PSYCHOPHARMACOLOGIC AND INTEGRATIVE TREATMENT OF PTSD AND TRAUMA

1. PSYCHOPHARMACOLOGIC AND INTEGRATIVE TREATMENT OF PTSD AND TRAUMA 39THANNUAL WINTER SYMPOSIUM THOMAS L. JEWITT MD

2. LEARNING OBJECTIVES • 1. PARTICIPANTS WILL BE ABLE TO IDENTIFY THE FIVE CRITICAL ELEMENTS TO THE DIAGNOSIS OF PTSD. • 2. PARTICIPANTS WILL BE ABLE TO DISCERN BETWEEN THE SPECIFIC PRESENTATIONS OF PTSD AT DIFFERENT DEVELOPMENTAL STAGES THROUGHOUT LIFE. • 3. PARTICIPANTS WILL BE ABLE TO DISCUSS THE FOUR PRIMARY CATEGORIES OF PHARMACOLOGIC TREATMENT OF PTSD. • 4. PARTICIPANTS WILL BE ABLE TO IDENTIFY THE SPECIFIC DIFFERENCES BETWEEN PHARMACOLOGIC AND PSYCHOTHERAPUTIC APPROACHES TO TREATMENT OF PTSD, AND THE STRENGTHS AND WEAKNESSES OF EACH APPROACH. • 5. PARTICIPANTS WILL BE ABLE TO DISCUSS THE IMPACT OF PTSD ON FAMILIES AND THE APPROACHES TO ASSIST THESE FAMILIES IN COPING.

3. PERSPECTIVES IN HISTORY • Homer – Iliad (J. Shay, 1994) • Civil War – Soldier’s heart • WW I • Shell Shock • WW II • Combat Stress • Vietnam • Problems in recognition of the syndrome • Confusion with substance use disorders, antisocial personality disorder and psychosis • DSM-III 1977

4. 309.81    DSM-IV Criteria for Posttraumatic Stress Disorder • A. The person has been exposed to a traumatic event in which both of the following have been present:  • (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

5. DSM V CHANGES TO CRITERION A • The person learned about an event where a close relative or friend experienced an actual or threatened violent or accidental death. • The person experienced repeated exposure to distressing details of an event, such as a police officer repeatedly hearing details about child sexual abuse.

6. B. The traumatic event is persistently reexperienced in one (or more) of the following ways: • (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. • (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. • (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. • (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

7. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:  • (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma  • (2) efforts to avoid activities, places, or people that arouse recollections of the trauma  • (3) inability to recall an important aspect of the trauma  • (4) markedly diminished interest or participation in significant activities  • (5) feeling of detachment or estrangement from others  • (6) restricted range of affect (e.g., unable to have loving feelings)  • (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

8. DSM V CHANGES TO C • C becomes primarily [1.] – avoidance of thoughts, feelings and physical surroundings. etc. • The remainder of C becomes the new criteria for D.

9. D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:  • (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response

10. CHANGES TO D • Becomes E. • Additional criteria of problems with sleeping.

11. E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. • F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more • Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

12. Changes to E and F • They will become criteria F and G. New criteria H: The symptoms are not due to a medical condition or some form of substance use. • In order to be diagnosed with PTSD according to the DSM-5, a person needs to meet Criterion A, one symptom (or more) from Criterion B, one symptom (or more) from Criterion C, three symptoms (or more) from Criterion D, 3 symptoms (or more) from Criterion E, and Criterion F through H.

13. LESSONS LEARNED IN WW II, Korea & Vietnam Vulnerability correlated with: • Prior trauma exposure • Length of time in theater (12 months max) • Level of responsibility: • Squad leaders • Medics • Nurses • Radiomen • Substance use disorders • Lack of unit cohesion / Poor leadership • Lack of support systems post-combat

14. Iraq & Afghanistan • DoD / VA Data – 2002 to Feb 2008 • 1.6 million Iraq & Afghanistan veterans • 837,458 OEF/OIF discharged veterans • 50 % former Active Duty troops • 50 % Reserve and National Guard • 39 % have sought VA services • 75,033 given PTSD diagnoses by the VA (9 % of total discharged veterans

15. Diagnoses among 324,846 OEF/OIF Veterans seen at VA Medical Centers • PTSD 67,525 (21%) • Nondependent Drug Abuse 54,415 (17%) • Alcohol Dependence 11,245 (3.4%) • Drug Dependence 5,062 (1.5%)

