University:
West Coast University
Course:
PHAR 835 | IPC Neurology/Psychiatry
Academic year:

2024
Views:

300

Pages:

41
Author:

Asal A.

Post Traumatic Stress Disorder P a r n a H a g h p a r a s t , P H A R M D , BCPS Assistant PROFESSOR WEST COAST U N I V E R S ITY Some slides has been adopted from Dr. Pondrom’s lecture slides Jared 36-year-old married veteran who had returned from Afghanistan, where he had served as an officer. He went to the Veterans Affairs outpatient mental health clinic complaining of having “a short fuse” and being “easily triggered.” Jared's symptoms involved out-of-control rage when startled, constant thoughts and memories of death-related events, weekly vivid nightmares of combat that caused trouble sleeping, anxiety and a loss of interest in hobbies he once enjoyed with friends. Jared Although all of these symptoms were very distressing, Jared was most worried about his extreme anger. His “hair-trigger temper” caused fights with drivers who cut him off, cursing at strangers who stood too close in checkout lines, and shifts into “attack mode” when coworkers startled him by accident. In a recent visit to the doctor, he was drifting off to sleep in the exam table. A nurse brushed by his foot, and he leapt up, cursing and threatening her — scaring both the nurse and himself. He kept a handgun in his car for self-protection, but Jared had no intent to harm others. He had deep remorse after a threatening incident and worried that he might accidently hurt someone. These moments reminded him of a time in the military when he was on guard at the front gate. While he was dozing, an enemy mortar round stunned him into action. Jared Jared was raised in a loving family that struggled to make ends meet as Midwestern farmers. At age 20 he joined the U.S. Army and deployed to Afghanistan. He described himself as having been upbeat and happy before his army service. He said he enjoyed basic training and his first few weeks in Afghanistan, until one of his comrades got killed. At that point, all he cared about was getting his best friend and himself home alive, even if it meant killing others. His personality changed, he said, from that of a happy-go-lucky farm boy to a frightened, overprotective soldier. When he returned to civilian life, he got a college degree and a graduate business degree. He chose to work as a self-employed plumber because of his need to stay alone in his work. He had been married for seven years and was the father of two young daughters. In his retirement, he looked forward to woodworking, reading and getting some "peace and quiet." Jared Jared was diagnosed with posttraumatic stress disorder. His main concerns were due to his symptoms of fear, and his aggression when startled by someone. Jared was jittery and always on the lookout for danger. He also had intrusive memories, nightmares and flashbacks. Jared’s attempts to reduce the risk of conflict have reduced his social and career opportunities. For instance, his decision to work as a plumber rather than to use his M.B.A. seemed based largely on his effort to control his personal space. Epidemiology 50% of women will be exposed to a life-threatening traumatic event 60% of men will be exposed to a lifethreatening traumatic event 4% will develop PTSD 10% will develop PTSD Assault & rape/sexual abuse result in more PTSD Physical assault, accidents, combat, disaster, witness death/injury 6.1%-life time prevalence of PTSD among US adults Prevalence higher in women (8%) than men (4%) Based on a US survey, Whites had higher prevalence than other races Introduction • Research has found that over 80% of people with ASD (acute stress disorder) have PTSD six months later • Those who do not get ASD can still develop PTSD later on • Those have CBT soon after ASD, are less likely to develop PTSD • • PTSD caused by traumatic and stressful events Co-occurrence (>50%) with anxiety disorders, depression, substance use, and traumatic brain injury • • Overlapping sx diagnostic uncertainty PTSD has been shown to increase the risk of lifetime suicide attempt Lifetime Prevalence Rates of Trauma and Their Association with PTSD Men PTSD Women PTSD 18.9% 3.7% 15.2% 5.4% 11.1% 1.8% 6.9% 21.3% six 6.4% 38.8% 0.0% -- Rape 0.7% 65.0% 9.2% 49.5% Any trauma 60.7% 8.2% 51.2% 20.4% Natural Disaster Criminal Assault Combat Epidemiology Rates higher among: ◦ Veterans ◦ Following military combat and captivity This Photo by Unknown Author is licensed under CC BY-SA ◦ Occupational exposure – (police, firefighters, emergency medical personnel) ◦ Rape victims Risk factors and Etiology Risk Factors • Pre-trauma: Individual factors present prior to trauma e.g. hx of anxiety, substance use • Peri-trauma: magnitude and type of stressor • Post trauma: development of acute stress d/o, inappropriate coping strategies. dish Genetics & environmental factors • May affect