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PTSD : An Update on the Evidence

This article provides an update on the evidence regarding PTSD, including its prevalence, factors contributing to its development, and effective treatments. It dispels myths about therapy and discusses the use of medication. It also touches on non-pharmacologic biological treatments and cannabis use. Additionally, it briefly mentions the lack of research on the use of complementary and integrative health practices for PTSD.

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PTSD : An Update on the Evidence

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  1. PTSD : An Update on the Evidence Kathleen M. Chard, PHD Associate Chief of Staff/Research Director, Trauma Recovery center Cincinnati VA Medical Center Professor, Psychiatry and Behavioral Neuroscience Director, UC Health Stress Center University of Cincinnati

  2. Combat • Violent personal assault: rape, mugging, physical assault • Kidnapping • POW and Concentration Camp survivors • Terrorist Attacks • Airplane Crashes • Severe Auto Accidents • Torture • Natural Disaster • Fires • Hostage situations etc. People can get PTSD from:

  3. Lifetime prevalence of 7-14%1 • 5-6% of men and 10-14% of women1 • 20-30% of Veterans • 5th most common psychiatric disorder2 • Only Major Depression, ADHD, Specific Phobias and Social Anxiety Disorder occur more often What we Know: Prevalence 1Yehuda R (2002) N Engl J Med 346(2):108-114 2Kessler R (2005) Arch. Gen. Psychiatry 62:592–602

  4. Genes • Temperament • Family environment • Trauma characteristics - age, chronicity, predictability, trust in perpetrator • Post-trauma perceived social support • PTSD is interrupted recovery Who Develops PTSD?

  5. Begins with normal response to extraordinary events • Behavior that is adaptive during trauma: • Hypervigilance • Increase Arousal • Emotional Numbing • Can lead to difficulty later • When recovery does not occur on its own, PTSD can develop • Increased risk of PTSD with chronic trauma, e.g. multiple deployments (Thomas et al, Arch Gen Psych, 2010) Recovery From PTSD

  6. Anterior Cingulate

  7. neurotransmitters Well-modulated emergency response PFC Amygdala Amygdala Brain stem Threat (UCS) Resick and Rasmusson, 2010

  8. neurotransmitters PTSD Response Bremner et al 1999b; Milad, et al. 2009; Rauch et al 1998, 2000; Shin, et al. 2001 PFC Amygdala Brain stem Trauma Triggers (CS) Resick and Rasmusson, 2010

  9. What DOES THE EVIDENCE SAY? Trauma-focused psychotherapy works • Untreated PTSD can impact health and enjoyment of life • With no treatment, symptoms are unlikely to get better and may get worse • Myth Busting: Trauma-focused psychotherapy for PTSD is not laying on a couch, won’t go on indefinitely, and is not the same as talking to a support group. • There are several recommended treatments, not just for PTSD but also for the comorbid symptoms • There are side effects to medications and to psychotherapy; it is hard work and symptoms may worsen initially

  10. Treatment Selection: Therapy over Medication • Trauma Focused Psychotherapy • SSRI/SNRI • Non-Trauma Focused Psychotherapy

  11. Recommend Trauma Focused Psychotherapy • PE • Specific cognitive behavioral therapies for PTSD • Individual, manualized trauma-focused psychotherapy • CPT • BEP • EMDR • NET • Additional trauma-focused psychotherapies • Written Narrative Exposure

  12. Lee et al. (2016) Systematic Review Both medication and psychotherapy are effective but trauma-focused psychotherapies are better.

  13. Effects of Trauma Focused Cognitive Psychotherapy Last

  14. If individual trauma-focused psychotherapy is • not readily available or not preferred, • then recommend: Next Step in Treatment Recommendations • Pharmacotherapy: • Sertraline • Paroxetine • Fluoxetine • Venlafaxine • Manualized individual non-trauma-focused psychotherapy • Present-Centered Therapy (PCT) • Stress Inoculation Training (SIT) • Interpersonal Psychotherapy (IPT)

  15. First Line Pharmacotherapy Recommendations • Sertraline • Paroxetine • Fluoxetine • Venlafaxine Recommendation against: Benzodiazepines

  16. WHAT DOES THIS ALL MEAN? • For a majority of people treatment will help • There are a number of treatment options and it is not a one size fits all model • Some people will need to try several different treatments to obtain the recovery level they desire

  17. Non-pharmacologic Biological Treatments • Repetitive transcranial magnetic stimulation (rTMS) • Electroconvulsive therapy (ECT) • Hyperbaric oxygen therapy (HBOT) • Stellate ganglion block (SGB) • Vagal nerve stimulation (VNS)

  18. Recommendation Regarding Cannabis • Preliminary evidence that cannabis could improve PTSD symptoms, particularly nightmares, is offset by the significant side effects. • The lack of well-designed RCTs evaluating the efficacy of cannabis in large samples of patients with PTSD combined with the serious side effects, does not support the use of natural or synthetic cannabinoids as a treatment for PTSD.

  19. What about Comorbidities, technology,and Complimentary and integrative Health?

  20. Complimentary and Integrative Health Recommendations • Important to clarify that we are not recommending against these treatments but are saying that at this time, the research does not support the use of any CIH practice for the primary treatment of PTSD. Recognize their value to improve wellness and promote recovery. • No studies evaluating the use of animal-assisted therapy met the threshold for inclusion.

  21. What Does Treatment Look Like? • 7-15 sessions • Sessions can be weekly or “massed” • Individual, Group or Combined • Focus on traumatic retelling can vary from none to prolonged • Adherence is Key • Homework is important

  22. neurotransmitters How Exposure Therapy May Work PFC Amygdala Brain stem Exposure activates the amygdala but keeps the PFC from going completely off-line. Client uses words. Resick and Rasmusson, 2010

  23. How Cognitive Therapy May Work neurotransmitters PFC Amygdala BL CE Brain stem CT forces the frontal lobe on-line which inhibits the amygdala and prevents extreme emotional responses, even while the trauma circuit is simultaneously & sufficiently activated. Trauma focused cognitive therapy Resick and Rasmusson, 2010

  24. Where Are We Going? • Improved assessment – biological • Change in Delivery – Massed • Couples Based Treatments • Medications • Medication facilitated therapy – CBD, MDMA • Prevention- medication in ED • 2nd Wave interventions

  25. Resources

  26. A new online tool to help patients learn about and compare evidence-based PTSD treatments www.ptsd.va.gov/decisionaid

  27. Mobile Apps • NCPTSD has partnered with a number of organizations to develop a variety of mobile apps. • Apps are focused on PTSD, related health problems (e.g., insomnia, alcohol use, etc.), or general well-being. • There are apps for patients, providers, and for use with patient-provider dyads. www.ptsd.va.gov/public/materials/apps/index.asp

  28. Stress Center513-558-5872 Cincinnati VA Medical Center Trauma Recovery Center 859-572-6208

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