelines.gov
PTSD
COSR/I
Mood
Disorders
ASD
Acute Stress
Disorder
Substance
Abuse
Anxiety
Military
Sexual Abuse
Grief
TBI