Clinical Guidelines forPost-traumatic Stress

DisorderMylea Charvat – PTSD Specialist

War Related Illness and Injury Study Center

VA Palo Alto Health Care Systemmylea.charvat@va.gov

Outline

Epidemiology and Criteria Risk Pathways to PTSD Gender & Cultural Issues in PTSD DoD Guidelines:

Diagnosis & Assessment Pharmacology Psychotherapies

Resources

DSM-IV CriteriaPerson Experiences Traumatic Event

Person Experiences Fear, Helplessness or Horror

The person experiences a combination of the following Sx which are still present > 4 weeks following the TE, last more than one month and cause significant distress

Re-experiencing >1Intrusive thoughts or memoriesTrauma related dreamsActing/feeling as though the trauma were reoccurringEmotional distress in response to triggersPhysical Sx in response to triggers

Avoidance >3Efforts to avoid trauma related thoughts or feelingsAvoidance of people, places or activities that trigger reminders of traumaMemory loss for all or parts of the traumaLoss of interest in activitiesFeelings of estrangement from othersExpectation of foreshortened future

Hyperarousal >2Difficulty with sleepIrritability and angerAttention and Concentration problemsHypervigilenceExaggerated startle reaction

Epidemiology of Trauma Exposure

Only National Sample (Kessler et al., 1995) of trauma exposure 61% of men reported DSM-III TE 51% of women reported DSM-III TE

Veteran Data (US DVA, 2003) – surveyed 20,000 Veterans in US Combat exposure (41% men/ 12% women) 36% exposure to dead/dying/wounded No MST data were collected WWII Veterans reported a 54% exposure rate to combat

compared to 19% for Korea

Epidemiology of PTSD

Rates Consistent since DSM-III-R Estimates range between 6% and 12% in

general population Kessler et al., 1995 - National survey

found PTSD rates of: 20% for women 8% for men

Epidemiology of PTSD in Veterans

Study of 2,300 Vietnam Era Veterans 31% of men met PTSD criteria 27% of women met PTSD criteria

Prevalence higher with Army service (compared to other branches) >12 months service Entering service between age of 17 and 19 (Kulka et al., 1990; Schlenger et al., 1992)

Estimates of TE Exposure & PTSD prevalence among

OEF/OIF Veterans

0102030405060708090

100

Military Personnel

Criterion AStressorPTSD Low Est.

PTSD High Est.

Risk Pathways to PTSD

TEs that involve injury to self or others TEs that are more “malicious” and “grotesque” Dissociation at the time of the TE Lower education levels Lower SES Minority racial/ethnic status Family psychiatric history (esp. childhood abuse) Lack of social support Feelings of guilt or shame re the TE Previous trauma history

Also small literature indicating prior trauma may inoculate against future trauma/PTSD

Gender Issues in PTSD

Women are at greater risk for PTSD than men

When trauma characteristics are more “equal” (political situations or violent community) gender differences in PTSD rates disappear

Gender Issues in PTSD

Differences seem to be defined by trauma characteristics Women are more likely to experience sexual assault

and chronic abuse (intimate partner or childhood sexual abuse)

VA-DOD Clinical Guidelines

Recommendations for the performance or exclusion of specific procedures or services for specific disease entities

Derived through a rigorous methodological approach Includes a systematic review of the evidence

to outline recommended practice Displayed in the form of a flowchart

algorithm

Treatment Guidelines

A potential solution to inefficiency and variation in care

A user-friendly format for training and education on PTSD treatment

Designed to inform and support clinicians Must always be applied in the context of an

individual provider's clinical judgment for the care of a particular patient

Development of DoD/VA Treatment Guidelines

DoD represented by members of Army, Navy, and Air Force

DVA represented by staff of VAMCs, Readjustment Counseling Service, and the National Center for PTSD

Disciplines represented include psychiatrists, primary care physicians, psychologists, nurses, pharmacists, occupational therapists, social workers, counselors, chaplains, and administrators

Scope of DoD Treatment Guidelines

Developed to address the full spectrum of traumatic-stress response Acute Stress Response/Combat Stress Response Acute Stress Disorder PTSD

Acute PTSD Chronic PTSD PTSD with co-morbid Major Depression and/or substance abuse Complex PTSD Negative health behaviors known to adversely affect clinical

outcomes in those with PTSD

Limitations and Challenges

Inadequate clinical trials in combined treatments (such as psychotherapy and pharmacotherapy) versus single treatment approaches.

Not clear whether a treatment effective for combat Veterans with PTSD will be equally useful for survivors of another trauma, such as recent sexual assault.

