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1/27/2015

Posttraumatic Stress Disorder


(PTSD): A Diagnostic Overview
and Treatment Options

Disclosures
Neither presenter has a vested interest in or affiliation with any
corporate organization offering financial support or grant monies
for this continuing education activity, or any affiliation with an
organization whose philosophy could potentially bias their
presentation.

LT Catherine Arnatt, PharmD, MS


Southcentral Foundation/Alaska Native Medical Center

Michael Arnatt, MS
University of Alaska Anchorage

Question 1

Question 2

1. DSM-5 diagnostic criteria of PTSD does not


include criterion for:
a.
b.
c.
d.

2. Cognitive-behavior therapy, is the only effective


method of psychotherapy in the treatment of
PTSD.

Stressors
Avoidance
Negative Cognitions and Mood
Arousal and Recovery

a. True
b. False

Question 3

Objectives

3. Initial pharmacotherapy options for treatment of


PTSD includes:
a.
b.
c.
d.

1. Discuss the DSM-5 diagnostic criteria of


Posttraumatic Stress Disorder (PTSD).
2. Review non-pharmacologic therapy
interventions for treatment of PTSD.
3. Identify pharmacotherapy options for
treatment of PTSD.
4. Develop a monitoring plan for the treatment of
patients with PTSD.

SSRIs
Benzodiazepines
Tricyclic Antidepressants
MAO Inhibitors

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DSM-5: Intrusion Symptoms

DSM-5: Stressor(s)

B. One (or more) of the following intrusion


symptoms associated with the traumatic
event(s):

A. Exposure to actual or threatened death,


serious injury, or sexual violence by:
Directly experiencing
Witnessing as occurred to others
Learning that the traumatic event(s)
occurred to a close family member or close
friend
Experiencing repeated or extreme exposure
to aversive details of the traumatic event(s)
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Recurrent, involuntary, and intrusive distressing


memories
Recurrent distressing dreams
Dissociative reactions (e.g., flashbacks)
Distress associated with traumatic event cues
Physiological reactions to internal or external
cues

(American Psychiatric Association, 2013)

(American Psychiatric Association, 2013)

DSM-5: Avoidance & - Symptoms

DSM-5: Cognitions & Mood

C. Persistent avoidance of stimuli associated


with the traumatic event(s) or negative
alterations in cognitions and mood:

D. Alterations in arousal and reactivity


associated with the traumatic event(s)

Avoidance of, or efforts to avoid, distressing


memories, thoughts, or feelings
Avoidance of, or efforts to avoid, external
reminders
Negative symptomology

Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance (e.g., difficulty falling or
staying asleep or restless sleep)

(American Psychiatric Association, 2013)

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(American Psychiatric Association, 2013)

DSM-5: Duration, Distress &


Exclusivity

DSM-5: Arousal & Reactivity

F. Duration of the disturbance (Criteria B, C, D,


and E) is more than 1 month.

E. Marked alterations in arousal and


reactivity associated with the traumatic
event(s)

G. The disturbance causes clinically significant


distress or impairment in social, occupational,
or other important areas of functioning

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(American Psychiatric Association, 2013)

H. The disturbance is not attributable to the


physiological effects of a substance (e.g.,
medication, alcohol) or another medical
condition.

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(American Psychiatric Association, 2013)

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Sources of Trauma

Epidemiology

Sources of trauma vary, but may include:

Estimated lifetime prevalence of PTSD is 6.8%


in the U.S. (Kessler et al., 2008)
~2% Active prevalence rate yields 6.3 million
cases of PTSD in the U.S. (Norris & Stone, 2013)
International statistics problematic (e.g. China = 0.6%)
12 month prevalence was 1.8% among men
and 5.2% among women (National Comorbidity Survey, 2005)
DSM-5 rates slightly lower then DSM-IV (INS
natural sudden death & 1 avoidance)

Combat
Sexual Abuse
Accidents
Persistent, direct exposure to tragedy or
gruesome events (i.e. first responders,
psychologists with sexual abuse victimsnot
indirect exposure through media)
The case of pre-combat exposure
Complex trauma

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PTSD Event Window


Conceptualization

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Psychotherapy
First line EB treatment (e.g., Bryant et al., 2008)
Patients who do not respond to pharmacotherapy
(Otto,Bruce, & Deckersbach, 2005)

Manualized Cognitive Behavioral Therapy (CBT)


Prolonged Exposure Therapy (PE)

Hyperarousal

Typical Upper Bound

In-vivo exposure: Engaging in avoided activities


Imaginal exposure: Revising experience out loud

Baseline

Group Cognitive Processing Therapy (CPT) (Bass et al., 2013)

Activating Event

Meaning centered rationalization


Typical Lower Bound

Others such as EMDR and Stellate Ganglion Block

Hypoarousal
(disassociation)

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(Adapted from Van der Kolk, 2006)

Pharmacotherapy Goals

Psychotherapy & Benzos

Treatment should be initiated shortly after diagnosis


Early treatment may prevent chronicity
Goals of therapy to decrease:

Benzodiazepines may effect psychotherapy


Exposure therapy not effective (root of most therapy)
(Otto, Smits, & Reese, 2005)

