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

2. 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

3. 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

4. PTSD in the Primary Care Setting
PTSD present in 8.6% of primary care patients
Trauma is common
% 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

5. 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

6. 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

7. 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.

8. 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.

9. 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).

10. 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.

11. 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

12. 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.

13. 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

14. Better than nothing screening: GAD-7
PTSD
66% sensitivity
81% specificity

15. 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
PCL-C (endorsed by SAMHSA), cut off score of 30
- 98% sensitive, specificity >80%
SPAN and Breslau have reasonable evidence
Very short screens are less useful

16. 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

17. 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

18. 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
%20CBT/pages/4%20Emotion%20Regulation%20Skills/Client%20Handouts/Relaxation/Ways%20to%20Rela x%20by%20Using%20breathing.pdf

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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 mg po bedtime and PRN
Prazosin 1-3mg po bedtime
Guanfacine not supported in studies

27. 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

28. 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

29. Obsessive- Compulsive Disorder
The End!
Obsessive- Compulsive Disorder
01/29/15
eye/?source=photoeditorspicks 29 29