vulnerability or conversely resilience • Abnormalities of HPA axis occurring pre-trauma, during trauma and post trauma contribute to PTSD • Low cortisol concentration more severe PTSD sx • Dysregulation of HPA axis is RF for PTSD Neuroendocrine Theories: The Stress Response Amygdala signals: • Parasympathetic & Sympathetic Nervous Systems during stress • HPA axis CRF (corticotropin releasing factor) stimulates cortisol secretion from the adrenal gland • Catecholamines and cortisol levels rise • Cortisol reduces the stress response by tempering the sympathetic reaction through negative feedback on the pituitary and hypothalamus Systems return to normal after a few hours HPA (Hypothalamic-Pituitary-Adrenal) Dysfunction • Patients with PTSD have hypersecretion of CRF but demonstrate subnormal levels of cortisol at the time of trauma and chronically E • Lower plasma cortisol concentrations were associated with greater severity of PTSD symptoms in nonmilitary patients • Dysregulation of the HPA axis is postulated to be a risk factor for eventual development of PTSD DSM-5 Criteria for PTSD p Exposure to traumatic event 2 My 1 or more intrusion sx 3Persistent avoidance of stimuli associated with traumatic event Symptoms lasting 1 month or more after trauma + impairment in social/occupation Bow or more negative alterations in cognition and mood U Two associated with traumatic event S Two or more arousal sx Categories of Symptoms 1. 2. 3. 4. Intrusion sx Negative Mood Avoidance sx Arousal sx +/- Dissociative sx accidentnaturaldisaster motor honingdramao you witness y Exposure to traumatic event Exposure to actual or threatened death, serious injury, or sexual violation, in one or more of the following ways: ◦ 1. Directly experiencing trauma ◦ 2. Witnessing, trauma happening to others ◦ 3. Learning that the traumatic event(s) occurred to a close family member/friend; cases of actual or threatened death must have been violent or accidental ◦ 4. Repeated or extreme indirect exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies or pictures unless this exposure is work-related Intrusive Symptoms One or more of the following sx -Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). -Recurrent 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. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings) -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 or external cues that symbolize or resemble an aspect of the traumatic event(s). Avoidance: One or both Persistent avoidance of stimuli ◦ Efforts to avoid thoughts, feelings, or conversations associated with trauma ◦ Efforts to avoid activities, places, or people that arouse recollections of the trauma Negative alterations in cognitions and moods 2 (or more): 1. Inability to recall an important aspect of the traumatic event(s) (typically due to dissociative amnesia) 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad.”, “No one can be trusted” 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themself or others Negative alterations in cognitions and moods Cont’d 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, shame). 5. Markedly diminished interest or participation in significant activities. 6. Feeling of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Alterations in arousal and reactivity 2 (or more): 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. so hyperactivetosomething 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Onset Can occur at any age: associated with incidence of trauma Symptoms usually begin within 3 months of the event May be delayed in some cases (months – years) PTSD Okla Detachment Reexperiencing the event Event had emotional effects Avoidance Month in Duration Sympathetic hyperactivity or hypervigilance Right after happening 133dgtmont yea Notto drew substance up 3 3 Acute Stress Disorder Vs. PTSD 1. ASD diagnosed only 3 days-1 month after the traumatic event PTSD only diagnosed when symptoms have persisted for at least one month 2. PTSD includes non-fear based symptoms e.g. risky or destructive behavior, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect, decreased interest in activities, feeling isolated Case Example CW is a 29 yo female who presents with a several year history of • Almost constant sadness • Significant fatigue / difficulty sleeping • She voices guiltPTSD about various issues in her life. PTSD • She also has nightmares and dissociative flashbacks several times per week. •She has difficulty maintaining sleep •She appears anxious and frequently looks at the door as people walk by in the hall. •She states she was physically and sexually abused as a child, PTSD •She says she doesn’t like to talk, or even think, about it. • When asked about future plans, she replies “what does it matter, my life is over.” Questions nightmares Feds unyoff What intrusive symptoms does CW have? Which avoidance symptoms does she