Post-Traumatic Stress Disorder

1. Post-Traumatic Stress Disorder William J. Resch, DO, FAPA Rural Health Scholars Retreat Athens, Ohio October 19, 2013

2. Disclosures Off-label indications will be discussed in this presentation I disclose that I have no relevant financial or other interest in any commercial company or entity pertaining to this educational talk

3. Objectives • Interactive lecture with multitude of questions and a brief representative case study • Give brief overview of PTSD • Look at diagnosing PTSD • Review current treatment(s) of PTSD • On own in Primary Care / Rural Health Area • Referral to VA

4. Current Understanding? How many members of the audience would feel comfortable diagnosing, and initiating PTSD treatment to a returning combat vet from Iraq or Afghanistan? How many members of the audience would know how to and what the VA has to offer veterans with PTSD?

5. Pre-Lecture Questions? When was PTSD officially recognized as a formal diagnosis? In 1980 the APA formally codified PTSD in the DSM-III Prior to 1980 it was documented under many names… ***

6. Critical Incident Stress (CIS)

7. Combat Stress Reaction / Battle Fatigue

8. Shell Shock

9. Acute Stress Disorder / Traumatic Stress

10. Posttraumatic Stress Disorder

11. Iraq / Afghanistan

12. Any Trauma…

13. Pre-Lecture Questions? T or F - People with PTSD are violent and unpredictable? False - Beliefs that violence and unpredictability are associated with serious mental problems are common, but untrue. This misguided fear is one of the most prominent barriers to acceptance and social inclusion. In reality, the presence of PTSD or a psychological condition does not make someone prone to violence. Therefore, someone with PTSD or some other psychological condition should not be viewed as a threat in the community, office, workplace, etc.

14. Pre-Lecture Questions? T or F - Once people develop PTSD, they will never recover. False - Studies show that most people with PTSD and other mental illnesses get better, and many recover completely. Recovery refers to the process in which people are able to live, work, learn and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life. For others, recovery implies the reduction or complete remission of symptoms.

15. Pre-Lecture Questions? T or F - Therapy and self-help are a waste of time. Why bother when you can just take a pill? False - Treatment and supports vary depending on the individual. A lot of people work with therapists, counselors, friends, psychologists, psychiatrists, nurses and social workers during the recovery process. They also use self-help strategies and community supports. Some choose medications in combination with other supports. The best approach is tailored to meet the specific needs and choices of the individual.

16. Pre-Lecture Questions? How many medications are FDA approved for the treatment of PTSD? Only two! sertraline (Zoloft) and paroxetine (Paxil). However, many other medications and classes are used in the treatment of this condition.

17. What is PTSD? Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that can develop in response to a traumatic event(s) Typically involves 3 types of symptoms / clusters *** lasting > 1 month Symptoms lead to problems in functioning in social / family life, work, or school

18. What is PTSD? Normal to have painful memories after a traumatic event Trauma affects the way people think about themselves, others, the world, and the future For most, these reactions lessen over time and thinking returns to normal For some, however, reactions continue, become severe, become disruptive, and lead to more lasting PTSD symptoms

19. DSM-5 Overview • Trauma and Stressor-Related Disorders (DSM-5) • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Posttraumatic Stress Disorder (aka PTSD) • Acute Stress Disorder • Adjustment Disorders • Chapter placed near anxiety disorders, obsessive-compulsive related disorders, and dissociative disorders due to close relationship of all of the diagnoses

20. DSM-5 Diagnostic Criteria • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: • Directly experiencing the traumatic event(s) • Witnessing, in person, the event(s) as it occurred to others • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) ***

21. DSM-5 Diagnostic Criteria • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s) • Recurrent, involuntary, and intrusive distressing memories of the traumatic event • Recurring distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s) • Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) • Marked physiological reactions to internal and external cues that symbolize or resemble an aspect of the traumatic event(s)

22. DSM-5 Diagnostic Criteria • Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or the following: • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings

