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Saturday General Session

Trauma‐DrivenLife:ASDandPTSDinPrimaryCare

DavidKaterndahl,MDProfessor, Department of Family and Community Medicine UT Health San Antonio San Antonio, Texas EducationalObjectivesBy the end of this educational activity, participants should be better able to:

1. Recognize and diagnose. trauma-related disorders. 2. Treat trauma-related disorders using psychotherapeutic and pharmacological

approaches. 3. Monitor treatment response and complication risk.

SpeakerDisclosure Dr. Katerndahl has disclosed that he has no actual or potential conflict of interest in relation to this topic.

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David Katerndahl, MD, MAFamily & Community MedicineUniversity of Texas Health Science CenterSan Antonio, Texas

Speaker Disclosure

Dr. Katerndahl has disclosed that he has no actual or potential conflict of interest in relation to this topic.

Celebrity Case P.I. is born to an esteemed father and strong mother

As an adolescent, father binds him, raises knife to kill him but relents

Soon after, his mother dies and father arranges son’s marriage

Spends his days ruminating and limits his activity

After 20 years, wife conceives and has twin sons who grow up self-centered

After father dies and famine strikes, experiences first auditory hallucination

Fearing local authorities, he moves to place linked to his childhood trauma Experiences auditory hallucination

Develops blindness and assumes he is dying

Manipulated, he bestows inheritance on wrong son who flees

Spends rest of life alienated from sons

Audience Polling Question #1

Which of the following trauma exposure is NOT known to cause Posttraumatic Stress Disorder (PTSD)?

1. Having a career that repeatedly exposes you to effects of violence

2. Being sexually assaulted

3. Learning that a close friend died in motor vehicle accident (MVA)

4. Experiencing child abuse

5. Watching terror attacks on television

Trauma Exposure

ADULTHOOD TRAUMA

90% ≥1 Lifetime Exposure 50% Adults Experience

Physical/Sexual Assault Violent Death Of Friend/Family Natural Disaster Accident/Fire

Multiple Exposures Common Mode = 3 Exposures

35%

26%

26%

13%

CHILDHOOD TRAUMA

0 Types

1 Type

2-3 Types

4+ Types

Learning Objectives

By the end of this educational activity, the learner should be better able to:

Recognize and diagnosis trauma-related disorders.

Treat trauma-related disorders using psychotherapeutic and pharmacological approaches.

Monitor treatment response and complication risk.

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Audience Polling Question #2

Which statement about PTSD is true?1. PTSD always begins within 3 months of the trauma

2. While 25% of adults will be exposed to trauma, 50% of those exposed will develop PTSD

3. 50% of those who develop PTSD recover within 3 months of onset

4. “Acute Stress Disorder (ASD)” and “Posttraumatic Stress Disorder (PTSD)” are actually the same condition

After Trauma

TRAUMA •61% Males•51% Females

ASD •13-33% if Exposed

PTSD• After Exposure:

• 8% Males• 20% Females

LIFETIME}

Screening for Trauma Indications for Trauma Screening

Screen for trauma if inappropriate anger or repeated nonspecific complaints*

Screen for trauma in insomnia with awakenings/nightmares

Interview Suggestions: Experienced or Witnessed

“Have you ever experienced or witnessed a serious injury or assault?”

Learning of Friend/Family Violence

“Have any family members or friends ever experienced serious violence?”

Occupational Exposure

“Have you ever worked in a job that exposed you to serious trauma?”

Childhood

“Do you remember everything about your childhood, or have you lost memories?”

“Do you feel that you might have been abused as a child even if you don’t actually remember it?”

