William J. Resch, DO, FAPA Rural Health Scholars Retreat
Athens, Ohio October 19, 2013
Slide 2
Off-label indications will be discussed in this presentation I
disclose that I have no relevant financial or other interest in any
commercial company or entity pertaining to this educational
talk
Slide 3
Interactive lecture with multitude of questions and a brief
representative case study Give brief overview of PTSD Look at
diagnosing PTSD Review current treatment(s) of PTSD On own in
Primary Care / Rural Health Area Referral to VA
Slide 4
How many members of the audience would feel comfortable
diagnosing, and initiating PTSD treatment to a returning combat vet
from Iraq or Afghanistan? How many members of the audience would
know how to and what the VA has to offer veterans with PTSD?
Slide 5
When was PTSD officially recognized as a formal diagnosis? In
1980 the APA formally codified PTSD in the DSM-III Prior to 1980 it
was documented under many names ***
Slide 6
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11
Slide 12
Slide 13
T or F- People with PTSD are violent and unpredictable? False -
Beliefs that violence and unpredictability are associated with
serious mental problems are common, but untrue. This misguided fear
is one of the most prominent barriers to acceptance and social
inclusion. In reality, the presence of PTSD or a psychological
condition does not make someone prone to violence. Therefore,
someone with PTSD or some other psychological condition should not
be viewed as a threat in the community, office, workplace,
etc.
Slide 14
T or F - Once people develop PTSD, they will never recover.
False - Studies show that most people with PTSD and other mental
illnesses get better, and many recover completely. Recovery refers
to the process in which people are able to live, work, learn and
participate fully in their communities. For some individuals,
recovery is the ability to live a fulfilling and productive life.
For others, recovery implies the reduction or complete remission of
symptoms.
Slide 15
T or F- Therapy and self-help are a waste of time. Why bother
when you can just take a pill? False - Treatment and supports vary
depending on the individual. A lot of people work with therapists,
counselors, friends, psychologists, psychiatrists, nurses and
social workers during the recovery process. They also use self-help
strategies and community supports. Some choose medications in
combination with other supports. The best approach is tailored to
meet the specific needs and choices of the individual.
Slide 16
How many medications are FDA approved for the treatment of
PTSD? Only two! sertraline (Zoloft) and paroxetine (Paxil).
However, many other medications and classes are used in the
treatment of this condition.
Slide 17
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder
that can develop in response to a traumatic event(s) Typically
involves 3 types of symptoms / clusters *** lasting > 1 month
Symptoms lead to problems in functioning in social / family life,
work, or school
Slide 18
Normal to have painful memories after a traumatic event Trauma
affects the way people think about themselves, others, the world,
and the future For most, these reactions lessen over time and
thinking returns to normal For some, however, reactions continue,
become severe, become disruptive, and lead to more lasting PTSD
symptoms
Slide 19
Trauma and Stressor-Related Disorders (DSM-5) Reactive
Attachment Disorder Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder (aka PTSD) Acute Stress Disorder
Adjustment Disorders Chapter placed near anxiety disorders,
obsessive-compulsive related disorders, and dissociative disorders
due to close relationship of all of the diagnoses
Slide 20
A. Exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) 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 exposure to aversive details of the traumatic
event(s) ***
Slide 21
B. Presence of one (or more) of the following intrusion
symptoms associated with the traumatic event(s) 1. Recurrent,
involuntary, and intrusive distressing memories of the traumatic
event 2. Recurring distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s) 3.
Dissociative reactions (e.g. flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring 4.
Intense or prolonged psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect of the
traumatic event(s) 5. Marked physiological reactions to internal
and external cues that symbolize or resemble an aspect of the
traumatic event(s)
Slide 22
C. Persistent avoidance of stimuli associated with the
traumatic event(s), beginning after the traumatic event(s)
occurred, as evidenced by one or the following: 1. Avoidance of or
efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s) 2. Avoidance of
or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings
Slide 23
D. Negative alterations in cognitions or mood associated with
the traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two or more of the following:
Memory disturbance, negative beliefs, distorted cognitions,
negative emotional state, anhedonia, detached feelings, and
inability to experience positive emotions
Slide 24
E. Marked alterations in arousal or reactivity associated with
the traumatic event(s) as evidenced by two or more of the
following: irritability/anger, reckless/destructive behavior,
hypervigilance, exaggerated startle response, problems
concentrating, sleep disturbance F. Duration > 1 month G.
