Post-traumatic Stress Disorder - PTSD

Learning Objectives

• Understand main symptom clusters of PTSD

• Explain core pathophysiology of PTSD that may lead to clinical symptoms

• Identify guideline recommended psychologic and pharmacological interventions for PTSD

• Explain the role of prazosin in the management of PTSD-related nightmares, including mechanism of action and key counseling points.

Prevalence of PTSD

70% of global population reported exposure to a traumatic event but 6% only developed PTSD

14.4% of VETERANS had lifetime PTSD

Risk factors for PTSD?

• Women > Men

• Past Diagnosis or family history of mental health disorder

• History of substance use disorder

• Lower socioeconomic status

• Lower education level

• Previous trauma

• Occupations (Veterans > civilians)

PTSD in patients can lead to an increased risk of what?

Increased risk of

• Substance use disorders

• Mood disorders/anxiety

• Personality changes/disorder

• Functional impairment and diminished quality of life

• Suicide attempts

• CVD, Neuro, respiratory, and metabolic disease

What is the gold standard for diagnosing PTSD by clinicans?

Clinican administered PTSD scale for DSM-5 (CAPS-5)

• 30 items, structured interview

• PTSD symptoms:

  • 0 = absent

  • 1 = mild PTSD

  • 2 = moderate PTSD

  • 3 = severe PTSD

  • 4 = Extreme PTSD

• to diagnose PTSD, specific criteria MUST be met in PTSD

Specific DSM-5 criteria needed to diagnose PTSD along with CAPS-5 interview:

What are the 4 PTSD clusters?

1. Avoidance

2. Negative thoughts or feelings

3. Trauma-related arousal and reactivity

4. Intrusion symptoms

What symptoms are related to the Trauma-related arousal and reactivity cluster?

Irritability, aggression, Hypervigilance, Startled reaction, concentration difficulties

What symptoms are related to intrusion symptoms cluster?

Nightmares, flashbacks (dissociative reactions), emotional distress and/or physical reactivity after exposure to traumatic reminders

What symptoms are related to negative thoughts or feelings cluster?

• Inability to recall key features of trauma

• Exaggerated blame of self or others for causing trauma

• Decreased interest in activities

• Feeling isolated

• Difficulty experiencing positive effect

What symptoms are related to Avoidance cluster?

Attempts to avoid reminders of traumatic events, places, people etc

• anything about AVOIDING remembering

What two components make up Dissociative specification?

Depersonalization and Derealization

What is depersonalization?

Experience of being an outside observer of or detached from oneself

What is Derealization ?

Experience of unreality, distance or distortion

Diagnosing PTSD in patients <6 years old

• Children may not be able to verbally describe the trauma

• Trauma may be expressed through behavioral changes

  • Reenactment, regression (bedwetting, etc), clinginess, acting out, symptoms

• Key differences in DSM-5 criteria

  • 3 cluster symptoms - avoidance and negative mood are combined

  • Criteria B (intrusion) includes trauma-themed play rather than verbal reports

3 components to PTSD pathophysiology

1. Neuroendocrine dysregulation

   1. HPA Axis

2. Neurobiological dysregulation

   1. Amygdala, Hippocampus, prefrontal cortex

3. Neurotransmitters alterations

Normal HPA axis function/pathway

Hypothalamus release CRH —- Anterior pituitary —- Adrenal glands —- Cortisol released —- causes stress and CRH release to stop by negative feedback

What is the problem with CRH and Cortisol in PTSD?

The CRH levels are increased and cortisol is reduced —- thus stopping the negative feedback loop and causing more CRH to be released and cause more stress

What is the activity of the Prefrontal cortex in PTSD?

It is HYPOactive in PTSD

What is the activity of the Amygdala in PTSD?

HYPERactive in PTSD

What is the Hippocampus activity in PTSD?

