post traumatic stress disorder jeff clothier, m.d

Post traumatic stress disorder

Jeff Clothier, M.D.

PTSD

Overview

Epidemiology Diagnosis Psychiatric Comorbidity Treatment

PTSD DSM-IV Criteria

Exposure to traumatic event withActual or threatened death or serious injury

andResponse involving intense fear, helplessness, or horror

American Psychiatric Association. American Psychiatric Association. DSM-IV.DSM-IV. 1994. 1994.

PTSD DSM-IV Criteria (cont.)

Re-experiencing the traumatic eventPersistent avoidance of stimuli associated with eventNumbing of general responsivenessSymptoms of increased arousalAt least 1 month’s duration (otherwise can diagnose

Acute Stress Disorder)Significant distress or impairment in social,

occupational, or other functioning

American Psychiatric Association. American Psychiatric Association. DSM-IV.DSM-IV. 1994. 1994.

PTSDAssociated Features

Alcohol/drug problemsAggression/violenceSuicidal ideation, intent, attemptsDissociationDistancingProblems at workMarital problemsHomelessness

Lifetime Prevalence of DSM-III-RMajor Psychiatric DisordersNCS Data

Mood Disorders

Major depressive episode 17.1Dysthymia 6.4Manic episode 1.6

Anxiety DisordersSocial Phobia 13.3Simple Phobia 11.3PTSD 7.8Agoraphobia without panic 5.3GAD 5.1Panic disorder 3.5

Substance Use DisordersAlcohol abuse/dependence 23.5Drug abuse/dependence 11.9

Adapted from Kessler et al. 1994, 1995.Adapted from Kessler et al. 1994, 1995.

%%

Function and Quality of Life In Vietnam Veterans With and Without PTSD

Pe

rcen

t

Not Working

PhysicalLimitation

ReducedWell-Being

Fair orPoor

Health

Zatzick DF et al. Zatzick DF et al. Am J PsychiatryAm J Psychiatry. 1997;154:1690–1695.. 1997;154:1690–1695.

Violent BehaviorPast Year

PTSDPTSD

Non-PTSDNon-PTSD

PTSD

Risk Factors for PTSD

Severity of trauma (ie, threat, duration, injury, loss)Prior traumatizationGenderPrior mood and/or anxiety disordersFamily history of mood or anxiety disordersEducation

PTSD risks

Epidemiologically, there are two other risk The risk of having a trauma exposure The risk for developing PTSD from that

exposure Has implications for public health policies

Risks of Specific Traumasin the US Population

Pe

rcen

tag

e

Natural Disaster

RapeCombatCriminalAssault

MenMen

WomenWomen

Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1048–1060.. 1995;52:1048–1060.

About 30% of people exposed to trauma developed PTSD

PTSD

Rates Related to Specific Traumas

Pe

rce

nta

ge

Natural Disaster

RapeCombatCriminalAssault

MenMen

WomenWomen

Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1048–1060.. 1995;52:1048–1060.

0

25

50

75

100

1 2 3 4 5 6 7 10

PTSD

Persistence Over Time

Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1048–1060.. 1995;52:1048–1060.

Years

% W

ith

ou

t R

eco

very

(Untreated Group)

PTSD

Impact of Treatment on Recovery

Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995;52:1057.. 1995;52:1057.

640 36

Treated

Untreated

Median Months to Recovery

(N = 459)

Biological Correlates of Chronic PTSD

Increased sympathetic responses to trauma reminders Normal resting catecholamines with increased responses

to trauma stimuli Decreased cortisol. Excessive feedback inhibition. Increased free T3 and T4 Insomnia and increased # of rapid eye movements during

REM sleep Possible reduction in hippocampal volume?

Epidemiology of PTSD

7.8% of adults in the U.S. (lifetime) Type of trauma most often the basis for

PTSD - rape in women (46% risk) combat in men (39% risk)

one third of cases have duration of many years

88% of cases have psychiatric comorbidity

Kessler et al., 1995

Depression 48 12 48 19

Mania 12 1 6 1

Panic Disorder 7 2 13 4

Social Phobia 28 11 28 14

GAD 17 3 15 6

Alcohol Abuse/Dependency 52 34 28 13

Substance Abuse/Dependency 34 15 27 8

Any Diagnosis 88 55 79 46

Kessler RC et al. Kessler RC et al. Arch Gen PsychiatryArch Gen Psychiatry. 1995. 1995

Lifetime Rates (%)

Men Women

PTSD Non-PTSD PTSD Non-PTSD

PTSD

Psychiatric Comorbidity

PTSD comorbidity

Patient usually has other psychiatric disorders

“Ticks and fleas”

Makes treatment difficult More deadly

0

20

40

60

80

Impact of Comorbid PTSD in Subjects With Other Anxiety Disorders

(%)

Ra

tes

38

48

30

6

30

21

AlcoholProblems

HospitalizedAttemptedSuicide

Anxiety DisorderAnxiety DisorderWith PTSDWith PTSD

Anxiety DisorderAnxiety DisorderWithout PTSDWithout PTSD

Warshaw MG et al. Warshaw MG et al. Am J PsychiatryAm J Psychiatry. 1993;150:1512–1516.. 1993;150:1512–1516.

