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Post traumatic stress disorder

Post traumatic stress disorder. Jeff Clothier, M.D. PTSD Overview. Epidemiology Diagnosis Psychiatric Comorbidity Treatment. PTSD DSM-IV Criteria. Exposure to traumatic event with Actual or threatened death or serious injury and Response involving intense fear, helplessness, or horror.

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Post traumatic stress disorder

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  1. Post traumatic stress disorder Jeff Clothier, M.D.

  2. PTSDOverview • Epidemiology • Diagnosis • Psychiatric Comorbidity • Treatment

  3. PTSDDSM-IV Criteria • Exposure to traumatic event with • Actual or threatened death or serious injury and • Response involving intense fear, helplessness, or horror American Psychiatric Association. DSM-IV. 1994.

  4. PTSDDSM-IV Criteria (cont.) • Re-experiencing the traumatic event • Persistent avoidance of stimuli associated with event • Numbing of general responsiveness • Symptoms of increased arousal • At least 1 month’s duration (otherwise can diagnose Acute Stress Disorder) • Significant distress or impairment in social, occupational, or other functioning American Psychiatric Association. DSM-IV. 1994.

  5. PTSDAssociated Features • Alcohol/drug problems • Aggression/violence • Suicidal ideation, intent, attempts • Dissociation • Distancing • Problems at work • Marital problems • Homelessness

  6. Lifetime Prevalence of DSM-III-RMajor Psychiatric DisordersNCS Data • % • Mood Disorders • Major depressive episode 17.1 • Dysthymia 6.4 • Manic episode1.6 • Anxiety Disorders • Social Phobia 13.3 • Simple Phobia 11.3 • PTSD 7.8 • Agoraphobia without panic 5.3 • GAD 5.1 • Panic disorder3.5 • Substance Use Disorders • Alcohol abuse/dependence 23.5 • Drug abuse/dependence11.9 Adapted from Kessler et al. 1994, 1995.

  7. Function and Quality of Life In Vietnam Veterans With and Without PTSD PTSD Non-PTSD Percent Not Working Fair orPoorHealth ReducedWell-Being PhysicalLimitation Violent BehaviorPast Year Zatzick DF et al. Am J Psychiatry. 1997;154:1690–1695.

  8. PTSDRisk Factors for PTSD • Severity of trauma (ie, threat, duration, injury, loss) • Prior traumatization • Gender • Prior mood and/or anxiety disorders • Family history of mood or anxiety disorders • Education

  9. PTSD risks • Epidemiologically, there are two other risk • The risk of having a trauma exposure • The risk for developing PTSD from that exposure • Has implications for public health policies

  10. Men Women Risks of Specific Traumasin the US Population Percentage Natural Disaster Criminal Assault Combat Rape • About 30% of people exposed to trauma developed PTSD Kessler RC et al. Arch Gen Psychiatry. 1995;52:1048–1060.

  11. Men Women PTSDRates Related to Specific Traumas Percentage Natural Disaster Criminal Assault Combat Rape Kessler RC et al. Arch Gen Psychiatry. 1995;52:1048–1060.

  12. PTSDPersistence Over Time (Untreated Group) 100 75 % Without Recovery 50 25 0 1 2 3 4 5 6 7 10 Years Kessler RC et al. Arch Gen Psychiatry. 1995;52:1048–1060.

  13. PTSDImpact of Treatment on Recovery (N = 459) Treated Untreated Median Months to Recovery Kessler RC et al. Arch Gen Psychiatry. 1995;52:1057.

  14. Biological Correlates of Chronic PTSD Increased sympathetic responses to trauma reminders Normal resting catecholamines with increased responses to trauma stimuli Decreased cortisol. Excessive feedback inhibition. Increased free T3 and T4 Insomnia and increased # of rapid eye movements during REM sleep Possible reduction in hippocampal volume?

  15. Epidemiology of PTSD • 7.8% of adults in the U.S. (lifetime) • Type of trauma most often the basis for PTSD - rape in women (46% risk) combat in men (39% risk) • one third of cases have duration of many years • 88% of cases have psychiatric comorbidity Kessler et al., 1995

  16. PTSDPsychiatric Comorbidity • Lifetime Rates (%) • Men Women • PTSD Non-PTSD PTSD Non-PTSD • Depression 48 12 48 19 • Mania 12 1 6 1 • Panic Disorder 7 2 13 4 • Social Phobia 28 11 28 14 • GAD 17 3 15 6 • Alcohol Abuse/Dependency 52 34 28 13 • Substance Abuse/Dependency 34 15 27 8 • Any Diagnosis 88 55 79 46 Kessler RC et al. Arch Gen Psychiatry. 1995

  17. PTSD comorbidity • Patient usually has other psychiatric disorders • “Ticks and fleas” • Makes treatment difficult • More deadly

  18. Impact of Comorbid PTSD in Subjects With Other Anxiety Disorders 80 Anxiety DisorderWith PTSD Anxiety DisorderWithout PTSD 60 48 (%) Rates 38 40 30 30 21 20 6 0 AttemptedSuicide Hospitalized AlcoholProblems Warshaw MG et al. Am J Psychiatry. 1993;150:1512–1516.

