Clinical Guidelines for Post-traumatic Stress Disorder

1
Clinical Guidelines forPost-traumatic Stress
Disorder

• Mylea Charvat PTSD Specialist
• War Related Illness and Injury Study CenterVA
  Palo Alto Health Care Systemmylea.charvat_at_va.gov

2
Outline

• Epidemiology and Criteria
• Risk Pathways to PTSD
• Gender Cultural Issues in PTSD
• DoD Guidelines
• Diagnosis Assessment
• Pharmacology
• Psychotherapies
• Resources

3
DSM-IV Criteria

• Person Experiences Traumatic Event
• Person Experiences Fear, Helplessness or Horror
• The person experiences a combination of the
  following Sx which are still present gt 4 weeks
  following the TE, last more than one month and
  cause significant distress

Re-experiencing gt1 Intrusive thoughts or memories Trauma related dreams Acting/feeling as though the trauma were reoccurring Emotional distress in response to triggers Physical Sx in response to triggers Avoidance gt3 Efforts to avoid trauma related thoughts or feelings Avoidance of people, places or activities that trigger reminders of trauma Memory loss for all or parts of the trauma Loss of interest in activities Feelings of estrangement from others Expectation of foreshortened future Hyperarousal gt2 Difficulty with sleep Irritability and anger Attention and Concentration problems Hypervigilence Exaggerated startle reaction
4
Epidemiology of Trauma Exposure

• Only National Sample (Kessler et al., 1995) of
  trauma exposure
• 61 of men reported DSM-III TE
• 51 of women reported DSM-III TE
• Veteran Data (US DVA, 2003) surveyed 20,000
  Veterans in US
• Combat exposure (41 men/ 12 women)
• 36 exposure to dead/dying/wounded
• No MST data were collected
• WWII Veterans reported a 54 exposure rate to
  combat compared to 19 for Korea

5
Epidemiology of PTSD

• Rates Consistent since DSM-III-R
• Estimates range between 6 and 12 in general
  population
• Kessler et al., 1995 - National survey found PTSD
  rates of
• 20 for women
• 8 for men

6
Epidemiology of PTSD in Veterans

• Study of 2,300 Vietnam Era Veterans
• 31 of men met PTSD criteria
• 27 of women met PTSD criteria
• Prevalence higher with
• Army service (compared to other branches)
• gt12 months service
• Entering service between age of 17 and 19
• (Kulka et al., 1990 Schlenger et al., 1992)

7
Estimates of TE Exposure PTSD prevalence among
OEF/OIF Veterans
8
Risk Pathways to PTSD

• TEs that involve injury to self or others
• TEs that are more malicious and grotesque
• Dissociation at the time of the TE
• Lower education levels
• Lower SES
• Minority racial/ethnic status
• Family psychiatric history (esp. childhood abuse)
• Lack of social support
• Feelings of guilt or shame re the TE
• Previous trauma history
• Also small literature indicating prior trauma may
  inoculate against future trauma/PTSD

9
Gender Issues in PTSD

• Women are at greater risk for PTSD than men
• When trauma characteristics are more equal
  (political situations or violent community)
  gender differences in PTSD rates disappear

10
Gender Issues in PTSD

• Differences seem to be defined by trauma
  characteristics
• Women are more likely to experience sexual
  assault and chronic abuse (intimate partner or
  childhood sexual abuse)

11
VA-DOD Clinical Guidelines

• Recommendations for the performance or exclusion
  of specific procedures or services for specific
  disease entities
• Derived through a rigorous methodological
  approach
• Includes a systematic review of the evidence to
  outline recommended practice
• Displayed in the form of a flowchart algorithm

12

13
Treatment Guidelines

• A potential solution to inefficiency and
  variation in care
• A user-friendly format for training and education
  on PTSD treatment
• Designed to inform and support clinicians
• Must always be applied in the context of an
  individual provider's clinical judgment for the
  care of a particular patient

14
Development of DoD/VA Treatment Guidelines

• DoD represented by members of Army, Navy, and Air
  Force
• DVA represented by staff of VAMCs, Readjustment
  Counseling Service, and the National Center for
  PTSD
• Disciplines represented include psychiatrists,
  primary care physicians, psychologists, nurses,
  pharmacists, occupational therapists, social
  workers, counselors, chaplains, and
  administrators

15
Scope of DoD Treatment Guidelines

• Developed to address the full spectrum of
  traumatic-stress response
• Acute Stress Response/Combat Stress Response
• Acute Stress Disorder
• PTSD
• Acute PTSD
• Chronic PTSD
• PTSD with co-morbid Major Depression and/or
  substance abuse
• Complex PTSD
• Negative health behaviors known to adversely
  affect clinical outcomes in those with PTSD

16
Limitations and Challenges

• Inadequate clinical trials in combined treatments
  (such as psychotherapy and pharmacotherapy)
  versus single treatment approaches.
• Not clear whether a treatment effective for
  combat Veterans with PTSD will be equally useful
  for survivors of another trauma, such as recent
  sexual assault.
• Inadequate research on treatment of PTSD in
  patients with dual diagnosis (i.e. substance
  abuse/MDD)

17
Diagnosis Assessment of PTSD

• All new patients should be screened for symptoms
  of PTSD
• Thereafter, annually or more frequently if
  suspicion, recent exposure, history of PTSD
• Paper-and-pencil or computer-based screening
  tools should be used
• Notes importance of
• Balancing efficacy with practical concerns
  (staffing, time constraints, current clinical
  practices)
• Avoiding stigmatization and adverse occupational
  effects of positive screens
• Individuals with positive screens should receive
  more detailed assessment of their symptoms (i.e.
  CAPS, MMPI)

