Posttraumatic Stress Disorder (PTSD): A Diagnostic Overview & Treatment Options

Posttraumatic Stress Disorder (PTSD): A Diagnostic Overview and Treatment Options

LT Catherine Arnatt, PharmD, MS Southcentral Foundation/Alaska Native Medical Center

Michael Arnatt, MS University of Alaska Anchorage

Disclosures Neither presenter has a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias their presentation.

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Question 1 1. DSM-5 diagnostic criteria of PTSD does not include criterion for: a. b. c. d.

Stressors Avoidance Negative Cognitions and Mood Arousal and Recovery

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Question 2 2. Cognitive-behavior therapy, is the only effective method of psychotherapy in the treatment of PTSD. a. True b. False

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Question 3 3. Initial pharmacotherapy options for treatment of PTSD includes: a. b. c. d.

SSRIs Benzodiazepines Tricyclic Antidepressants MAO Inhibitors

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Objectives 1. Discuss the DSM-5 diagnostic criteria of Posttraumatic Stress Disorder (PTSD). 2. Review non-pharmacologic therapy interventions for treatment of PTSD. 3. Identify pharmacotherapy options for treatment of PTSD. 4. Discuss a monitoring plan for the treatment of patients with PTSD. 6

DSM-5: Stressor(s) A. Exposure to actual or threatened death, serious injury, or sexual violence by: ● Directly experiencing ● Witnessing as occurred to others ● Learning that the traumatic event(s) occurred to a close family member or close friend ● Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) 7

(American Psychiatric Association, 2013)

DSM-5: Intrusion Symptoms B. One (or more) of the following intrusion symptoms associated with the traumatic event(s): ● Recurrent, involuntary, and intrusive distressing memories ● Recurrent distressing dreams ● Dissociative reactions (e.g., flashbacks) ● Distress associated with traumatic event cues ● Physiological reactions to internal or external cues (American Psychiatric Association, 2013)

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DSM-5: Avoidance & - Symptoms C. Persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood: ● Avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings ● Avoidance of, or efforts to avoid, external reminders ● Negative symptomology 9

(American Psychiatric Association, 2013)

DSM-5: Cognitions & Mood D. Negative alterations in cognitions and mood that began or worsened after the traumatic event ● Inability to recall key features of the traumatic event ● Persistent negative beliefs about oneself or the world ● Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences (American Psychiatric Association, 2013)

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DSM-5: Cognitions & Mood D. Negative alterations in cognitions and mood (cont): ● Persistent negative trauma-related emotions ● Markedly diminished interest in (pretraumatic) significant activities ● Feeling alienated from others (e.g. detachment or estrangement) ● Constricted affect: persistent inability to experience positive emotions (American Psychiatric Association, 2013)

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DSM-5: Arousal & Reactivity E. Marked alterations in arousal and reactivity associated with the traumatic event(s) ● ● ● ● ● ●

Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance (American Psychiatric Association, 2013)

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DSM-5: Duration, Distress & Exclusivity F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. (American Psychiatric Association, 2013)

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Easy way to Remember

Traumatic event(s) occurred Re-experiences traumatic event(s) Avoidance of stimuli associated Month Arousal and reactivity

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Sources of Trauma Sources of trauma vary, but may include: ● ● ● ●

Combat Sexual Abuse Accidents Persistent, direct exposure to tragedy or gruesome events (i.e. first responders, psychologists with sexual abuse victims—not indirect exposure through media) ● The case of “pre-combat” exposure 15

Epidemiology ● Estimated lifetime prevalence of PTSD is 6.8% in the U.S. (Kessler et al., 2008) ● ~2% Active prevalence rate yields 6.3 million cases of PTSD in the U.S. (Norris & Stone, 2013) ● International statistics problematic (e.g. China = 0.6%) ● 12 month prevalence was 1.8% among men and 5.2% among women (National Comorbidity Survey, 2005) ● DSM-5 rates slightly lower then DSM-IV (1-6%) 16

PTSD Event Window Conceptualization

Hyperarousal

Typical Upper Bound

Baseline Activating Event

Typical Lower Bound

Hypoarousal (disassociation)

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(Adapted from Van der Kolk, 2006)

Psychotherapy First line EB treatment (e.g., Bryant et al., 2008) Patients who do not respond to pharmacotherapy (Otto,Bruce, & Deckersbach, 2005)

Manualized Cognitive Behavioral Therapy (CBT) Exposure Therapy (PE) ● In-vivo exposure: Engaging in avoided activities ● Imaginal exposure: Revising experience out loud

Group Cognitive Processing Therapy (CPT) (Bass et al., 2013) ● Meaning centered rationalization

Others such as EMDR and Stellate Ganglion Block

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Psychotherapy & Benzos Benzodiazepines may effect psychotherapy ● Exposure therapy not effective (root of most therapy) (Otto, Smits, & Reese, 2005)

