Post-traumatic Stress Disorder in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 01/22/2014 1 1

Learning Objectives: Disclosures and 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. 2 2

Review epidemiology of PTSD Review the diagnostic criteria for PTSD 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 3 3

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

Personal or Family history of psychiatric disorder 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 non- professional 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 T - Trauma exposure R - Re-experiencing A - Avoidance of reminders U - Undermined cognition and mood M - Magnified arousal and reactivity A - 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 Avoid positioning yourself between patient and exit 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 Move at the patient’s pace Take breaks as necessary Use grounding techniques if patient seems disconnected or distressed 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 trauma- related 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- %20CBT/pages/4%20Emotion%20Regulation%20Skills/Client%20Handouts/Relaxation/Ways%20to%20Rela x%20by%20Using%20breathing.pdf

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 28 28

Obsessive- Compulsive Disorder The End! Obsessive- Compulsive Disorder 01/29/15 http://proof.nationalgeographic.com/2014/11/05/musings-corey-arnold-looks-wildlife-straight-in-the- eye/?source=photoeditorspicks 29 29