18
PTSD Checklist (PCL-M or PCL-C)

• 17 item self report questionnaire
• In the public domain
• Available in CPRS or pen and paper
• Short and easy to score/interpret
• Total Severity Score correlation with the CAPS
  .94
• For women Veterans utilize the PCL-C

19
Pharmacology Guidelines

• Monotherapy
• Strongly recommend SSRIs
• 2nd line TCAs and MAOIs
• Consider trial of at least 12 weeks before
  changing medications
• Consider 2nd generation (e.g., trazodone,
  buproprion)
• Augmented therapy for targeted symptoms
• Consider prazosin for nightmares and other PTSD
  symptoms
• Recommend medication compliance assessment at
  each visit
• Recommend against
• Benzodiazepines to manage core symptoms of PTSD
• Typical antipsychotics in management of PTSD

20
Psychotherapies

• Significant benefit Strongly recommended
• Cognitive Therapy
• Exposure Therapy
• Stress Inoculation Training
• Eye Movement Desensitization Reprocessing (EMDR)
• Some benefit
• Imagery rehearsal therapy
• Psychodynamic therapy
• Patient education (recommended for all patients)

21
Cognitive Therapy

• Systematic approach to challenging negative
  trauma-related beliefs (e.g., I should have
  prevented it)
• Educate about role of beliefs in causing distress
• Identify distressing beliefs
• Discuss, review evidence, and generate
  alternative beliefs
• Rehearse revised beliefs

22
Exposure Therapy

• Imaginal exposure repeated retelling of trauma
  story with emotional activation
• In vivo exposure assignments to confront feared
  stimuli in environment

23
Prolonged Exposure

• Multiple repetitions via homework
• Listening to cassette
• Writing
• Intended to help survivors habituate to stimuli

24
Stress Inoculation

• Focus on management of symptoms
• Coping skills training
• Education
• Muscular relaxation training
• Breathing retraining (slow abdominal breathing)
• Assertiveness
• Covert modeling
• Role playing
• Thought stopping
• Positive thinking and self-talk

25
EMDR

• Identify
• Disturbing image (worst part of event)
• Associated body sensation
• Negative self-referring cognition (what learned
  from event)
• Positive self-referring cognition
• Hold image/sensation/negative cognition in mind
  while tracking clinicians moving finger for 20
  seconds
• Describe changes, new associations
• Repeat tracking episodes and reinforce positive
  cognition

26
Imagery Rehearsal Therapy

• Select a memory or nightmare
• Change the memory any way you wish
• Patient writes down the new version
• Rehearse daily
• Includes education, tools for controlling imagery

27
Psychodynamic Therapy

• Re-engage normal adaptation by addressing
  unconscious to make it conscious.
• Deals with fears, fantasies, wishes, and
  defenses.
• Managing transference and counter-transference
  issues with an emphasis on the importance of the
  therapeutic relationship.
• Strength of evidence few clinical trials exist
  overall. Most evidence is in clinical case
  studies

28
Patient Education

• Recommended for all Veterans diagnosed with PTSD
• Usually conducted as a once a week group with a
  different topic each week
• Topics include (but are not limited to)
• What is PTSD?
• Types of symptoms
• Sleep and PTSD
• Anger and PTSD

29
Evaluation of Treatment Efficacy

• Regular use of self-administered checklists
• Follow up status should be routinely monitored at
  least every 3 months, using interview and
  questionnaire methods

30
Trauma Assessment in Primary Care

• If presumed PTSD or positive PTSD screen, then
  conduct or refer for in-depth PTSD Assessment
• Recommend use of self-report measures (PCL-M,
  PCL-C, Mississippi-M, Mississippi-C)

31
PTSD Evaluation in Primary Care

• If H/O Trauma - Recommend assessment of
• PTSD Symptoms
• Dangerousness to self or others
• Family and social environment
• Ongoing health risks
• Medical/psychiatric co-morbidities
• Thorough history and physical
• Appropriate lab evaluation
• Radiological assessment
• Level of functioning
• Risk factors for development of ASD/PTSD
• Substance use

32
Primary Care Treatment Recommendations

• Formulate presumptive diagnosis
• Consider initiating treatment or referral
• Treat complicating problems
• Pain, insomnia, anxiety, depression
• If complicated, refer to mental health
• Consult with MH
• Stay involved in treatment
• Take leadership in convening collaborative team

33
Primary Care Encouraged to

• Routinely provide
• Early recognition of PTSD
• Supportive counseling
• PTSD-related education
• PTSD symptoms
• Other traumatic stress problems/consequences
• Practical ways of coping with symptoms
• Processes of recovery
• Nature of treatments
• Regular follow-up and monitoring of symptoms

34
Guideline Concordance

• Assessment
• Complete PTSD MST Clinical Reminders as part of
  routine patient care
• Assess war-zone experiences systematically
• Screen for trauma history - PTSD
• Use standardized initial and follow-up
  assessments (i.e. PCL) to monitor progress and
  evaluate treatment
• Treatment
• Increase use of strongly recommended treatments
• Combined prolonged exposure and cognitive therapy
  
• Stress inoculation training
• EMDR
• Contact NCPTSD Education Division
  (josef.ruzek_at_va.gov ) or War Related Illness
  Injury Study Center (mylea.charvat_at_va.gov)

35
Resources

• List of all inpatient and outpatient PTSD
  treatment programs
• vaww.nepec.mentalhealth.va.gov/PTSD
• National Center for PTSD Information Center
• http//www.ncptsd.va.gov/ncmain/information