● Effect of withdrawal: Relapse prevention (Bruce, Spiegel, & Hegel, 1999) ● Learning Impairment: Explicit and implicit memory so integration of concepts can be an issue (e.g.,Buffett-Jerrott & Stewart, 2002)

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Pharmacotherapy Goals ● Treatment should be initiated shortly after diagnosis ● Early treatment may prevent chronicity ● Goals of therapy to decrease:      

Intrusive thoughts and images Phobic avoidance Hyperarousal* Hypervigilance Irritability and anger* Depression*

* Symptoms drug therapy most effective at decreasing, less effective for other symptoms such as emotional numbing, re-experiencing, and behavioral avoidance (Pharmacotherapy for posttraumatic stress disorder. www.UpToDate.com, 2014)

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Pharmacotherapy

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Pharmacotherapy Antidepressants: SSRIs, SNRIs Alpha-1 antagonists: prazosin Beta adrenergic antagonists: propranolol Anticonvulsants/Mood stabilizers Atypical antipsychotics: risperidone, olanzapine  Overall not supported, some clinical trials with mixed results  Atypical antipsychotics can be used as augmentation therapy in cases of partial response to SSRI therapy

Benzodiazepines 22

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Pharmacotherapy Algorithm

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(DiPiro, J. T. 2014. Pharmacotherapy: A pathophysiologic approach. 9th ed.)

Pharmacotherapy – First Line Agents ● Selective Serotonin Reuptake Inhibitors (SSRIs)  Start at low end of therapeutic range and titrate up gradually until desired response is achieved  May push dose to higher therapeutic range (per patient tolerance) before concluding that therapy has failed  Fluoxetine, paroxetine*, sertraline*

● Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)  Venlafaxine XR

* FDA indication for treatment of PTSD

(Pharmacotherapy for posttraumatic stress disorder. www.UpToDate.com, 2014)

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VA/DoD Guidelines 2010

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Monitoring ● Acute Phase    

PTSD symptoms respond slowly to pharmacotherapy Initate SSRIs within 3-4 wks of exposure Gradual titration up to therapeutic dose 8-12 wks to determine response

● Continuation Phase  Many patients undergoing concurrent psychotherapy during this phase  6 month relapse prevention

● Maintenance and Discontinuation  Patients responding to pharmacotherapy should continue therapy for at least 12 months  If residual symptoms persist, continue drug therapy  Drug therapy can be withdrawn and slowly tapered over 1 month to reduce potential for relapse (DiPiro, J. T. 2008. Pharmacotherapy: A pathophysiologic approach. )

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Question 1 1. DSM-5 diagnostic criteria of PTSD does not include criterion for: a. b. c. d.

Stressors Avoidance Negative Cognitions and Mood Arousal and Recovery

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Question 2 2. Cognitive-behavior therapy, is the only effective method of psychotherapy in the treatment of PTSD. a. True b. False

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Question 3 3. Initial pharmacotherapy options for treatment of PTSD includes: a. b. c. d.

SSRIs Benzodiazepines Tricyclic Antidepressants MAO Inhibitors

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References American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., Wachter, K., Murray, L. K., & Bolton, P. A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368, 2182-219. Bruce, T. J., Spiegel, D. A., & Hegel, M. T. (1999). Cognitive–behavioral therapy helps prevent relapse and recurrence of panic disorder following alprazolam discontinuation: A long-term follow-up of the Peoria and Dartmouth studies. Journal of Consulting and Clinical Psychology, 67(1), 151. Bryant, R.A., Mastrodomenico, J., Felmingham, K.L., Hopwood, S., Kenny, L., Kandris, E., Cahill, C. & Creamer, M. (2008). Treatment of acute stress disorder: A randomized controlled trial. Archives of General Psychiatry, 65, 659-667.

DiPiro, J. T., et al. (2008). Pharmacotherapy: A pathophysiologic approach. New York: McGraw-Hill Medical. Kessler, R. C., Berglund, P. A., WaiTat, C., Demler, O., Glantz, M., Lane, M. A., ... & Üstün, T. B. (2008). The National Comorbidity Survey Replication (NCS-R): cornerstone in improving mental health and Mental Health Care in the United States. The WHO world mental health surveys: global perspectives on the epidemiology of mental disorders, 165-210. National Comorbidity Survey. (2005). NCS-R appendix tables: Table 1. Lifetime prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Table 2. Twelve-month prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Accessed at: http://www.hcp.med.harvard.edu/ncs/publications.php Norris, F. H., & Slone, L. B. (2013). Understanding Research on the Epidemiology of Trauma and PTSD Special Double Issue of the PTSD Research Quarterly. PTSD Research Quarterly, 24(2), 1-13. Pharmacotherapy for posttraumatic stress disorder. (2014). Accessed at: www.UpToDate.com. Stahl, S. M. (2008). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications. Cambridge: Cambridge University Press.

U.S. Department of Veterans Affairs. (2014). A VA Clinician’s Guide to Managing Posttraumatic Stress Disorder: Improving quality of life through the use of evidence-based medicine. Van der Kolk, B. A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 1071(1), 277293.

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