recent advances in the treatment of post traumatic stress ... · borderline personality disorder...
TRANSCRIPT
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Recent Advances in the Treatment of
Post Traumatic Stress Disorder
Jon Bisson
School of Medicine
Cardiff University
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Agenda
• What are we treating
• Psychological approaches
• Pharmacological approaches
• Treatment resistance
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What Are We Treating?
• How is PTSD diagnosed?
• How does PTSD present?
• Are any symptoms more important to target than others?
• Does time of presentation matter?
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Diagnosing PTSD
• DSM-IV (2000) replaced by DSM-5 in
2013
• ICD-10 (1992) to be replaced by ICD-11 in
2018
• Definition challenged by heterogeneity of
presentation and absence of diagnostic
tests
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DSM-5 PTSD Criterion A
• Exposure to actual or threatened death, serious
injury, or sexual violence through:
– 1. Direct experience
– 2. Witnessing, in person
– 3. Learning of event happening to a close family
member or friend (actual or threatened death must be
violent or accidental)
– 4. Repeated or extreme exposure to aversive details
(e.g. Human remain collection, police and details of
child abuse. Not TV, etc. unless work related)
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DSM-5 PTSD
• Trauma and Stressor Related Disorder
• Exposure to traumatic event
• Re-experiencing
• Avoidance
• Negative alterations in cognitions and mood
• Alterations in arousal and reactivity
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ICD-11 PTSD
• 2 Re-experiencing
– Flashbacks/powerful
images & nightmares
• 2 Avoidance
– Thoughts & feelings
– Places, people, activities
• 2 Hyperarousal
– Startle & hypervigilance
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ICD-11 Complex PTSD
• Emotion Regulation– Hyperactivation, de-
activation
• Negative Self-Concept– feeling diminished, defeated,
worthless,
– shame, guilt, despair
• Disturbed Relationships – difficulties in feeling close,
little interest in relationships or social engagement
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Borderline Personality Disorder
• Pervasive pattern of instability of interpersonal relationships, self-image, and affects, beginning by early adulthood
• Frantic efforts to avoid real or imagined abandonment
• Extremes of idealization and devaluation
• Impulsivity• Recurrent suicidal
behaviour
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Complex PTSD vs Borderline PD
• Focuses on the effects of trauma
• PTSD symptoms core element
• Trauma-focused treatment
• Stable negative self concept
• Avoidance of relationships
• High risk of suicide, suicide attempts and self-injurious behavior are salient features
• Diagnosis and effective treatment organized around these issues
• Lack of a stable self concept and fears of abandonment
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PTSD Registry
• 300 and growing• NCMH participants • PTSD diagnosis or TSQ
+ve• CAPS-5, ICD-TI, ICD-TQ,
PHQ, AUDIT• Attachment, social
support, emotional regulation, coping skills, interpersonal functioning, post traumatic cognitions, MUS
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PTSD Registry Participants
• Mean age 47.4 (12.3), range 16-76
• 49% female
• 95% white
• 50% married or cohabiting
• 34% in work
• Trauma characteristics– Mean age 25.4 (14.6)
– 19.1 (14.7) years since worst trauma• 14 (7.3%) MVA, 30 (15.6%) CSA, 27 (14.1%) combat
– 92 (49%) reported CPA or CSA
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Diagnosis
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ICD11 PTSD & Complex PTSD
0
10
20
30
40
50
60
70
Female Working Childhood Abuse
Complex PTSD
PTSD
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DSM-5 & ICD-11
54%
10%
13%
24%
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Borderline PD & ICD11 Complex PTSD
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Borderline PD less age & ICD11
Complex PTSD
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U.S. Prevalence
• US National Co-morbidity Survey
• > 5,500 15 to 54 year olds
• Trauma Exposure
– 60.7% M, 51.25% F
• Lifetime Prevalence
– 10.4% F, 5.0% M, 6.8%
• 12 Month Prevalence
– 3.5%
Kessler et al (1995 & 2005)
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Adult Psychiatric Morbidity Survey 2014
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Adult Psychiatric Morbidity Survey 2014
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Co-morbidity
• Present in > 50% cases
• Commonest co-diagnoses
– Major depressive disorder
– Panic disorder
– Other anxiety disorder
– Substance abuse/dependence
• NB personality disorder
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How can we prevent PTSD?
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SingIe Session Early Intervention
• No certain clinical effects
for any intervention tested
in 12 RCTs
• Single session debriefing
may cause harm to some
individually debriefed
individuals
• No convincing evidence
emerging for group
debriefing
Rose et al, 2005
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How can we treat PTSD?