23. DSM-5 Diagnostic Criteria • Negative alterations in cognitions or mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: Memory disturbance, negative beliefs, distorted cognitions, negative emotional state, anhedonia, detached feelings, and inability to experience positive emotions

24. DSM-5 Diagnostic Criteria Marked alterations in arousal or reactivity associated with the traumatic event(s) as evidenced by two or more of the following: irritability/anger, reckless/destructive behavior, hypervigilance, exaggerated startle response, problems concentrating, sleep disturbance Duration > 1 month Significant distress and impairment Not attributable to substance or other medical condition

25. Can I do anything for a pt/vet with PTSD? You can do a great deal, starting with how you act and speak to people with mental illness You can create an environment that builds on people’s strengths, promotes understanding, and of acceptance Be “Psychiatrically Minded”! Never say “that is for your other doctor”!

26. Diagnosis in Primary Care “If you don’t take the temperature, you can’t find the fever…” Know something about our nation’s military history and about our present military conflicts Know something about DoD and VA Ask each and every patient if he/she was a service member/veteran? If so: ask the branch, years served, job, rank, combat, and type of discharge? ***

27. Diagnosis in Primary Care • Common themes and problems • Marriage, relationship problems • Medical issues • Financial hardships • Endless questions from family and friends • Guilt, shame, anger • Lack of structure

28. Diagnosis in Primary Care • Common themes and problems • Feelings of isolation • Nightmares, sleeplessness • Lack of motivation • Forgetfulness • Anger • Feeling irritable, anxious, “on edge”

29. Diagnosis in Primary Care Don’t label people with words like “crazy,” “wacko” or “loony” or define them by their diagnosis (e.g. PTSD’er) It is important to make a distinction between the person and the illness Instead of saying someone is “mentally-ill,” say he or she “has PTSD” Don’t say “a mentally-ill person,” say “a person with PTSD” This is called “people-first” language

30. Assessment Measures Primary Care PTSD Screen (PC-PTSD) Combat Exposure Scale (CES) PTSD Checklist – Civilian Version (PCL-C) Trauma Symptom Checklist - 40 (TSC-40) 3 Question DVBIC TBI Screening Tool Other measures as appropriate

31. Representative Case Steve is a 29 yo MWM who presents to your rural primary care office complaining of chronic insomnia, nightmares, depression, anxiety, difficulty concentrating, and inability to tolerate large crowds. States most of the time “I feel like I am in a fog”. *** Reports his wife encouraged him to come to your office “to get some help” or she was going to consider moving out?

32. Case Study • What other questions do you need to ask Steve? • Duration • Impairment / Occupational Functioning • Military history • Psych history • Substance Use / History • Psychiatry ROS • What tests could you administer in your office? • Who else could you talk to for increased collateral information? • What labs would you want to order?

33. Case Study • What treatment options might you consider? • Antidepressant • Anxiolytic / Benzodiazepine • Antihypertensive • Antipsychotic • Hypnotic • Mood Stabilizer

34. Case Study • What non-pharmacological treatment recommendations could you recommend to Steve… • Abstinence from alcohol and other illicit drugs • Evidence Based Psychotherapy referral • Cognitive Processing Therapy (CBT) • Prolonged Exposure Therapy • Eye Movement Desensitization Reprocessing (EMDR)

35. Treatment Evidence Based Medicine exists in all of medicine… and certainly in Psychiatry! Clinical Practice Guidelines are the “gold standards” of competent care The best studies and research regarding PTSD is coming from DoD/VA!

