CNS Lecture 16: Pharmacotherapy of PTSD and OCD

What is the average duration of symptoms in patients undergoing treatment for PTSD?

36 months

What is the average duration of symptoms in patients NOT undergoing treatment for PTSD?

5 years

True or false: PTSD is remitted and does not reactivate years later.

False - PTSD can reactivate years after it has resolved

Symptoms of PTSD are ___________ and ____________.

intermittent and residual

What is the gold standard treatment for PTSD?

Trauma-Focused Therapy

What are the 3 phases of PTSD treatment?

Phase 1 - Stabilizing

Phase 2 - Exposure therapy

Phase 3 - Re-establishing

What is phase 1 of PTSD therapy?

Stabilizing the patient and addressing acute symptoms

What is phase 2 of PTSD therapy?

working through trauma with exposure therapy

What is the goal of exposure therapy in PTSD?

disrupt the link between the trauma-related cues and the resulting anxiety/avoidance that is typical by alowing them to modify their response to the memory

What is phase 3 of PTSD therapy?

Re-establishing social relationships and occupational functioning

What agents are FDA approved for PTSD?

Sertraline

Paroxetine

What pharmacotherapy is first line for PTSD?

SSRIs and SNRIs

What is the function of SSRIs/SNRIs in PTSD?

help with intrusive thoughts and hyperarousal

What do SSRIs/SNRIs NOT treat in PTSD?

avoidance symptoms

What is an adequate trial of SSRIs/SNRIs in PTSD?

6-8 weeks

What are the options if there is no response to an initial antidepressant dose in PTSD?

Increase dose

Wait longer

Switch to another agent

What are the options if there is a SECOND no response to another antidepressant in PTSD?

switch to another SSRI/SNRI or Mirtazapine

What is maintenance therapy for PTSD?

continuing the full doage for a MINIMUM of 12 months for patients who repond to pharmacotherapy

What should the approach be for a PTSD patient who wants to get off of their medications?

Taper slowly over at least a month to avoid potential for relapse

What is Prazosin used for in PTSD?

Nightmares

What percentage of PTSD patients experience nightmares?

50-70%

Prazosin (Minipress) MOA

blunts NE activity at alpha-1 receptors in the CNS to reduce the severity of nightmares

ADRs of Prazosin

Orthostatic hypotension

Dizziness

HA

Syncope

Drowsiness

When should Prazosin be taken?

at bedtime

What is the initial dosing of Prazosin?

1 mg QHS

What is the max dosing of Prazosin?

16mg QHS

How is Prazosin titrated?

1mg Q 2-3 days, then 2-5 mg per week

What drugs should be AVOIDED in PTSD?

Benzodiazepines

TCAs

Why should BZDs be avoided in PTSD?

leff effective than in anxiety disorders

Can exacerbate dissociation

May interfere w/ therapy

Abuse potential

Why should TCAs be avoided in PTSD?

Limited positive control data

Safety

What are common co-morbidities in PTSD?

Depression

Alcohol/substance use disorder

Attempted suicide

MDMA Assisted-Therapy

using MDMA, a serotonergic drug that increaes the release of monoamines and oxytocin release in a controlled therapeutic environment to enhance a deeper processing of trauma

What is the neurobiological processes are associated with OCD?

Highly genetic

5HT transmssion abnormalities

Cortico-Striato-Thalamo-Cortical Loop dysfunction

Which is longer in OCD, benefits from CBT or pharmacotherapy?

CBT

Which symptoms does CBT target?

compulsive symptoms

What is the treatment of choice for OCD in adolescents?

CBT

Exposure and Response Prevention (ERP)

type of CBT that is considered the gold standard for OCD

gradually exposes patients to their triggers while having them resist performing their compulsions

What is considered an adequate trial of ERP?

13-20 weekly sessions

OR

3 weeks of daily sessions

What is the first line pharmacotherapy treatment for OCD?

SSRIs

What are the FDA approved SSRIs for OCD?

Paroxetine

Sertraline

Fluvoxamine

Fluoxetine

What should be done when an OCD patient isn't responding adequately to an SSRI?

increase dose incrementally

Clomipramine in OCD

not considered first line but an option for inadequate response to SSRI, more severe, or refractory cases

Can BZDs be used alone in OCD? Why?

No, they are ineffective alone but used with co-morbid anxiety

ADRs of Clomipramine

Sedation

Dry mouth

Hypotension

Seizure

Arrhythmias

Contraindications to Clomipramine

MI

Concurrent MAOI use

What are the treatment goals for OCD?

Decrease symptom frequency and severity

Improve functioning

Imrove QoL

True or false: Achieving remission in OCD is very rare.

True

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

commonly used scale to assess SEVERITY of OCD and treatment response