• Psychological treatments
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Psychological Treatments for PTSD
• Systematic review and meta-analysis
• Primary outcome reduction in clinician assessed severity of PTSD symptoms
• Wait list/usual care control
• 70 studies
• 4,761 participants
• Quality low overall
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PsychoRx vs Waitlist
Bisson et al, 2013
Effect Size
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PsychoRx vs Waitlist Dropout
0
1
2
3
4
5
6
7
TFCBT EMDR Non TFCBT GroupTFCBT
OtherTherapies
Exp TFCBT Cog TFCBT
Bisson et al, 2013
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Guided Self Help
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Pilot 2
• Acceptable
• Empowerment
• Refine diary
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Spring
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RAPID
• NIHR funded phase III RCT
• GSH vs TFCBTCT
• GSH developed through phase I & II studies
• Multi-centre
• 192 participants
• Oct 2016 – Jan 2020
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How can we treat PTSD?
• Pharmacological treatments
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Pharmacotherapy for PTSD
• Systematic review and meta-analysis
• Primary outcome reduction in clinician
assessed severity of PTSD symptoms
• Placebo control
• 70 studies, 5,300 participants
• Quality moderate overall
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PharmacoRx vs Placebo
Hoskins et al, 2015
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CAPS–SX Reductions in Means
-60
-50
-40
-30
-20
-10
0
12 week study 6 month study
Venlafaxine
Sertraline
Placebo
Davidson et al, 2006 x 2
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How do we approach treatment resistant PTSD?
• Psychological
• Pharmacological
• Other
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Evidence-based Practice
• Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient
• Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients
• Knowledge sources– Invention, research, innovation,
improvement, practice
Sackett et al, 1996
“Good healthcare professionals use
both individual clinical expertise and
the best available external evidence,
and neither alone is enough.”
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Phased Approaches for Complex Presentations
• Phase one– Physical difficulties, accommodation, food, clothes,
money
– Emotional stabilisation• Social support
• Psychological input – stress management, skills training
• Pharmacological treatment
• Phase two– Trauma focused therapy
• Phase three– Integration to new situation
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STAIR-MPE
• Phase I: Skills Training in Affective and Interpersonal Regulation (STAIR)
• Phase II: Modified Prolonged Exposure (MPE)
• 8 x one hour of each with handouts & homework
Cloitre et al, 2002
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3MDR Study
• Motion-assisted, multi-modular memory desensitisation and reconsolidation
• FiMT funded Phase II RCT
• 42 participants
• Oct 2016 - Sept 2018
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Background
• Urgent need to identify effective treatments for military veterans who do not respond to, or are unable to engage with, current first line treatments
• Based on therapeutic principles of virtual reality exposure therapy and EMDR
• Exposure by virtual reality, enhanced with walking, music and high affect pictures, eliminates cognitive avoidance during exposure and promotes presence
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Background
• Working memory theory– Working memory has limited resources
– A dual task uses resources
– Less memory available for other processes
– Recollection of memories less vivid and less affect-laden
• Pilot research in the Netherlands– Decrease in PTSD symptoms
– No dropout or adverse effects
– Participants positive
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Other Psychosocial Approaches
• Mindfulness
• Yoga
• Emotional Freedom Therapy
• Rewind Technique
• Surf Therapy
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Hopwood and Schutte, 2017
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Other Pharmacological Approaches
• Trazodone
• Quetiapine
• Prazosin (alpha 1 antagonist)
• Phenelzine
• Carbamazepine
• Cortisol
• Oxytocin
• D-cycloserine
• 3,4-methylenedioxy methamphetamine
Raskind et al (2013) – American Journal of Psychiatry
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What would be an appropriate treatment pathway for PTSD?
• First line
• Second line
• Third line
• ? Fourth line
• When do you stop treatment?
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Possible Treatment Pathway
• Full assessment• First line
– Individual TFCBT or EMDR
• Second line– Alternative TFPT, Non TFCBT, Group TFCBT,
pharmacotherapy (paroxetine, fluoxetine, sertraline or venlafaxine)
• Third line– Further pharmacotherapy (quetiapine, prazosin,
trazodone, carabmazepine)
• Other issues– To phase or not to phase
• Stabilisation
– Stepped/stratified/precision approach– Individual choice
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Cardiff University Traumatic Stress
Research Group
• Kali Barawi
• Jon Bisson
• Sarah Cosgrove
• Tony Downes
• Mat Hoskins
• Neil Kitchiner
• Catrin Lewis
• Neil Roberts
• Ben Sessa
• Natalie Simon
• Rob Sinnerton
• Stan Zammitt