*VA/DoD,2010

Common Symptoms After Trauma

PHYSICAL Chills Dyspnea Dizziness/Faintness Elevated BP Fatigue Bruxism Headaches Tremors Nausea Pain Sweating Tachycardia Twitching Weakness

EMOTIONAL Agitation Anxiety Apprehension Denial Depression Shock Fear Overwhelmed Grief Guilt Inappropriateness Irritability Loss Of Control

COGNITIVE Blaming Alertness Change Confusion Hypervigilance Awareness Change Intrusive Images Poor Memory Nightmares Poor Abstract Thinking Poor Attention Poor Concentration Poor Decisions Poor Problem-Solving

BEHAVIORAL Antisocial Activity Change Appetite Change Communication Change Sexual Dysfunction Speech Change Outbursts Rest Inability Alcohol Increase Startle Reaction Pacing Social Withdrawal Suspiciousness

After Trauma

Patient Education and Advice Expect Symptoms Psychological First Aid

Contact and Engagement Information Gathering Current Needs Concerns

Safety and Comfort Stabilization

Practical Assistance Connection with Social Support Information on Coping Connection with Collaborative Services Self-Efficacy Hope

Self-Help Exercise Self-Regulation

Mindful Breathing Sensory Input

Healthy Lifestyle Relaxation & Sleep Diet Avoid Alcohol & Drugs

After Trauma

Management TALK about trauma ONLY if patient wants

AVOID retraumatization

NO psychological (Critical Incident Stress) debriefing

Monitor frequently for warning signs

Insomnia and Nightmares

Anger and Paranoia

Withdrawal and Isolation

Psychiatric Symptoms (Anxiety, Depression, Substance Use)

AVOID Benzodiazepines → Increased risk of PTSD development

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ACUTE STRESS DISORDER

Risk Factors Loss of Loved One

Depression After Trauma

Loss of Home/Community

Extended Danger Exposure

Prior Mental Disorder

Low Self-Efficacy/Esteem

Avoidant Coping

Prior Trauma History

Absent Adequate Healthy Social Support

Prevalence(Higher with interpersonal assault) MVA = 13-21%

Mild TBI = 14%

Assault = 19%

Associated Symptoms Catastrophic Interpretations

Impulsivity

Panic Attacks

ACUTE STRESS DISORDER (DMS-5)A. Exposure or Threat of Death, Serious Injury or Sexual ViolationB. Presence of ≥ 9 Symptoms, Beginning/Worsening after Trauma:

A. Intrusion Symptoms1. Distressing memories2. Nightmares3. Flashbacks4. Distress/reaction to cues that symbolize trauma

B. Negative MoodInability to have positive emotions

C. Dissociative Symptoms6. Altered sense of reality7. Inability to remember details of trauma

D. Avoidance Symptoms8. Avoid memories9. Avoid reminders

E. Arousal Symptoms10. Insomnia11. Irritable/angry outbursts*12. Hypervigilance13. Problems with concentration*14. Startle response

C. Duration 3-30 Days after TraumaD. Significant Distress or ImpairmentE. Not Due to Substance, Another Medical Condition or Brief Psychotic Disorder

ACUTE STRESS DISORDER Treatment1,2

Brief Psychotherapy to Prevent PTSD (Level A) CBT = Most Effective Intervention

Medication Do NOT Routinely Use Psychotropic Medication AVOID BENZODIAZEPINES (Level D)

Monitor = Frequent Visits ASD Scale → Predicts PTSD

Excellent Likelihood Ratios: +LR = 13, –LR = 0.1 Cutoff ≥ 56 = High Risk For Development Of PTSD

Refer if Unresolved

Indications for PTSD Screening Routine: Periodic Screening with Validated Instrument ASD Unresolved/Warning Signs/Dissociative Episodes 1Kavan et al, 2012