PTSD

Treatment Options

PsychotherapyPharmacotherapyMultimodal treatment

Expert Consensus Guidelines

J Clin Psychiatry, ‘99

Noncomorbid children, adults, geriatric patients

Psychotherapy first

Comorbidpopulation

Psychotherapy firstor combine

meds/psychotherapy

Mild PTSD

More severe

Combine meds/psychotherapy

from start

Considerations for psychotherapy

Capacity to tolerate distress with exposureMotivation/preferenceAbility to participate and follow structureProblems with interpersonal adjustment

Treatment of PTSD by Exposureand/or Cognitive Restructuring

Marks I et al. Marks I et al. Arch Gen PsychiatryArch Gen Psychiatry. 1998;55:317–325.. 1998;55:317–325.

IES

Sco

res

Treatment1 mo 3 mos 6 mos

r = relaxationc = cognitive restructuringe = prolonged exposureec = e + c

rr

cc

ecec

ee

Follow Up

PTSD

Goals of Pharmacotherapy Reduction/amelioration of target symptoms

Improve sleep Affects improvement in other symptoms (eg, irritability, preoccupation,

vigilance, impaired concentration) Decreased risk for development of comorbidity

Reduce re-experiencing and intrusive symptomsImprove mood and numbingReduce phasic and tonic hyperarousalReduce impulsivityReduce psychotic or dissociative symptoms

Davidson and van der Kolk, 1996.Davidson and van der Kolk, 1996.

Pharmacologic treatment

Multiple conditions Medical comorbidities Side effects from one treatment may impact

other symptoms and medications.

PTSD

Medications Studied

BenzodiazepinesAntidepressants

TCAs MAOIs SSRIs 5-HT2 antagonists

Anticonvulsants/antipsychoticsNoradrenergic agents: clonidine, propranolol

4040

100100

00

2020

8080

FluoxetineFluoxetine

Van der Kolk BA et al. Van der Kolk BA et al. Prim CarePrim Care. 1993;20:417–432.. 1993;20:417–432.

CA

PS

T

ota

l Sc

ore

Effect of Trauma Population

PTSD Treatment With SSRIs

Effect of Fluoxetine

PlaceboPlacebo

PrePre PostPost

6060

Trauma Clinic (n = 23)PrePre PostPost PrePre PostPost

VA (n = 24)PrePre PostPost

Sertraline Efficacy in PTSD

-40

-35

-30

-25

-20

-15

-10

-5

0

SertralinePlacebo

(N=187)

*

*

†

*p<0.05; †p=0.07; Brady et al, JAMA, 2000

DTSIESCAPS-2

PTSD and Comorbid Depression: Sertraline Studies

PTSD with No ComorbidDepressive Disorder

PTSD with ComorbidDepressive Disorder

Per

cen

t R

esp

on

der

s*

0

10

20

30

40

50

60

70

80

Sertraline(N=104)

Placebo(N=112)

Sertraline(N=87)

Placebo(N=82)

*Response is defined as CGI=I score of 1 (very much improved) or 2 (much improved) at end point Brady et al., 2000, Davidson et al. , 1998

56.7%

40.2%

60.9%

37.8%

p=0.0034p=0.011

Quality of Life In PTSD

0

2

4

6

8

10

12

14

Total Scores*

Ch

ang

e in

Q-L

ES

-Q

Sertraline

Placebo

Sertraline vs. Placebo• Subscales all p0.05

– Mood – Social relationship – Leisure time – Ability to fix – Living/housing – Physical ability– Work/hobby

*p0.004, Brady et al., 2000

8080

7070

6060

5050

4040

3030

2020

1010

00BaselineBaseline

Sertraline in PTSD: The Effect of Continuation Treatment with Sertraline

Week 12Week 12 Week 20Week 20 Week 28Week 28 Week 36Week 36 Endpoint(LOCF)

Endpoint(LOCF)

Acute Phase Continuation Phase Acute Phase Continuation Phase

CAPS-2Total Score

CAPS-2Total Score

Londborg, APA/CINP 2000

5HT2 antagonists

1. Trazodone – commonly used for sleep, may reduce nightmares

2. Cyproheptadine – reports of improved sleep with decreased nightmares as well, appetite stimulant as well. (Pharmacologically rich compound)

Anti-Psychotic Agents

• Not first-line but often required in difficult cases

• Indications:– Reduce disorganizing hyperarousal, paranoid ideation,

and aggressive impulsivity– Co-morbid psychotic disorder– Low doses are often effective– Atypical agents preferred

Mood Stabilizers

• Carbamazepine– Open clinical trial: decreased intrusions, flashbacks,

insomnia, irritability, impulsivity, and violent behavior (Lipper et al., Psychosomatics, 1986)

• Valproic acid – Open trial: decreased hyperarousal and avoidance (Stein, J

Clin Psych, 1995)

• Lamotrigine– Small controlled trial: decreased re-experiencing,

numbing and avoidance (Hertzberg et al., Biol Psychiatry, 1999)

Immediately after exposure: Normalize distress Educate patient, family and significant others Repeated retelling of the event Provide emotional support Relieve irrational guilt Refer to peer support group or trauma counseling Consider short-term sleep medication for insomnia

Foa, Davidson, Frances, J Clin Psychiatry 1999

Early Intervention and Prevention

Recommendations for Early Intervention and Prevention

PTSD

SummaryPTSD is common Usually chronic Presentations vary Comorbidity is the ruleComprehensive assessment of patients is

critical to develop an individualized treatment planTreatment often involves multiple modalities