1. New Approaches to Posttraumatic Stress Disorder Robert K. Schneider, MD Assistant Professor Departments of Psychiatry and Internal Medicine The Medical College of Virginia of the Virginia Commonwealth University

2. 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

3. Diagnosis Exposure of self or others to an “extreme” stressor (“the trauma”) –Avoidance –Re-experiences –Hyperarousal

4. Avoidance or Numbing Avoidance of associated thoughts, feelings, activities, or places Diminished interest Detachment Restricted range of affect

5. Re-experience the trauma Flashbacks Nightmares Intrusive thoughts Intense reaction when exposed to “triggers”

6. Hyperarousal Sleep problems Irritability Hypervigilance Exaggerated startle Difficulty concentrating

7. Progression of symptoms - Blank Acute stress disorder Acute PTSD Chronic PTSD Delayed PTSD Intermittent Residual Reactivated

8. Areas of focus tonight Stressor Criterion & Non-Assaultive Trauma The “Great Imposter” Management Update

9. 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)

10. 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%

11. 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%

12. 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%

13. Bullets PTSD is a civilian disease Non-assaultive trauma is a common and real stressor in the genesis of PTSD

14. The “Great Imposter” Depression Panic attacks Substance abuse Personality Physical symptoms (somatization)

15. 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

16. 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

17. 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

18. 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%

19. Personality and PTSD PTSD is very common but not universal in Borderline Personality Disorder Early trauma associated Repeated or chronic trauma associated

20. “Complex” PTSD - Herman Occurs after prolonged and repeated trauma Three broad areas of disturbance –Multiplicity of symptoms –Characterological changes –Repetition of harm

21. Bullet The most common diagnosis missed is the second diagnosis- Sir William Osler

22. Management Treatments –Psychopharmacology –Psychotherapy Setting –Specialty Mental Health –Primary Care

23. 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

24. 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

25. 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

26. Psychotherapies Education and supportive Cognitive therapy Behavioral therapy (relaxation techniques) Exposure therapy EMDR (eye movement desensitization reprocessing)

27. 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

28. 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

29. 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

30. 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?