2VA/DoD, 2010

PTSD SCREENING

50% with ASD Develop PTSD

Symptoms – Usually begin within 3 months of trauma

Disorder

25-30% develop within 6 months of event

30-36% develop within 12 months

“Delayed Expression” Possible

But some symptoms begin immediately

PTSD SCREENING TESTS

INSTRUMENT NUMBER OF QUESTIONS

+LR -LR

SPAN1

PC-PTSD244

4.3-9.36.0-6.9

0.18-0.280.25-0.30

Interpretation (impact): Moderate Small+LR 5-10 2-5–LR 0.1-0.2 0.2-0.5

1Meltzer-Brody et al, 19992Prins et al, 2004

PTSD RISK FACTORS (Personality + Environment + Stressor)*

*American Psychiatric Association, 2013

PERSONALITY ENVIRONMENT

Prior Trauma (Child Abuse)Pre-existing: • Depression• Anxiety• Panic DisorderMaladaptive Personality:• Borderline• DependentLow Self-Esteem

Low Socioeconomic StatusFamily History:• Anxiety• Neuroticism

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PTSD RISK FACTORS (Stressor)1

1American Psychiatric Association, 20132Van Pampus et al, 2004

TRAUMATIC EVENT POST-TRAUMA

Event:• Life-Threatening• Physical InjuryObstetric Trauma:2

• Pre-Eclampsia• Miscarriage• Intrauterine DeathFeeling During Trauma:• Horror• Helplessness Dissociation During TraumaMilitary Experience:• Perpetrating Injury• Killing Others

NO SOCIAL SUPPORTPoor CopingAcute Stress DisorderOther Losses/Life EventsTriggers

PTSD TRIGGERS

EXTERNAL INTERNAL

Sights, Sounds, SmellsPeople, Places, ThingsDatesNatureNews CoverageConfining SituationsRelationships, Stress, ArgumentsHospitals, Medical Care, Funerals

DiscomfortSensationsEmotionsFeelings About Others

DSM-5 PTSD CRITERIAA. Exposure to actual or threatened death, serious injury, or sexual violence

B. Presence of intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month

G. Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

Specify whether: With dissociative symptoms

DSM-5 PTSD CHANGES FROM DSM-4

Traumatic Event: Recurrent Occupational Exposure Added

Emotional Response Dropped

Re-Experiencing Criterion Rewritten

Developmentally-Appropriate Criteria for Children Added

Avoidance Criterion Split: Avoidance of Behaviors/Reminders

Negative Cognitions/Mood

Arousal Criterion Revised & Added

“Posttraumatic Stress Disorder” = “Posttraumatic Stress Injury”?

DSM-5 PTSD CRITERIA

A. Actual or threatened death, serious injury, or sexual violence in ≥1 of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme occupational exposure to aversive details of the traumatic event(s).

DSM-5 PTSD CRITERIA

B. ≥1 Intrusion symptoms after the traumatic event(s) occurred:

1. Distressing memories

2. Distressing dreams related to the trauma

3. Dissociative reactions (e.g., flashbacks)

4. Distress at exposure to cues of the trauma

5. Physiological reactions to cues of the trauma

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DSM-5 PTSD CRITERIA

C. ≥1 Avoidance of stimuli associated with the trauma:

1. Avoidance of distressing memories/thoughts associated with the trauma

2. Avoidance of external reminders that arouse distressing memories/thoughts associated with the trauma

DSM-5 PTSD CRITERIA

D. ≥2 Negative cognitions/mood associated with the trauma:

1. Inability to remember an important aspect of the trauma

2. Negative beliefs/expectations about oneself, others, or the world- Paranoia

3. Distorted cognitions about the cause/consequences of the trauma that lead the individual to blame himself/herself or others

4. Persistent negative emotional state

5. Diminished interest in significant activities

6. Detachment or estrangement from others

7. Inability to experience positive emotions

DSM-5 PTSD CRITERIA

E. ≥2 Alterations in arousal/reactivity associated with the trauma:

1. Irritability/angry outbursts2. Reckless/self-destructive behavior3. Hypervigilance

- Peripheral “Shadows”

4. Startle response5. Problems with concentration6. Sleep disturbance

DSM-5 PTSD CRITERIA

F. Duration of criteria B, C, D, and E more than 1 monthG. Significant distress/impairment in:

Social, occupational, or other areas of functioningH. Disturbance not attributable to a substance or another condition