16. RAND Corporation Survey of Returning Veterans, 2008 • Surveyed 1,965 returning veterans • 19.5 % probable Traumatic Brain Injury • 11.2% PTSD or depression alone • 7.3% PTSD or depression and TBI • 18.5% PTSD or depression, with or without TBI • 12.2% TBI alone • 69.3% no PTSD, depression or TBI

17. Projected Incidence of PTSD • 20 % of combat injured veterans (Vietnam) • 75% of combat veterans with PTSD also meet criteria for substance use disorders (Vietnam; Kulka, 1990) • Persistent symptoms and greater severity with co-occurring psychiatric disorders • New report released by VA in October 2012 suggests that 30% of returning vets from Middle East theater meet criteria for PTSD.

18. OEF/OIF Vets seen at VA • Men 88% • Women 12% • Age <20 7% 20-29 51% 30-39 23% >40 19% • Rank Enlisted 92% Officer 8%

19. BIMODAL DISTRIBUTION OF VETERANS • < 30 Years Old • Fewer supports at home • More exposure to drugs • Less education • More psychological distress • >30 Years Old • More family ties / support • Career Military • Better Prognosis

20. Unique OEF/OIF Issues • Longer & repeated exposure to combat • All soldiers at high risk – no safe havens • Financial & family stresses for National Guard troops • High incidence TBI • Higher number of women in combat • All volunteer troops; better educated • Affiliation with strong units • Strong public support

21. Comparing the Risk

22. Assessing Returning Veterans • Office, Emergency, Inpatient, Detox, Medical • History, Collateral Information, Remote Data • Physical Exam, Vital Signs • Laboratory, Toxicology • MSE: suicide, perceptual, agitation, anxiety • Diagnosis: Expect Comorbidity • Treatment, Referral, Psychoeducation • Follow-Up

23. DIAGNOSTIC SETTINGS FOR PTSD IN RETURNING VETERANS • Primary care screening • VA triage • DSM-IV criteria • Self-administered checklist or screening tool • Structured Interviews • In-depth trauma history

24. PTSD DIFFERENTIAL DIAGNOSIS & Comorbidity • Acute Stress Disorder • Adjustment Disorder • Brief Psychotic Disorder • Anxiety, Mood, Psychotic, Personality • Substance Use Disorder (SUD) • Anemia, arthritis, asthma, back pain, diabetes, kidney disease, lung disease, ulcers. There is rapidly growing evidence that stress alters both immune and genetic function.

25. SUD: Lab indications • Serum, Urine, Saliva, Hair, Nails, other • Routine, Random, Observed • Urine toxicology and Benzodiazepines • Indices of Chronic Alcohol Dependence • False Positives

26. Sensitivity and Specificity of Alcohol Biomarkers

27. DSM-IV Substance Abuse Disorder • Alcohol • Amphetamine • Caffeine (intoxication) • Cannabis • Cocaine • Hallucinogen • Inhalant • SUD = have criteria for both intoxication and withdrawal • No nicotine or polysubstance abuse • No criteria for caffeine dependence or abuse • Nicotine (withdrawal) • Opioid • Phencyclidine • Sedative, Hypnotic, Anxiolytic • Polysubstance Dependence

28. SUD/PTSD Symptom Overlap Intoxication Withdrawal Alcohol Amphetamine Cocaine • Amphetamine • Caffeine • Cannabis • Cocaine • Hallucinogen • Hallucinogen Persisting Perceptual Disorder

29. Functional Associations: Trauma, PTSD, and SUD • Pathways, Time course • Patient perception of substances • PTSD with and without SUD • Specific PTSD dimensions and SUD • Substance Abuse and Intrusions • Substance Abuse and Arousal • Drug-induced Reactivation and Maintenance • Memory Network Models

30. PHARMACOTHERAPY OF PTSD • Medications can be effective in the treatment of PTSD • Effects are modest • Evidence is limited • Major clinical practice guidelines to date suggest that medications should not be used in the setting of ongoing psychotherapy – HOWEVER I AM NOT TOTALLY IN AGREEMENT.