report? Don'twantto How does she report and demonstrate arousal symptoms? looks at thedoorwhenpepolewalkbythehall ONE difficultysleeping Kaboutitthink Goal of Tx of PTSD Desired Outcomes ◦ Short-term: reduction in core symptoms ◦ Improvements in disability ◦ Tx of concurrent psychiatric conditions ◦ Quality of Life ◦ Long term: remission 8 d Prevention of PTSD • For the prevention of PTSD among individuals who have been exposed to trauma, there is insufficient evidence to recommend for or against psychotherapy or pharmacotherapy in the immediate post-trauma period • For the prevention of PTSD among patients diagnosed with ASD, trauma-focused cognitive behavioral psychotherapy is recommended (WEAK recommendation) • For the prevention of PTSD among patients diagnosed with ASD, there is insufficient evidence to recommend for or against any pharmacotherapy General Approach for PTSD Treatment Assess ◦ Severity of PTSD sx ◦ Symptoms using validated instruments: PTSD Checklist for DSM-5 (PCL-5), structured clinician-administered interview (e.g., CAPS-5) ◦ Existence and severity of co-occurring d/o ◦ Current and past mental health esp. past PTSD sx ◦ Current and past medications including OTC, herbals ◦ Mental Status Exam Treatment Selections: • Initiate psychotherapy • If psychotherapy not available or not preferred, initiate pharmacotherapy ◦ Treat acute stress based on symptoms Approach to Treatment Continued… • Psychotherapy: • • • Initial treatment effect noticeable after 4-8 sessions over 8-12 weeks Psychotherapy might have an attenuated effect if delivered less than weekly Pharmacological therapy: • • • • Medication should be given at an appropriate dosage for an adequate time to allow for the full therapeutic effects before moving to alternative or augmentative treatment options. Initiate at recommended starting dose and titrate based on clinical response and tolerability The duration of the trial: 8-12 weeks (2-3 months) Discuss risk and benefits of tapering medications Treatment of PTSD 1. Psychotherapy strongly recommended over pharmacotherapy 2. Mindfulness-Based Stress Reduction® weakly recommended for the treatment of PTSD 1. Pharmacotherapies strongly recommended 1. 2. 3. Paroxetine (FDA approved) Sertraline (FDA approved) Venlafaxine (off-label) 2. Prazosin is weakly recommended for the treatment of nightmares associated with PTSD 3. There is insufficient evidence for combination therapy (psychotherapy + medications or two medications, or two different types of psychotherapy) Pharmacotherapies Recommendations: Neither for or against use SSRIs • Citalopram • Escitalopram • Fluoxetine SNRI: • Duloxetine • Desvenlafaxine Other antidepressants: • Bupropion • Mirtazapine • Nefazodone • Amitriptyline • Imipramine • Phenelzine Antipsychotics: • Olanzapine • Quetiapine Others: • Topiramate • Lamotrigine • Eszopiclone • Buspirone Consider patient preference, stigma and side effect profile when choosing medications from this list Pharmacotherapy Recommendation: Against Use WEAK AGAINST: • Divalproex • Ketamine • Prazosin • Guanfacine • Risperidone • Vortioxetine • Augmentation w/ antipsychotics • ECT/Vagus Nerve stimulation STRONGLY AGAINST: • • Benzodiazepines Cannabis/Cannabis derivatives Pharmacotherapy Dosing Diagnosis of PTSD NONRESPONSE Switch to second SSRI or venlafaxine Switch to third SSRI, venlafaxine SSRI/venlafaxine for 4-6 weeks PARTIAL RESPONSE Maximize dose RESPONSE Continue for at least 8-12 weeks Symptoms Medications Nightmares Prazosin Evaluation of Therapeutic Outcomes Monitor identified target symptoms including: • Insomnia • Suicidal ideation • Anger outbursts • Irritability • Psychosis • Ongoing trauma • Disability Pharmacist Patient Care Process Collect: • • • • • • Characterize patient symptoms – intrusive, avoidance, mood/affective, hyperarousal Identify traumatic event & disposition Risk factors, resiliency – coping mechanisms, support system Psychosocial interventions & modalities Level of function – occupational, social Substance use, social history Assess: • • • • Indication for drug therapy, efficacy for target symptoms Co-morbid conditions that need intervention Side effects of medications Treatment compliance Pharmacist Patient Care Process Plan/Implement: • Optimal drug therapy, duration of therapy • Adjunctive treatments (pharmacologic & nonpharmacologic) Monitoring/Follow-Up: • Improvement in target symptoms • Rating scales - CAPS Summary PTSD is a chronic condition characterized by ◦ ◦ ◦ ◦ ◦ Exposure to a traumatic event Intrusive symptoms Avoidance symptoms Mood/affective symptoms Physical (hyperarousal symptoms) Treatment is challenging ◦ Psychotherapy treatment is considered first line ◦ Pharmacotherapy: Start with paroxetine, sertraline or venlafaxine ◦ Add additional therapy based on symptoms

PTSD Post Traumatic Stress Disorder

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