Reduced Volume in pTSD

Neurotransmitters Alterations

Increased NE

• increased sympathetic activity = intrusion symptoms and hypersrousal

• Alpha-1 stimulation disrupts sleep

Decreased Serotonin (5HT)

• Regulates fear and anxiety in the amygdala

• Associated with hyper vigilance, impulsivity, and irritability

Goals of PTSD treatment

Reduce core symptoms, disability, and comorbidity to improve quality of life

Are medications first line for PTSD?

NO, meds are NOT. first line for therapy —- Psychotherapy is!!!!

Evidence based trauma-focused Psychotherapies for FIRST LINE tx of PTSD?

• Cognitive processing Therapy

• Prolonged exposure (PE)

• Eye movement and Desensitization and reprocessing (EMDR)

What is Cognitive processing Therapy Psychotherapy?

• It reframes the negative thoughts about the trauma

• You talk about thoughts, sometimes contains writing

• Weekly sessions, 60 minutes or 90 min group sessions x 3 months

What is Prolonged Exposure Psychotherapy?

• Teaches how to gain control by facing fears

• You talk about the trauma, and do safe activities that were previously avoided; may include listening to recordings

• weekly individual sessions x 3 months

What is EMDR (eye movement, etc) psychotherapy?

• Facilitates reprocessing of traumatic memories

• You call the trauma to mind while focusing on an external motion or sound

• weekly sessions x 3 months

What is SECOND line therapy for PTSD?

Pharmacotherapy!!!

Recommended agents:

• Paroxetine

• Sertraline

• Venlafaxine

all treatment lasts for 8-12 weeks

What is Paroxetine’s indications for PTSD?

• Reexperiencing

• avoidance/numbing

• hyperarousal

RANH

20-50mg x day

important considerations:

• Strong CYP2D6 inhibitor

• Short half life - risk of discontinuation syndrome

• Anticholinergic effects — caution with geriatric

What is Sertraline’s indications for PTSD?

• Reexperiencing

• Intrusion and avoidance

• numbing

• NOT hyperarousal

RIAN

typical maintenance dose 50-200mg/day

What is Venlafaxines indications for TSD?

• acts primarily as an SSRI at lower dosages but SMRI at higher dosages

• Reduces hyperarousal and comorbid anxiety

• modulating signals at specific synapes

Short half-life increases risk of discontinuation syndrome

caution HTN patients

Other medications that are neither recommended nor against for PTSD treatment

• Antipsychotics (risperidone)

• Bupropion

• TCAs

• Benzodiazepines!!!

  • may worsen PTSD

  • increase fall risk and mental clouding

  • mortality risk

points about symptom specific treatment of sleep issues in PTSD

• 50-70% of patients with pTSD have sleep issues

• Insomnia and nightmares are associated with higher risk of suicide

Treatment for INSOMNIA

• CBT

• Trazadone, mirtazapine or hydroxyzine (T<H)

Treatment for OSA

• CPAP

Nightmares

• Prazosin

• Cannabis

Points about prazosin for nightmares in PTSD

• It is an ANTAGONIST that crosses BBB — vasodilation - reduces sympathetic outflow

• Only for PTSD nightmares, not broad treatment

• FIRST DOSE PHENOMENON - drop in BP within 30-090 minutes

• caution with concomitant alpha antagonists for BPH

Is Cannabis recommended in PTSD treatment?

NO — lack of evidence for efficacy, known AE’s

• Dronabinol has some potential with nightmares

Lecture summary points

• PTSD may occur after traumatic events and manifest as symptoms of avoidance, negative thoughts or feelings, trauma arousal, and reactivity

• Pathophysiology ofPTSD is multifactorial

  • HPA axis dysregulation

  • Neurobiological dysregulation

  • neurotransmitter changes

• Psychotherapy is first-line treatment with MEDS AS SECOND LINE

• Prazosin is alpha-1 antagonist used for PTSD nightmares - risk of HYPOTENSION