Significant distress and impairment H. Not attributable to
substance or other medical condition
Slide 25
You can do a great deal, starting with how you act and speak to
people with mental illness You can create an environment that
builds on peoples strengths, promotes understanding, and of
acceptance Be Psychiatrically Minded! Never say that is for your
other doctor!
Slide 26
If you dont take the temperature, you cant find the fever Know
something about our nations military history and about our present
military conflicts Know something about DoD and VA Ask each and
every patient if he/she was a service member/veteran? If so: ask
the branch, years served, job, rank, combat, and type of discharge?
***
Slide 27
Common themes and problems Marriage, relationship problems
Medical issues Financial hardships Endless questions from family
and friends Guilt, shame, anger Lack of structure
Slide 28
Common themes and problems Feelings of isolation Nightmares,
sleeplessness Lack of motivation Forgetfulness Anger Feeling
irritable, anxious, on edge
Slide 29
Dont label people with words like crazy, wacko or loony or
define them by their diagnosis (e.g. PTSDer) It is important to
make a distinction between the person and the illness Instead of
saying someone is mentally-ill, say he or she has PTSD Dont say a
mentally-ill person, say a person with PTSD This is called
people-first language
Slide 30
Primary Care PTSD Screen (PC-PTSD) Combat Exposure Scale (CES)
PTSD Checklist Civilian Version (PCL- C) Trauma Symptom Checklist -
40 (TSC-40) 3 Question DVBIC TBI Screening Tool Other measures as
appropriate
Slide 31
Steve is a 29 yo MWM who presents to your rural primary care
office complaining of chronic insomnia, nightmares, depression,
anxiety, difficulty concentrating, and inability to tolerate large
crowds. States most of the time I feel like I am in a fog. ***
Reports his wife encouraged him to come to your office to get some
help or she was going to consider moving out?
Slide 32
What other questions do you need to ask Steve? Duration
Impairment / Occupational Functioning Military history Psych
history Substance Use / History Psychiatry ROS What tests could you
administer in your office? Who else could you talk to for increased
collateral information? What labs would you want to order?
Slide 33
What treatment options might you consider? Antidepressant
Anxiolytic / Benzodiazepine Antihypertensive Antipsychotic Hypnotic
Mood Stabilizer
Slide 34
What non-pharmacological treatment recommendations could you
recommend to Steve Abstinence from alcohol and other illicit drugs
Evidence Based Psychotherapy referral Cognitive Processing Therapy
(CBT) Prolonged Exposure Therapy Eye Movement Desensitization
Reprocessing (EMDR)
Slide 35
Evidence Based Medicine exists in all of medicine and certainly
in Psychiatry! Clinical Practice Guidelines are the gold standards
of competent care The best studies and research regarding PTSD is
coming from DoD/VA!
Slide 36
Assist clinicians in learning about available treatments,
reviewing their evidence base and making practical,
patient-specific choices among them Provide clinical algorithms
that walk clinicians through the necessary steps from screening and
initial assessment through treatment and re-assessment Most
relevant among these is the VA / DoD Clinical Practice Guideline
for the Management of Posttraumatic Stress
Slide 37
Created by a working group of VA and DoD clinicians and
researchers Separate algorithms defined for primary care providers
and mental health professionals Evidence tables provided for each
recommendation and a substantial literature review included
Available at: http://www.healthquality.va.gov/
http://www.healthquality.va.gov/ In the public domain
Slide 38
Slide 39
VA / DOD Guidelines for Treatment of PTSD Washington (DC):
Veterans Health Administration, Department of Veterans Affairs.
Available at: VHA Web site. www.guidelines.gov Data reviewed up to
9/10VHA Web sitewww.guidelines.gov
Slide 40
VA / DOD Guidelines for Treatment of PTSD Washington (DC):
Veterans Health Administration, Department of Veterans Affairs.
Available at: VHA Web site. www.guidelines.govVHA Web site
Slide 41
The American Psychiatric Association (APA) has published a
Practice Guideline for Patients with Acute Stress Disorder and
Posttraumatic Stress Disorder The International Society for
Traumatic Stress Studies, the worlds largest international
multidisciplinary professional organization working in the field of
psychological trauma, provided a comprehensive set of treatment
guidelines in 2000 with an update version in 2008 Both guidelines
provide a thoughtful introduction to available therapies,
significant background information and evidence-based treatment
recommendations.