  19. PTSDTreatment Options • Psychotherapy • Pharmacotherapy • Multimodal treatment

  20. Expert Consensus GuidelinesJ Clin Psychiatry, ‘99 Psychotherapy first Mild PTSD Noncomorbid children, adults, geriatric patients Psychotherapy first or combine meds/psychotherapy More severe Combine meds/ psychotherapy from start Comorbid population

  21. Considerations for psychotherapy • Capacity to tolerate distress with exposure • Motivation/preference • Ability to participate and follow structure • Problems with interpersonal adjustment

  22. Treatment of PTSD by Exposureand/or Cognitive Restructuring r = relaxationc = cognitive restructuringe = prolonged exposureec = e + c r c IES Scores ec e Treatment Follow Up 1 mo 3 mos 6 mos Marks I et al. Arch Gen Psychiatry. 1998;55:317–325.

  23. PTSDGoals of Pharmacotherapy • Reduction/amelioration of target symptoms • Improve sleep • Affects improvement in other symptoms (eg, irritability, preoccupation, vigilance, impaired concentration) • Decreased risk for development of comorbidity • Reduce re-experiencing and intrusive symptoms • Improve mood and numbing • Reduce phasic and tonic hyperarousal • Reduce impulsivity • Reduce psychotic or dissociative symptoms Davidson and van der Kolk, 1996.

  24. Pharmacologic treatment • Multiple conditions • Medical comorbidities • Side effects from one treatment may impact other symptoms and medications.

  25. PTSDMedications Studied • Benzodiazepines • Antidepressants • TCAs • MAOIs • SSRIs • 5-HT2 antagonists • Anticonvulsants/antipsychotics • Noradrenergic agents: clonidine, propranolol

  26. PTSD Treatment With SSRIsEffect of Fluoxetine Effect of Trauma Population 100 Fluoxetine Placebo 80 60 CAPS Total Score 40 20 0 Pre Post Pre Post Pre Post Pre Post Trauma Clinic (n = 23) VA (n = 24) Van der Kolk BA et al. Prim Care. 1993;20:417–432.

  27. Sertraline Efficacy in PTSD (N=187) 0 -5 -10 -15 † -20 -25 Sertraline Placebo * -30 * -35 CAPS-2 IES DTS -40 *p<0.05; †p=0.07; Brady et al, JAMA, 2000

  28. PTSD and Comorbid Depression: Sertraline Studies PTSD with No ComorbidDepressive Disorder PTSD with ComorbidDepressive Disorder 80 p=0.011 p=0.0034 60.9% 70 56.7% 60 50 40.2% Percent Responders* 37.8% 40 30 20 10 0 Sertraline (N=104) Placebo (N=112) Sertraline (N=87) Placebo (N=82) *Response is defined as CGI=I score of 1 (very much improved) or 2 (much improved) at end point Brady et al., 2000, Davidson et al. , 1998

  29. Quality of Life In PTSD Sertraline vs. Placebo 14 • Subscales all p0.05 • Mood • Social relationship • Leisure time • Ability to fix • Living/housing • Physical ability • Work/hobby 12 Sertraline 10 Placebo 8 Change in Q-LES-Q 6 4 2 0 Total Scores* *p0.004, Brady et al., 2000

  30. Sertraline in PTSD: The Effect of Continuation Treatment with Sertraline CAPS-2Total Score 80 70 60 50 40 30 20 10 0 Baseline Week 12 Week 20 Week 28 Week 36 Endpoint(LOCF) Acute Phase Continuation Phase Londborg, APA/CINP 2000

  31. 5HT2 antagonists • Trazodone – commonly used for sleep, may reduce nightmares • Cyproheptadine – reports of improved sleep with decreased nightmares as well, appetite stimulant as well. (Pharmacologically rich compound)

  32. Anti-Psychotic Agents • Not first-line but often required in difficult cases • Indications: • Reduce disorganizing hyperarousal, paranoid ideation, and aggressive impulsivity • Co-morbid psychotic disorder • Low doses are often effective • Atypical agents preferred

  33. Mood Stabilizers • Carbamazepine • Open clinical trial: decreased intrusions, flashbacks, insomnia, irritability, impulsivity, and violent behavior (Lipper et al., Psychosomatics, 1986) • Valproic acid • Open trial: decreased hyperarousal and avoidance (Stein, J Clin Psych, 1995) • Lamotrigine • Small controlled trial: decreased re-experiencing, numbing and avoidance (Hertzberg et al., Biol Psychiatry, 1999)

  34. Recommendations for Early Intervention and Prevention Early Intervention and Prevention • Immediately after exposure: • Normalize distress • Educate patient, family and significant others • Repeated retelling of the event • Provide emotional support • Relieve irrational guilt • Refer to peer support group or trauma counseling • Consider short-term sleep medication for insomnia Foa, Davidson, Frances, J Clin Psychiatry 1999

  35. PTSD Summary • PTSD is common • Usually chronic • Presentations vary • Comorbidity is the rule • Comprehensive assessment of patients is critical to develop an individualized treatment plan • Treatment often involves multiple modalities

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