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This slide show explores key aspects of treating PTSD in primary care. It explored assessing for symptoms of trauma, flow chart for treatment and collaborative team development and psychopharmachology.
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TREATING TRAUMA IN PRIMARY CAREIntegrated Approach to Individual and Community health
Objectives
PTSD – Rates and Presentation in Primary Care
Impacts on Health and Health Care
PTSD – Assessment in Primary Care
PTSD – Treatments in Primary Care
PTSD – Treatment Teams
Trauma is not in the event.
It is in the reaction to the event.
Post-Traumatic Stress
DSM5
PTSD
Event
Avoidance
Intrusion
Cog/Mood
Arousal
PTSD – Rates in Primary Care Nearly 70% of adults experience an event that could
be classified as traumatic Over all Rates of PTSD are 8% in America, 5% in men
and 10% in women. Close to 80% of individuals have symptoms post a
traumatic event that decrease over time. In communities with high levels of community
violence, poverty, and other forms of oppression rates are at or above combat levels 25%
34% of adolescent survivors of MVA, 48% in survivors of rape, 67% prisonors of war, 64% ICU PTs (wide rage), 15% post cartic event, 11% of all MVA.
35%-50% of Chronic Pain Patients
Comorbid Health Conditions
Heart Disease Autoimmune Disease Hyperlipidemea Interstitial Cystitis Dementia Fibromyalgia/Chronic
fatigue Chronic Pain
PTSD
Stress
Health
PTSD Comorbid Mental Health
Major Depression (35% - 50%)
Substance Abuse (21%-43% PTSD+SUD)
Generalized Anxiety
Bipolar Disorder
Borderline Personality
Resiliency Factors
Family closeness/Positive Family Relationships
School attachment Neighbor support when
parental support and monitoring were low.
Peer support/Social support Emotional regulation
skills/Amount of positive emotions.
Religiosity Achievement/Self-regard Spirituality Inner-directed locus of
control Thought-control/
cognitive strategies. Mobilization after a
threat.
PTSD is endemic but so is resiliency – 60% of people in the US have an event that could be traumatic 8-10% of individuals display symptoms of PTSD.
Allostatic Load…
Bruce McEwen, PhD Stress Researcher
Stress response is meant to be short-term and then return to homeostatic range.
Short-term Stress is beneficial to the body and mind.Long-term Stress reduces the bodies efficacy.
Trauma In The Brain and BodyHyperactivation
1. Hyperactive insula (Body Information)
2. Under-activated anterior cingulate cortex (ACC). (Regulation)
3. Under-activation medial prefrontal cortex (mPFC). (Regulation)
Dr. Lanius fMRI Study
Hypoactivation
1. Down regulation of physical sensations from the insula cortex.
2. Hyperactivation activation in the anterior cigulet cortex (ACC).
3. Hyperactivation in the medial prefrontal cortex mPFC.
Dr. Lanius fMRI Study
Y
Assessment – PC PTSD
Brief Screeni
ng
Changes
Lives
DREAMS: A Mnemonic for Screening Patients for Post-traumatic Stress Disorder
(D)etachment (R)e-experiencing the event (E)vent had emotional effects (A)voidance (M)onth in duration (S)ympathetic hyperactivity or
hypervigilance
Assess Comorbidities
PHQ9 – Assess Depression
Symptoms
GAD7 – Assess Generalized
Anx
MDQ – Assess Bipolar
SBIRT – Assess SUD (Sub Use
Diss)
Recognize the Clinical Presentation
• Isolation • Loss of
relationships• Homelessness
• Irritability• Avoidance• Non-
Compliance
• Depression• Substance
Abuse• Anxiety
• Chronic Pain/Migraines
• Multiple Complaints
• Obesity
Physical Mental
SocialBehavioral
Normal defensive responses to high threat can impact treatment and treatment adherence.
Normal Defensive Responses to High Threat
FightFligh
tFreez
e
• Irritability• Loss of
Temper• Defensivenes
s • Avoidance• Anxiety• Fear• Numbing• Detachment• Giving Up
Easily
Treatment Frame
Educate About PTSD 1. Inform, 2. Normalize, 3. Join
Treatment Options: 1. CBT, 2. EMDR 3. Pharm – PTSD, 4. Pharm - SymptDevelop Common Goals
(Rapport): 1. Identify Needs, 2. Target Sympt. (e.g. insomnia, dreams, mood)Develop Treatment Team
and Ref: 1. Beh Health, 2. Providers, 3. Pain Tx, 4. Specialty Mental Health, 5. Psychiatry, 6. Social Work
Relational Tools that Create Safety
• Creating Social Bonds: Social bonds increase the impact of the doctor/patient relationship.