Specify Dissociative Symptoms: (Stressor → depersonalization or derealization)• Pseudohallucinations

• Effect: Dissociation > Psychosis1

• Dissociation leads to negative cognitions2

• Risk for auditory hallucinations3

• PTSD associated with conversion disorder4,5 and blindness6

• Sensory Defensiveness (80% in PTSD)7

• Misinterpretation of sensory events, social withdrawal & unusual eating habits• Symptoms wax & wane with stress & environment• Impacts self-esteem, safety & sexual relationships• Anosognosia = Denial/Unawareness of neurological deficits8

1. Brewin & Patel, 2010 3. Morrison & Peterson, 2003 5. Shiri et al, 2003 7. Moore, 20062. Kilcommons et al, 2008 4. Ciano-Federoff & Sperry, 2005 6. Mattson, 1993 8. Sullivan, 2012

PREVALENCE OF SYMPTOMS*

SYMPTOM PREVALENCE (%)Intrusive Thoughts/Sensations

NightmaresFlashbacksAnxiety at reminder cues

Avoidance of Stimuli Avoiding thinking aboutAvoiding activities/places

Negative Alterations in Cognitions and Mood Foreshortened futureDetachment from othersDiminished interests

- Decreased libidoNegative emotionsRestricted affect

Alterations in Arousal and Reactivity HypervigilanceStartle reactionPoor concentration

91%83%36%93%83%73%83%

78%76%85%69%71%31%

53%45%90% *Green, 2003

PTSD COMORBIDITIES*

DISORDER (%) MEN WOMEN

Major Depressive DisorderDysthymiaAlcohol AbuseDrug AbuseSimple PhobiaSocial Phobia

482152353128

492328272928

• 80-85% with ≥1 comorbid mental disorder • Attempted Suicide = 20%

* Thombs et al, 2005

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PTSD & RELATIONSHIPS

Couples – Poor Adjustment1

Children Perceive more parenting challenge1

Poorer parenting behaviors2

Increase physical abuse and child anxiety3

Numbing/Avoidance present Decreased parenting satisfaction4

Increased parent-child aggression5

1. Gewirtz et al, 2010 3. Leen-Feldner et al, 2011 5. Lauterbach et al, 2007 2. Zerach et al, 2012 4. Samper et al, 2004

PTSD THERAPY

TOO MUCH EVIDENCE!

PTSD PHARMACOTHERAPYSystematic Review Results Medication Effects1

Decreased symptom severity, depression & disability Response 60%; Full Remission 20-30%2

Only FDA-Approved Medications for PTSD: Paroxetine & Sertraline

Medication Comparisons: Paroxetine > Sertraline & Fluoxetine3

Sertraline/Venlafaxine/Nefazodone > Other Meds4

Augmentation: Risperodone5

Discontinuation of Antidepressants among Responders 3X Relapse rate within 1 year6

1. Cochrane, 2009 3. Ipser & Stein, 2012 5. Watts et al, 2013 2. Steckler & Risbrough, 2012 4. Lee et al, 2016 6. Batelaan et al, 2017

PTSD PSYCHOTHERAPYSystematic Review Results

Effective Approaches Trauma-focused CBT (TF-CBT) – Individual/Group Stress Management (SM) Eye Movement Desensitization & Reprocessing (EMDR)

Novel Approaches “Mantra” Therapy > Stress + Problem-Solving1

Written Exposure = Cognitive Processing (written exposure fewer sessions)2

Comparison TF-CBT & SM > Other Psychotherapy3

EMDR > TF-CBT4

Group CBT Only Adjunctive5

1Bormann et al, 20182Sloan et al, 20183Cochrane, 20104Chen et al, 20155Phoenix Australia, 2013

