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Clinical Guidelines for Post-traumatic Stress Disorder

Clinical Guidelines for Post-traumatic Stress Disorder. Mylea Charvat – PTSD Specialist War Related Illness and Injury Study Center VA Palo Alto Health Care System mylea.charvat@va.gov. Outline. Epidemiology and Criteria Risk Pathways to PTSD Gender & Cultural Issues in PTSD

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Clinical Guidelines for Post-traumatic Stress Disorder

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  1. Clinical Guidelines forPost-traumatic Stress Disorder Mylea Charvat – PTSD Specialist War Related Illness and Injury Study CenterVA Palo Alto Health Care Systemmylea.charvat@va.gov

  2. Outline • Epidemiology and Criteria • Risk Pathways to PTSD • Gender & Cultural Issues in PTSD • DoD Guidelines: • Diagnosis & Assessment • Pharmacology • Psychotherapies • Resources

  3. DSM-IV Criteria Person Experiences Traumatic Event Person Experiences Fear, Helplessness or Horror The person experiences a combination of the following Sx which are still present > 4 weeks following the TE, last more than one month and cause significant distress

  4. Epidemiology of Trauma Exposure • Only National Sample (Kessler et al., 1995) of trauma exposure • 61% of men reported DSM-III TE • 51% of women reported DSM-III TE • Veteran Data (US DVA, 2003) – surveyed 20,000 Veterans in US • Combat exposure (41% men/ 12% women) • 36% exposure to dead/dying/wounded • No MST data were collected • WWII Veterans reported a 54% exposure rate to combat compared to 19% for Korea

  5. Epidemiology of PTSD • Rates Consistent since DSM-III-R • Estimates range between 6% and 12% in general population • Kessler et al., 1995 - National survey found PTSD rates of: • 20% for women • 8% for men

  6. Epidemiology of PTSD in Veterans • Study of 2,300 Vietnam Era Veterans • 31% of men met PTSD criteria • 27% of women met PTSD criteria • Prevalence higher with • Army service (compared to other branches) • >12 months service • Entering service between age of 17 and 19 • (Kulka et al., 1990; Schlenger et al., 1992)

  7. Estimates of TE Exposure & PTSD prevalence among OEF/OIF Veterans

  8. Risk Pathways to PTSD • TEs that involve injury to self or others • TEs that are more “malicious” and “grotesque” • Dissociation at the time of the TE • Lower education levels • Lower SES • Minority racial/ethnic status • Family psychiatric history (esp. childhood abuse) • Lack of social support • Feelings of guilt or shame re the TE • Previous trauma history • Also small literature indicating prior trauma may inoculate against future trauma/PTSD

  9. Gender Issues in PTSD • Women are at greater risk for PTSD than men • When trauma characteristics are more “equal” (political situations or violent community) gender differences in PTSD rates disappear

  10. Gender Issues in PTSD • Differences seem to be defined by trauma characteristics • Women are more likely to experience sexual assault and chronic abuse (intimate partner or childhood sexual abuse)

  11. VA-DOD Clinical Guidelines • Recommendations for the performance or exclusion of specific procedures or services for specific disease entities • Derived through a rigorous methodological approach • Includes a systematic review of the evidence to outline recommended practice • Displayed in the form of a flowchart algorithm

  12. Treatment Guidelines • A potential solution to inefficiency and variation in care • A user-friendly format for training and education on PTSD treatment • Designed to inform and support clinicians • Must always be applied in the context of an individual provider's clinical judgment for the care of a particular patient

  13. Development of DoD/VA Treatment Guidelines • DoD represented by members of Army, Navy, and Air Force • DVA represented by staff of VAMCs, Readjustment Counseling Service, and the National Center for PTSD • Disciplines represented include psychiatrists, primary care physicians, psychologists, nurses, pharmacists, occupational therapists, social workers, counselors, chaplains, and administrators

  14. Scope of DoD Treatment Guidelines • Developed to address the full spectrum of traumatic-stress response • Acute Stress Response/Combat Stress Response • Acute Stress Disorder • PTSD • Acute PTSD • Chronic PTSD • PTSD with co-morbid Major Depression and/or substance abuse • Complex PTSD • Negative health behaviors known to adversely affect clinical outcomes in those with PTSD

  15. Limitations and Challenges • Inadequate clinical trials in combined treatments (such as psychotherapy and pharmacotherapy) versus single treatment approaches. • Not clear whether a treatment effective for combat Veterans with PTSD will be equally useful for survivors of another trauma, such as recent sexual assault. • Inadequate research on treatment of PTSD in patients with dual diagnosis (i.e. substance abuse/MDD)

  16. Diagnosis & Assessment of PTSD • All new patients should be screened for symptoms of PTSD • Thereafter, annually or more frequently if suspicion, recent exposure, history of PTSD • Paper-and-pencil or computer-based screening tools should be used • Notes importance of • Balancing efficacy with practical concerns (staffing, time constraints, current clinical practices) • Avoiding stigmatization and adverse occupational effects of positive screens • Individuals with positive screens should receive more detailed assessment of their symptoms (i.e. CAPS, MMPI)