Slide 42
aka CPT Identify and clarify patterns of thinking Identify
distressing trauma-related thoughts Convert these thought patterns
into more accurate thoughts Address core beliefs about self,
others, larger world
Slide 43
aka PET Reduce the fear associated with traumatic experience
through repetitive, therapist- guided confrontation of feared
places, situations, memories, thoughts, and feelings Exposure can
be imaginal or in vivo Reduced intensity of emotional and
physiological response is achieved through habituation.
Slide 44
aka SIT Anxiety management is among the most useful
psychotherapeutic treatments for PTSD clients (Expert Consensus
Guideline Series) SIT can be thought of as a set of skills for
managing stress and anxiety Breathing control, Deep Muscle
Relaxation, Assertiveness Training, Role Playing, Covert Modeling,
Thought Stopping, Positive Thinking, Self Talk
Slide 45
aka EMDR Accessing and processing traumatic memories to bring
these to resolution The client focuses on emotionally disturbing
material while at the same time focusing on an external stimulus
(usually therapist directed bilateral eye movements, hand tapping,
sounds)
Slide 46
Specific serotonin reuptake inhibitors (SSRIs) and venlafaxine
(Effexor) have the strongest evidence While many drugs from a wide
range of classes have been studied in PTSD, there is little
evidence for their use except as adjunctive treatment
Antipsychotics often prescribed in VA/DoD settings Available
research suggests that prazosin reduces the frequency and intensity
of posttraumatic nightmares and may be effective in managing other
symptoms of PTSD Benzodiazepines are NOT effective as first line
agents in the treatment of PTSD Because of potential for dependence
and abuse, their use as single agents is strongly
discouraged!!!!!!!!!!!!!!!
Slide 47
153 medical centers at least one in each state, Puerto Rico and
the District of Columbia 909 ambulatory care and community-based
outpatient clinics (CBOCs) in Southern Ohio alone there are CBOCs
in Marietta, Cambridge, Athens, Wilmington, Portsmouth, and
Lancaster 47 residential rehabilitation treatment programs 232
Veterans Centers
Slide 48
88 comprehensive home-care programs 4 DoD/VA Polytrauma Centers
My HealtheVet http://www.myhealth.va.gov/
http://www.myhealth.va.gov/ PTSD Coach Application for
Droid/I-phone 21 Veterans Integrated Service Networks (VISNs)
Slide 49
PTSD Clinic Group therapies MHRRTP = PRRTP/SATP Suboxone Clinic
Transcranial Magnetic Stimulation (TMS) Community Residential Care
(CRC) Homes TeleBuddy System Telepsychiatry Acute Inpatient
Psychiatry Long Term Psychiatry Community Living Centers
Slide 50
Learn the facts about mental health and PTSD and share them
with others, especially if you hear something that isnt true If you
treat people with PTSD in your practice, consider hosting workshops
to educate patients, families, and co-workers on the facts
Slide 51
There should be No Wrong Door to which veterans can come to
physicians for help PTSD should be a fairly straightforward
diagnosis when using good history, DSM-5 criteria, screening tests,
and sound clinical judgment Multitude of Evidenced Based Therapies
to either initiate or refer to The VA has many effective, safe, and
groundbreaking tools to treat its veterans who have borne the
battle
Slide 52
Slide 53
1) American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. Washington, DC: American
Psychiatric Association. 2013. 2) APA Practice Guidelines for PTSD,
2004, www.psych.org. www.psych.org 3) Becker ME et el, Journal of
Clinical Psychopharmacology 2007; 27(2):193-197. 4) Berger et al,
Prog Neuropsychopharmacological Biological Psychiatry
2009;33(2):169-180. 5) Cukor J et al, Ann. N. Acad. Sci
2010;1208:82-89. 6) Davis et al, J Clin Psychopharmacology
2008;28(1):84- 88. 7) Washington (DC): Veterans Health
Administration, Department of Veterans Affairs. Available at: VHA
Web site. www.guidelines.govVHA Web site
Slide 54
Slide 55
Slide 56
PTSD Mood Disorders Acute Stress Disorder AnxietyGriefTBI
Military Sexual Abuse Substance Abuse ASDCOSR/I