PTSD COMBINED THERAPYSystematic Review Results

SSRI + (Prolonged Exposure or CBT)1,2

No difference than monotherapy

Psychotherapy = Combined > Pharmacotherapy3

1Cochrane, 20102Rauch et al, 20193Merz et al, 2019

American Family Physician REVIEWS

REVIEW LEVEL OF EVIDENCEA B C

Saguil, 2019 PSYCHOTX PHARMACOTXCBT

PSYCHOTX PHARMACOTXCognitive FluoxetineEMDR ParoxetineNarrative Venlafaxine

PSYCHOTX PHARMACOTXImagery SertralineEclectic Prazosin

TopiramateOlanzapineRisperidone

Warner et al, 2013

1st Line = TF-CBT / SSRI / NSRI Prazosin = AdjunctiveAvoid Benzodiazepines*

Hx Trauma → ScreenOptimize MonoTx FirstAvoid Antipsychotics**

*Substance abuse risk + Compromises psychotherapy**Monotherapy

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PTSD CLINICAL GUIDELINES

1. Veterans Administration/Department Of Defense (USA) - 2004, 2017

2. American Psychiatric Association (USA) - 2004, 2010

3. National Institute for Health & Clinical Excellence (UK) - 2005

4. National Health & Medical Research Council (Australia) - 2007

5. Institute Of Medicine (USA) - 2007

6. International Society For Traumatic Stress Studies (WHO) - 2008

7. American Academy Of Child & Adolescent Psychiatry (USA) - 2010

8. Phoenix Australia (Australia) - 2013

PTSD CLINICAL GUIDELINES Comparisons*

Guideline Performance1st Line: Guidelines Advocating TF-Therapy Over Meds Outperformed2nd Line: No Consensus / Poor Consistent Performance

THERAPY RECOMMENDATIONS

TRAUMA ASD PTSD

Psychotherapy1st Line

2nd Line

NO Psychological Debriefing Trauma-Focused Therapies# Trauma-Focused Therapies#

EMDR

Differ

Pharmacotherapy1st Line

2nd Line

NONE NONE SSRI

Differ

*Lee et al, 2016

#“Trauma-Focused Therapies”: TF-CBTPE/IE (Prolonged Exposure with Imaginal Exposure)PE/CR (Prolonged Exposure with Cognitive Restructuring)CPT (Cognitive Processing Therapy)

PATIENT PREFERENCE?

“Can I just take a pill?”

“Band-aids don’t fix bullet holes…”---Taylor Swift

Bad Blood

PTSD SYMPTOM-SPECIFIC TREATMENT

SYMPTOM PROPRANOLOL MOODSTABILIZERS

ANTIPSYCHOTICS OMEGA-3-FAs

Aggression X X

Flashbacks X(carbamazepine?)

Re-Exposure Distress

X

PsychoticSymptoms

X

Suicidality X(lithium?)

X

Impact1

Increased PTSD Severity Suicide Risk Can Persist after PTSD Abates

Treatment Medication

Prazosin Initially Titrate to 3 mg qhs Max = 20 mg qhs + 5 mg qam2

Terazosin1 – Start Low (hypotension risk) Dosing – 1-20 mg qhs

Cyproheptadine1 – 4-16 mg qhs

Psychotherapy Imagery Rehearsal Therapy1

Potential Other Approaches: Rescripting & Relaxation Systematic Desensitization

Exposure EMDR

1El-Solh, 20182Breen & Fine, 2017

PTSD SYMPTOM-SPECIFIC TREATMENTSymptom-Specific Treatment (Nightmares)

PTSD PROGNOSIS

Course Affected by event proximity, duration and intensity

As patient ages: Arousal, avoidance and negative symptoms improve

Health perceptions worsen

Spontaneous resolution 50% recover within 3 months of PTSD onset

Mean duration = 36 months (those receiving treatment)