  17. PTSD Checklist (PCL-M or PCL-C) • 17 item self report questionnaire • In the public domain • Available in CPRS or pen and paper • Short and easy to score/interpret • Total Severity Score correlation with the CAPS = .94 • For women Veterans utilize the PCL-C

  18. Pharmacology Guidelines • Monotherapy • Strongly recommend SSRIs • 2nd line: TCAs and MAOIs • Consider trial of at least 12 weeks before changing medications • Consider 2nd generation (e.g., trazodone, buproprion) • Augmented therapy for targeted symptoms • Consider prazosin for nightmares and other PTSD symptoms • Recommend medication compliance assessment at each visit • Recommend against… • Benzodiazepines to manage core symptoms of PTSD • Typical antipsychotics in management of PTSD

  19. Psychotherapies • Significant benefit – Strongly recommended • Cognitive Therapy • Exposure Therapy • Stress Inoculation Training • Eye Movement Desensitization Reprocessing (EMDR) • Some benefit – • Imagery rehearsal therapy • Psychodynamic therapy • Patient education (recommended for all patients)

  20. Cognitive Therapy • Systematic approach to challenging negative trauma-related beliefs (e.g., “I should have prevented it”) • Educate about role of beliefs in causing distress • Identify distressing beliefs • Discuss, review evidence, and generate alternative beliefs • Rehearse revised beliefs

  21. Exposure Therapy • Imaginal exposure = repeated retelling of trauma story with emotional activation • In vivo exposure = assignments to confront feared stimuli in environment

  22. Prolonged Exposure • Multiple repetitions via homework • Listening to cassette • Writing • Intended to help survivors habituate to stimuli

  23. Stress Inoculation • Focus on management of symptoms • Coping skills training • Education • Muscular relaxation training • Breathing retraining (slow abdominal breathing) • Assertiveness • Covert modeling • Role playing • Thought stopping • Positive thinking and self-talk

  24. EMDR • Identify • Disturbing image (worst part of event) • Associated body sensation • Negative self-referring cognition (what learned from event) • Positive self-referring cognition • Hold image/sensation/negative cognition in mind while tracking clinician’s moving finger for 20 seconds • Describe changes, new associations • Repeat tracking episodes and reinforce positive cognition

  25. Imagery Rehearsal Therapy • Select a memory or nightmare • “Change the memory any way you wish” • Patient writes down the “new version” • Rehearse daily • Includes education, tools for controlling imagery

  26. Psychodynamic Therapy • Re-engage normal adaptation by addressing unconscious to make it conscious. • Deals with fears, fantasies, wishes, and defenses. • Managing transference and counter-transference issues with an emphasis on the importance of the therapeutic relationship. • Strength of evidence:few clinical trials exist overall. Most evidence is in clinical case studies

  27. Patient Education • Recommended for all Veterans diagnosed with PTSD • Usually conducted as a once a week group with a different topic each week • Topics include (but are not limited to): • What is PTSD? • Types of symptoms • Sleep and PTSD • Anger and PTSD

  28. Evaluation of Treatment Efficacy • Regular use of self-administered checklists • Follow up status should be routinely monitored at least every 3 months, using interview and questionnaire methods

  29. Trauma Assessment in Primary Care • If presumed PTSD or positive PTSD screen, then conduct or refer for in-depth PTSD Assessment • Recommend use of self-report measures (PCL-M, PCL-C, Mississippi-M, Mississippi-C)

  30. PTSD Evaluation in Primary Care • If H/O Trauma - Recommend assessment of: • PTSD Symptoms • Dangerousness to self or others • Family and social environment • Ongoing health risks • Medical/psychiatric co-morbidities • Thorough history and physical • Appropriate lab evaluation • Radiological assessment • Level of functioning • Risk factors for development of ASD/PTSD • Substance use

  31. Primary Care Treatment Recommendations • Formulate presumptive diagnosis • Consider initiating treatment or referral • Treat complicating problems • Pain, insomnia, anxiety, depression • If complicated, refer to mental health • Consult with MH • Stay involved in treatment • Take leadership in convening collaborative team

  32. Primary Care Encouraged to: • Routinely provide: • Early recognition of PTSD • Supportive counseling • PTSD-related education • PTSD symptoms • Other traumatic stress problems/consequences • Practical ways of coping with symptoms • Processes of recovery • Nature of treatments • Regular follow-up and monitoring of symptoms

  33. Guideline Concordance • Assessment • Complete PTSD & MST Clinical Reminders as part of routine patient care • Assess war-zone experiences systematically • Screen for trauma history - PTSD • Use standardized initial and follow-up assessments (i.e. PCL) to monitor progress and evaluate treatment • Treatment • Increase use of “strongly recommended” treatments • Combined prolonged exposure and cognitive therapy • Stress inoculation training • EMDR • Contact NCPTSD Education Division (josef.ruzek@va.gov ) or War Related Illness & Injury Study Center (mylea.charvat@va.gov)

  34. Resources • List of all inpatient and outpatient PTSD treatment programs: vaww.nepec.mentalhealth.va.gov/PTSD • National Center for PTSD Information Center: http://www.ncptsd.va.gov/ncmain/information

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