Inadequate research on treatment of PTSD in patients with dual diagnosis (i.e. substance abuse/MDD)

Diagnosis & Assessment of PTSD

All new patients should be screened for symptoms of PTSD Thereafter, annually or more frequently if suspicion, recent exposure,

history of PTSD Paper-and-pencil or computer-based screening tools should be

used Notes importance of

Balancing efficacy with practical concerns (staffing, time constraints, current clinical practices)

Avoiding stigmatization and adverse occupational effects of positive screens

Individuals with positive screens should receive more detailed assessment of their symptoms (i.e. CAPS, MMPI)

PTSD Checklist (PCL-M or PCL-C)

17 item self report questionnaire In the public domain Available in CPRS or pen and paper Short and easy to score/interpret Total Severity Score correlation with the

CAPS = .94 For women Veterans utilize the PCL-C

Pharmacology Guidelines

Monotherapy Strongly recommend SSRIs 2nd line: TCAs and MAOIs Consider trial of at least 12 weeks before changing medications Consider 2nd generation (e.g., trazodone, buproprion)

Augmented therapy for targeted symptoms Consider prazosin for nightmares and other PTSD symptoms

Recommend medication compliance assessment at each visit Recommend against…

Benzodiazepines to manage core symptoms of PTSD Typical antipsychotics in management of PTSD

Psychotherapies

Significant benefit – Strongly recommended Cognitive Therapy Exposure Therapy Stress Inoculation Training Eye Movement Desensitization Reprocessing (EMDR)

Some benefit – Imagery rehearsal therapy Psychodynamic therapy Patient education (recommended for all patients)

Cognitive Therapy

Systematic approach to challenging negative trauma-related beliefs (e.g., “I should have prevented it”) Educate about role of beliefs in causing

distress Identify distressing beliefs Discuss, review evidence, and generate

alternative beliefs Rehearse revised beliefs

Exposure Therapy

Imaginal exposure = repeated retelling of trauma story with emotional activation

In vivo exposure = assignments to confront feared stimuli in environment

Prolonged Exposure Multiple repetitions via homework

Listening to cassette Writing Intended to help survivors habituate to stimuli

Stress Inoculation

Focus on management of symptoms Coping skills training

Education Muscular relaxation training Breathing retraining (slow abdominal breathing) Assertiveness Covert modeling Role playing Thought stopping Positive thinking and self-talk

EMDR

Identify Disturbing image (worst part of event) Associated body sensation Negative self-referring cognition (what learned from event) Positive self-referring cognition

Hold image/sensation/negative cognition in mind while tracking clinician’s moving finger for 20 seconds

Describe changes, new associations Repeat tracking episodes and reinforce positive

cognition

Imagery Rehearsal Therapy

Select a memory or nightmare “Change the memory any way you wish”

Patient writes down the “new version” Rehearse daily Includes education, tools for controlling

imagery

Psychodynamic Therapy

Re-engage normal adaptation by addressing unconscious to make it conscious. Deals with fears, fantasies, wishes, and

defenses. Managing transference and counter-

transference issues with an emphasis on the importance of the therapeutic relationship.

Strength of evidence: few clinical trials exist overall. Most evidence is in clinical case studies

Patient Education

Recommended for all Veterans diagnosed with PTSD

Usually conducted as a once a week group with a different topic each week

Topics include (but are not limited to): What is PTSD?

Types of symptoms

Sleep and PTSD Anger and PTSD

Evaluation of Treatment Efficacy

Regular use of self-administered checklists

Follow up status should be routinely monitored at least every 3 months, using interview and questionnaire methods

Trauma Assessment in Primary Care

If presumed PTSD or positive PTSD screen, then conduct or refer for in-depth PTSD Assessment

Recommend use of self-report measures (PCL-M, PCL-C, Mississippi-M, Mississippi-C)

PTSD Evaluation in Primary Care

If H/O Trauma - Recommend assessment of: PTSD Symptoms Dangerousness to self or others Family and social environment Ongoing health risks Medical/psychiatric co-morbidities Thorough history and physical Appropriate lab evaluation Radiological assessment Level of functioning Risk factors for development of ASD/PTSD Substance use

Primary Care Treatment Recommendations

Formulate presumptive diagnosis Consider initiating treatment or referral Treat complicating problems

Pain, insomnia, anxiety, depression

If complicated, refer to mental health Consult with MH Stay involved in treatment Take leadership in convening collaborative team

Primary Care Encouraged to:

Routinely provide: Early recognition of PTSD Supportive counseling PTSD-related education

PTSD symptoms Other traumatic stress problems/consequences Practical ways of coping with symptoms Processes of recovery Nature of treatments

Regular follow-up and monitoring of symptoms

Guideline Concordance Assessment

Complete PTSD & MST Clinical Reminders as part of routine patient care

Assess war-zone experiences systematically Screen for trauma history - PTSD Use standardized initial and follow-up assessments (i.e. PCL) to monitor

progress and evaluate treatment Treatment

Increase use of “strongly recommended” treatments Combined prolonged exposure and cognitive therapy Stress inoculation training EMDR

Contact NCPTSD Education Division (josef.ruzek@va.gov ) or War Related Illness & Injury Study Center (mylea.charvat@va.gov)

Resources

List of all inpatient and outpatient PTSD treatment programs:

vaww.nepec.mentalhealth.va.gov/PTSD

National Center for PTSD Information Center:

http://www.ncptsd.va.gov/ncmain/information