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PTSD PROGNOSIS

Predictors Of Good Prognosis Early/Ongoing Support

Rapid Onset of Treatment

Avoidance of Retraumatization

Absence of Comorbid Mental/Substance Disorders

Repression of Anger Mortality1

PTSD, Anxiety, & Depressive Symptoms2

Disability2

1. Boscarine & Figley, 20092. Palyo & Beck, 2005

PCP ROLE

Screening & Diagnosis

Provide Education1

Monitor Symptoms & Comorbidity1

PTSD Checklist for DSM-5 (PCL-5)2

Range = 0-80

Threshold for Treatment ≥ 33

Clinically-Significant Change = Δ10

Treatment & Referral1

Team Leader11VA/DoD, 20102National Center for PTSD, 2016

RECOMMENDATIONS Low threshold for screening – Both Trauma & PTSD AVOID BENZODIAZEPINES! Acute Trauma

Psychological First Aid

Monitor For Warning Signs & Refer

Acute Stress Disorder – Brief Psychotherapy Monitor for Warning Signs & Refer

Posttraumatic Stress Disorder ALL Patients Need Trauma-Focused Therapy

Assess & Treat Nightmares – Prazosin First

Assess & Treat Anger

Antipsychotics

Mood Stabilizers

Assess & Treat Psychosis (Paranoia, Hallucinations) – Antipsychotics

Monitor For Substance Abuse & Suicidality

INDICATIONS FOR PSYCHIATRY REFERRAL

1. Patient Requests Psychiatrist2. Inability To Access Trauma-Focused Psychotherapy3. Concerning Symptoms

1. Suicidal2. Homicidal3. Dissociation (Dissociative Identity Disorder)

4. Active Substance Abuse5. If You Feel Unsafe

CELEBRITY CASE: Patriarch Isaac*A. Exposure to actual or threatened death, serious injury, or sexual violence =

A. FATHER BINDS HIM & THREATENS TO KILL HIM

B. Presence of intrusion symptoms associated with the traumatic event = A. MEDITATES = RUMINATIONS?B. “VISIONS OF GOD” TRIGGERED BY BEERSHEBA

C. Persistent avoidance of stimuli associated with the traumatic event = AVOIDS PRAYER & ALTARS

D. Negative alterations in cognitions and mood associated with the traumatic event = A. BELIEF HE IS DYINGB. DETACHED FROM SONSC. LETHARGY

E. Marked alterations in arousal and reactivity associated with the traumatic event = A. ASSUMES MALEVOLENCE FROM ABIMELECHB. LIFETIME INDECISIVENESS

F. Clinically significant distress or impairment =A. POOR PARENTINGB. LIMITED TRAVELC. ALLOWS OTHERS TO SEIZE WELLSD. AVOIDS GOD

*Katerndahl, 2019

SUMMARY

Trauma Exposure Common Psychological First Aid & Monitor for Warning Signs → Psychotherapy AVOID Benzodiazepines

ASD Within First Month after Trauma Brief Psychotherapy can Prevent PTSD AVOID Benzodiazepines

PTSD Can Begin Months Later ALL Patients Need Trauma-Focused Therapy SSRI/NSRI Can Help Treat Specific Symptoms as Needed AVOID Benzodiazepines

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QUESTIONS?ACUTE STRESS DISORDER SCALE

Cutoff ≥ 56 = Predictive Of PTSD Development

SPANThe following questions are a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each question carefully, then select the answer that indicates how much you have been bothered by that problem in the past month.

PROBLEM NOT AT ALL

A LITTLE BIT

MODERATELY QUITE A BIT

EXTREMELY

1. Having physical reactions (e.g. heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience?

2. Felling emotionally numb or being unable to have loving feelings for those close to you?

3. Feeling irritable or having angry outbursts?

4. Feeling jumpy or easily startled?

0

0

0

0

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

Score ≥5 is positive for PTSD

PC-PTSD

≥3 “Yes” is positive for PTSD

“In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:”

“YES” “NO”

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?4. Felt numb or detached from others, activities, or your

surroundings?

Y

Y

YY

N

N

NN

PTSD CHECKLIST FOR DSM-5 (PCL-5)Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to indicate how much you have been bothered by that problem in the past month.

Notes