New Approaches to Posttraumatic Stress Disorder

Robert K. Schneider, MD

Assistant ProfessorDepartments of Psychiatry and Internal Medicine

The Medical College of Virginia of

the Virginia Commonwealth University

Epidemiology

• Epidemiological Catchment Area Study (1987)– Lifetime prevalence: 1-2%

• Urban sample of HMO enrollees (1991)– 11.3% of women

• National Comorbidity Study (1995)– 7.8% of responders

Diagnosis

• Exposure of self or others to an “extreme”

stressor (“the trauma”)

– Avoidance

– Re-experiences

– Hyperarousal

Avoidance or Numbing

• Avoidance of associated thoughts, feelings, activities, or places

• Diminished interest

• Detachment

• Restricted range of affect

Re-experience the trauma

• Flashbacks

• Nightmares

• Intrusive thoughts

• Intense reaction when exposed to “triggers”

Hyperarousal

• Sleep problems

• Irritability

• Hypervigilance

• Exaggerated startle

• Difficulty concentrating

Progression of symptoms - Blank

• Acute stress disorder

• Acute PTSD

• Chronic PTSD

• Delayed PTSD

• Intermittent

• Residual

• Reactivated

Areas of focus tonight

• Stressor Criterion & Non-Assaultive Trauma

• The “Great Imposter”

• Management Update

Stressor Criteria

• Exposed to event that involved serious

injury, or a threat to the physical integrity of

self or others

• The person’s response involved intense

fear, helplessness or horror (change from

DSM-IIIR)

Trauma and PTSD in the community,

The 1996 Detroit area survey of trauma

Breslau N, Kessler RC, et. al. Arch Gen Psychiatry, July

1998;55:626-632• A representative sample (2181) persons aged 18-45 years old in the Detroit metropolitan area screened for traumatic events

• 90% of respondents had experienced one or more traumas

• Most prevalent trauma: the unexpected death of a loved one

• Contingent risk for PTSD (all traumas)– women: 13% men: 6.2%

Categories of traumatic events

• Personally experienced assaultive violence – 37.7%

• Other personally experience injury or shocking experience – 59.8%

• Learning about traumas to others– 62.4%

• Sudden unexpected death of a loved one – 60.0%

Conditional Risk

• Rape 40-60%

• Combat 35%

• Violent Assault 20%

• Sudden death of a loved one 14%

• Witnessing a traumatic event 7%

• Learning about trauma to others 1-2%

Bullets

• PTSD is a civilian disease

• Non-assaultive trauma is a common and

real stressor in the genesis of PTSD

The “Great Imposter”

• Depression

• Panic attacks

• Substance abuse

• Personality

• Physical symptoms (somatization)

Concurrent Psychiatric Illness in Inpatients with PTSD

• 374 inpatients at a VA Medical Center

• 16.8% have PTSD diagnosis

• Mean number of diagnoses– 1.4 diagnoses non-PTSD– 2.9 diagnoses PTSD

• Alcohol abuse; unipolar depression; atypical psychosis and intermittent explosive disorder

Depression and PTSD

• Significantly associated

• Posttraumatic depression may occur without PTSD

• Depression more likely later in the course of PTSD

• Later in the course the patient may no longer meet criteria for PTSD but may still have major depression

Panic and PTSD

• Panic attack may be a marker for PTSD– Incidence is 69%

• PTSD more common in patients with Major Depression and Panic disorder

• Benzodiazepines are effective in Panic but not in PTSD

Substance Abuse and PTSD

• At least 2 possible courses:– PTSD before the Substance Abuse– PTSD after the Substance Abuse

• Substance Abuse and PTSD likely to be hospitalized more than Substance Abuse alone

• In veterans the incidence of concurrent substance abuse is 60-80%

Personality and PTSD

• PTSD is very common but not universal in

Borderline Personality Disorder

• Early trauma associated

• Repeated or chronic trauma associated

“Complex” PTSD - Herman

• Occurs after prolonged and repeated trauma

• Three broad areas of disturbance– Multiplicity of symptoms

– Characterological changes

– Repetition of harm

Bullet

The most common diagnosis missed is the second diagnosis-

Sir William Osler

Management

• Treatments

– Psychopharmacology

– Psychotherapy

• Setting

– Specialty Mental Health

– Primary Care

Psychopharmacology

• SSRIs (e.g. sertraline)

• Tetracyclics (i.e. trazadone and nafazadone)

• Tricyclics (i.e.imipramine and amitriptyline)

• MAOIs (e.g. phenelzine)

• Benzodiazepines

• Mood stabilizers

• Antipsychotics

Which to choose?

SSRIs are first line treatment

• TCAD: side effects and lethal in suicide

• Benzodiazapines: no RCT showing efficacy and some evidence that PTSD deteriorates with treatment.

• MAOIs: only second line

• Neuroleptics: no RCT to support, the newer novel antipsychotics would be used first and found to have unique clinical application

Medication trail

• 8-12 weeks of SSRI

• If no response then another antidepressant

• If partial response and:– Sleep disturbance then tetracyclic– Irritability then mood stabilizer– Peripsychosis then antipsychotic

Psychotherapies

• Education and supportive

• Cognitive therapy

• Behavioral therapy (relaxation techniques)

• Exposure therapy

• EMDR (eye movement desensitization reprocessing)

Primary Care Setting

• Only 38% of cases receive treatment

• 28% of cases and 75% in treatment are seen in the

primary care setting

– 10% of all PTSD and 25% of those treated are in

the specialty mental health sector

• “did not have a problem requiring treatment” was

the most common reason of the 62% of PTSD

patients not receiving treatment

Management Bullets

• Screen for “worst traumas”

• Suggest and use psychotherapies early

• SSRIs are the first line treatment

• Start low and go slow

• Combine other medications if symptoms persist

Conclusions

• A civilian disease

• The “trauma” may be non-assaultive

• Often masquerades as another illness

• SSRIs are the treatment of choice

• Combine psychotherapy and medications

• Most PTSD is treated in primary care

Questions

• How much PTSD do you see?

• How do you screen for PTSD?

• What traumas do you see?

• What treatments do you use?

• What are you doing to treat PTSD in primary care?