36. Clinical Practice Guidelines Assist clinicians in learning about available treatments, reviewing their evidence base and making practical, patient-specific choices among them Provide clinical algorithms that walk clinicians through the necessary steps from screening and initial assessment through treatment and re-assessment Most relevant among these is the VA / DoD Clinical Practice Guideline for the Management of Posttraumatic Stress

37. VA / DoD Practice Guidelines Created by a working group of VA and DoD clinicians and researchers Separate algorithms defined for primary care providers and mental health professionals Evidence tables provided for each recommendation and a substantial literature review included Available at: http://www.healthquality.va.gov/ In the public domain

39. VA / DOD Guidelines for Treatment of PTSD Washington (DC): Veterans Health Administration, Department of Veterans Affairs. Available at: VHA Web site. www.guidelines.gov Data reviewed up to 9/10

40. VA / DOD Guidelines for Treatment of PTSD Washington (DC): Veterans Health Administration, Department of Veterans Affairs. Available at: VHA Web site.www.guidelines.gov

41. Other Guidelines The American Psychiatric Association (APA) has published a Practice Guideline for Patients with Acute Stress Disorder and Posttraumatic Stress Disorder The International Society for Traumatic Stress Studies, the world’s largest international multidisciplinary professional organization working in the field of psychological trauma, provided a comprehensive set of treatment guidelines in 2000 with an update version in 2008 Both guidelines provide a thoughtful introduction to available therapies, significant background information and evidence-based treatment recommendations.

42. Cognitive Processing Therapy aka CPT Identify and clarify patterns of thinking Identify distressing trauma-related thoughts Convert these thought patterns into more accurate thoughts Address core beliefs about self, others, larger world

43. Prolonged Exposure Therapy aka PET Reduce the fear associated with traumatic experience through repetitive, therapist-guided confrontation of feared places, situations, memories, thoughts, and feelings Exposure can be “imaginal” or “in vivo” Reduced intensity of emotional and physiological response is achieved through habituation.

44. Stress Inoculation Training • aka SIT • Anxiety management is among the most useful psychotherapeutic treatments for PTSD clients (Expert Consensus Guideline Series) • SIT can be thought of as a set of skills for managing stress and anxiety • Breathing control, Deep Muscle Relaxation, Assertiveness Training, Role Playing, Covert Modeling, Thought Stopping, Positive Thinking, Self Talk

45. Eye Movement Desensitization and Reprocessing aka EMDR Accessing and processing traumatic memories to bring these to resolution The client focuses on emotionally disturbing material while at the same time focusing on an external stimulus (usually therapist directed bilateral eye movements, hand tapping, sounds)

46. Medications • Specific serotonin reuptake inhibitors (SSRI’s) and venlafaxine (Effexor) have the strongest evidence • While many drugs from a wide range of classes have been studied in PTSD, there is little evidence for their use except as adjunctive treatment • Antipsychotics often prescribed in VA/DoD settings • Available research suggests that prazosin reduces the frequency and intensity of posttraumatic nightmares and may be effective in managing other symptoms of PTSD • Benzodiazepines are NOT effective as first line agents in the treatment of PTSD • Because of potential for dependence and abuse, their use as single agents is strongly discouraged!!!!!!!!!!!!!!!

47. Referral to VA? • 153 medical centers • at least one in each state, Puerto Rico and the District of Columbia • 909 ambulatory care and community-based outpatient clinics (CBOC’s) – in Southern Ohio alone there are CBOC’s in Marietta, Cambridge, Athens, Wilmington, Portsmouth, and Lancaster • 47 residential rehabilitation treatment programs • 232 Veterans Centers

48. Referral to VA? 88 comprehensive home-care programs 4 DoD/VA Polytrauma Centers My HealtheVethttp://www.myhealth.va.gov/ PTSD Coach Application for Droid/I-phone 21 Veterans Integrated Service Networks (VISNs)

49. Other Services available at VA PTSD Clinic Group therapies MHRRTP = PRRTP/SATP Suboxone Clinic Transcranial Magnetic Stimulation (TMS) Community Residential Care (CRC) Homes TeleBuddy System Telepsychiatry Acute Inpatient Psychiatry Long Term Psychiatry Community Living Centers

50. What else can you do? Learn the facts about mental health and PTSD and share them with others, especially if you hear something that isn’t true If you treat people with PTSD in your practice, consider hosting workshops to educate patients, families, and co-workers on the facts