STEPS: 1. Create Safety (eye contact – upper face working) 2. Approach Proximity (physical/ emotional closeness)3. Establish Contact (physical/ emotional contact)
• Self-Empowerment: Uses positive emotions to build on existing patient strengths.
How: Identify successful coping, positive support, nurturing self care,and current strengths. This helps you get more mileage and impact when teaching new information.
Map for safe containment in clinical contact
To establishsafety:
Orient: Direct
attention outward
through the senses
Joining / Resource
Stressful Content
Joining / Resource
Orient: Direct
attention outward
through the senses
Treatment Process Overview
Psychopharmacological Treatment of PTSD
The only two FDA approved medications for the treatment of PTSD are sertraline (Zoloft) and paroxetine (Paxil).
There is also strong evidence for: SSRI fluoxetine (Prozac), SNRI venlafaxine (Effexor) which are considered first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD.
Other Antidepressants: There have been smaller RCTs with mirtazapine as well as open trials.
(Mirtazapine may be particularly helpful for treatment of insomnia in PTSD).
Trazodone is also commonly used for insomnia in PTSD even though there is little empirical evidence available for its use.
Nefazodone (serazone) Is still available in a generic form but carries a black box warning regarding liver failure.
Depression is one of the major comorbidities (above medications are effective in comorbid depression). Bupropion is useful in treating comorbid MDD (not PTSD)
Psychopharmacological Treatment of PTSD
Mood stabilizers These medications, also known as anticonvulsants or anti-epileptic drugs, either block glutamate or potentiate GABA or do both.
Topiramate has demonstrated promising results in randomized controlled trials with civilians and Veterans with PTSD.
Despite some promising open label studies, other RCTs have been negative for this group of medications in treating PTSD
Psychopharmacological Treatment of PTSD
Small single-site studies suggested that atypical antipsychotic agents were effective adjunctive treatment for PTSD patients who had poor responses to first-line SSRIs or SNRIs
A recent large-scale multi-site trial of risperidone as an adjunctive agent for SSRI poor/partial responders showed that there was no benefit (in comparison with a placebo group).
VA/DoD PTSD Clinical Practice Guideline has been revised as follows: Atypical antipsychotics are not recommended as mono-therapy for PTSD. Risperidone (Risperdal) is contraindicated for use as an adjunctive agent
- potential harm (side effects) exceeds benefits. There is insufficient evidence to recommend any other atypical
antipsychotic as an adjunctive agent for PTSD.
Psychopharmacological Treatment of PTSD
Prazosin has been found to be effective in RCTs in decreasing nightmares in PTSD. It blocks the noradrenergic stimulation of the alpha 1 receptor. Its effectiveness for PTSD symptoms other than nightmares has not been determined at this time.
The tricyclic antidepressants and MAOIs act on a number of neurotransmitters. While there are RCTs supporting their use, these medications are not used as first line agents due to their safety and side effect profiles
The tricyclics have quinidine like effects on the heart and can cause ventricular arrhythmias especially in overdose.
The MAOI phenezine has been shown to be effective in PTSD. Careful management of the MAOIs and strict dietary controls are important because they can cause potentially fatal reaction.
Psychopharmacological Treatment of PTSD
Buspirone is sometimes used adjunctively in treatment of hyperarousal symptoms.
Beta blockers also have been used to treat hyperarousal. Beta blockers block the effects of adrenalin (epinephrine) on organs such as the heart, sweat glands, and muscles. The evidence is not definitive at this time. It is thought to re-wire the memories with out fight/flight response. This is a neuroplastic based treatment.
Benzodiazepines act directly on the GABA system which produces a calming effect on the nervous system. This is the only potentially addictive group of medications discussed. Studies have not shown them to be useful in PTSD treatment as they do not work on the core PTSD symptoms. Also these medications are addictive.
Questions???
Thank You!