31. Efficacy of Sertraline in PTSD

32. SSRI’s in the treatment of PTSD

33. Sympatholytics

34. Antipsychotics in PTSD

35. Bisson, J. I. Adv Psychiatr Treat 2007;13:119-126

36. Anticonvulsants in PTSD

37. Benzodiazepines in PTSD

38. Psychotropic Treatment of PTSD: Use Patterns

39. An Approach to Pharmacotherapy of PTSD

40. PSYCHOTHERAPY MODELS • ACT • EXPOSURE • EMDR • PSYCHODYNAMIC • INDIVIDUAL • GROUP THERAPY • COUPLES/FAMILY THERAPY

41. Acceptance and Commitment Therapy for PTSD • WHEN WE EXPERIENCE EMOTIONAL PAIN, WE TRY TO AVOID IT. THIS DOES NOT WORK VERY WELL. • AVOIDANCE LEADS TO ADVERSE EMOTIONAL CONSEQUENCES.

42. FIVE GOALS OF ACT • Recognizing that trying to escape emotional pain will never work. “Creative hopelessness” • Control is the problem. • Viewing yourself as separate from your thoughts. • Stopping the struggle. • Commitment to action

43. EFFICACY OF CBT IN NON-COMBAT PTSD PREVENTION • Bryant et al., in treating motor vehicle and industrial accident victims who met criteria for ASD, compared five sessions of nondirective supportive counseling (providing support and education and teaching problem-solving skills), with brief cognitive-behavioral treatment (trauma education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in vivo exposure to avoided situations). At the conclusion of treatment, 8% of the participants in the CBT group and 83% of the participants in the supportive counseling (SC) group met criteria for PTSD. Six months posttrauma, 17% in the CBT group and 67% in the SC group met criteria for PTSD. There were also significant reductions in depressive symptoms in the CBT group compared to the SC group. Clearly, this is one of the most important developments in years regarding early intervention.

44. EYE MOVEMENT DESENSITIZATION AND REPROCESSING • EVIDENCE BASED TREATMENT • EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other semantic memory networks. • Stages: 1.) Target; 2.) Safe place; 3.) “Snapshot”; 4.) Image/cognition/emotion + series of eye movements; 5.) Check patient’s experience; 6.) Body check + new motion sets; 7.)Debriefing; 8.) Reevaluation of situation at next session.

45. ISSUES TO CONSIDER WHEN DEVELOPING TREATMENT PLAN, INCLUDING PSYCHOTHERAPIES • Excessive avoidance • Dissociation • Anger • Grief • Extreme anxiety • Catastrophic beliefs • Prior trauma • Substance abuse • Depression and suicide risk • Poor motivation • Ongoing stressors • Cultural issues • Appropriate versus inappropriate avoidance • Multiple survivors of the same trauma

46. http://couplestherapyforptsd.com/home • The "Couples HOPE" study, located in Boston, MA, and Toronto, Canada, is designed to evaluate Cognitive-Behavioral Couple Therapy (CBCT), an intervention for couples in which one partner has Posttraumatic Stress Disorder (PTSD). CBCT for PTSD consists of 15-sessions of couple therapy focused on improving both PTSD symptoms and the couple's relationship. • NICE ARTICLE ABOUT COUPLES TX FOR PTSD • http://www.apa.org/pubs/journals/features/pro-366626.pdf

47. A FEW REFERENCES • http://www.ptsd.va.gov/index.asp • INTRODUCTION TO PSYCHONEUROIMMUNOLOGY, 2nd edition; Jorge H. Daruna; Academic Press; 2012. • NEUROBIOLOGY OF ADDITION; Koob and Le Moal; Academic Press; 2006. • HANDBOOK OF PTSD: Science and Practice; Friedman, Keane, Resick. Guilford Press; 2007. • PTSD AND MILD TRAUMATIC BRAIN INJURY; Vasterling, Bryant, Keane; Guilford Press; 2012.

48. TRAUMATIC BRAIN INJURY GCS = Glasgow Coma Scale LOC = Loss of consciousness PTA = Posttraumatic amnesia

49. American Congress of Rehabilitation Medicine: Mild Traumatic Brain Injury (MTBI) Definition A traumatically induced physiological disruption of brain function manifested by at least one of these symptoms: • Loss of consciousness < 30 minutes • Loss of memory for events immediately before (retrograde amnesia) or after the accident (Post Traumatic Amnesia <24 hours) • Any alteration in mental state at the time of the injury (dazed, disoriented, confused) • Presence of focal neurological deficits • If given, GCS score > 13

50. Relative Proportion of Levels of Care for TBI 50,000 Deaths 235,000 Hospitalizations 1,111,000 Emergency Department Visits ??? Other Medical Care or No Care