Effect of withdrawal: Relapse prevention (Bruce, Spiegel, & Hegel, 1999)


Learning Impairment: Explicit and implicit memory so
integration of concepts can be an issue (e.g.,Buffett-Jerrott & Stewart, 2002)

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Intrusive thoughts and images


Phobic avoidance
Hyperarousal*
Hypervigilance
Irritability and anger*
Depression*

* Symptoms drug therapy most effective at decreasing, less effective for other symptoms

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such as emotional numbing, re-experiencing, and behavioral avoidance


(Pharmacotherapy for posttraumatic stress disorder. www.UpToDate.com, 2014)

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Pharmacotherapy

Pharmacotherapy
Antidepressants: SSRIs, SNRIs
Alpha-1 antagonists: prazosin
Beta adrenergic antagonists: propranolol
Anticonvulsants/Mood stabilizers
Atypical antipsychotics: risperidone, olanzapine
Overall not supported, some clinical trials with mixed results
Atypical antipsychotics can be used as augmentation
therapy in cases of partial response to SSRI therapy

Benzodiazepines
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Pharmacotherapy Algorithm

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(DiPiro, J. T. 2014. Pharmacotherapy: A pathophysiologic approach. 9th ed.)

Pharmacotherapy First Line


Agents

VA/DoD Guidelines 2010

Selective Serotonin Reuptake Inhibitors (SSRIs)


Start at low end of therapeutic range and titrate up gradually
until desired response is achieved
May push dose to higher therapeutic range (per patient
tolerance) before concluding that therapy has failed
Fluoxetine, paroxetine*, sertraline*

Serotonin-Norepinephrine Reuptake Inhibitors


(SNRIs)
Venlafaxine XR

* FDA indication for treatment of PTSD


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(Pharmacotherapy for posttraumatic stress disorder. www.UpToDate.com, 2014)

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Monitoring

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Question 1

Acute Phase

PTSD symptoms respond slowly to pharmacotherapy


Initate SSRIs within 3-4 wks of exposure
Gradual titration up to therapeutic dose
8-12 wks to determine response

1. DSM-5 diagnostic criteria of PTSD does not


include criterion for:
a.
b.
c.
d.

Continuation Phase
Many patients undergoing concurrent psychotherapy during
this phase
6 month relapse prevention

Stressors
Avoidance
Negative Cognitions and Mood
Arousal and Recovery

Maintenance and Discontinuation


Patients responding to pharmacotherapy should continue
therapy for at least 12 months
If residual symptoms persist, continue drug therapy
Drug therapy can be withdrawn and slowly tapered over 1
month to reduce potential for relapse

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(DiPiro, J. T. 2008. Pharmacotherapy: A pathophysiologic approach. )

Question 2

Question 3

2. Cognitive-behavior therapy, is the only effective


method of psychotherapy in the treatment of
PTSD.

3. Initial pharmacotherapy options for treatment of


PTSD includes:
a.
b.
c.
d.

a. True
b. False

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SSRIs
Benzodiazepines
Tricyclic Antidepressants
MAO Inhibitors

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1/27/2015

References
American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5.
Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., Wachter, K., Murray, L. K., & Bolton, P. A. (2013). Controlled trial
of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368, 2182-219.
Bruce, T. J., Spiegel, D. A., & Hegel, M. T. (1999). Cognitivebehavioral therapy helps prevent relapse and recurrence of panic disorder following
alprazolam discontinuation: A long-term follow-up of the Peoria and Dartmouth studies. Journal of Consulting and Clinical Psychology, 67(1),
151.
Bryant, R.A., Mastrodomenico, J., Felmingham, K.L., Hopwood, S., Kenny, L., Kandris, E., Cahill, C. & Creamer, M. (2008). Treatment of acute
stress disorder: A randomized controlled trial. Archives of General Psychiatry, 65, 659-667.
DiPiro, J. T., et al. (2008). Pharmacotherapy: A pathophysiologic approach. New York: McGraw-Hill Medical.
Kessler, R. C., Berglund, P. A., WaiTat, C., Demler, O., Glantz, M., Lane, M. A., ... & stn, T. B. (2008). The National Comorbidity Survey
Replication (NCS-R): cornerstone in improving mental health and Mental Health Care in the United States. The WHO world mental health
surveys: global perspectives on the epidemiology of mental disorders, 165-210.
National Comorbidity Survey. (2005). NCS-R appendix tables: Table 1. Lifetime prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort.
Table 2. Twelve-month prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Accessed at:
http://www.hcp.med.harvard.edu/ncs/publications.php
Norris, F. H., & Slone, L. B. (2013). Understanding Research on the Epidemiology of Trauma and PTSD Special Double Issue of the PTSD Research
Quarterly. PTSD Research Quarterly, 24(2), 1-13.
Pharmacotherapy for posttraumatic stress disorder. (2014). Accessed at: www.UpToDate.com.
Stahl, S. M. (2008). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications. Cambridge: Cambridge University
Press.
U.S. Department of Veterans Affairs. (2014). A VA Clinicians Guide to Managing Posttraumatic Stress Disorder: Improving quality of life through
the use of evidence-based medicine.
Van der Kolk, B. A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 1071(1), 277293.

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