PTSD

Post-Traumatic Stress Disorder:

Post-Traumatic Stress Disorder Saad A.Shakir,MD and Associates 2011

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Saad A. Shakir, MD, DFAPA, FACIP. Private Practice-Los Gatos, SF Bay Area. Adjunct Clinical Associate Professor Emeritus of Psychiatry and Behavioral Medicine. Stanford University,California. Email shakirmd@verizon.net , Phone (408)358-8090 Los Altos/

Anxiety Disorders: DSM-IV Classification:

American Psychiatric Association. DSM-IV. 1994, p. 393 Anxiety Disorders Panic + Agoraphobia Agoraphobia Specific Phobia PTSD Panic Disorder Social Phobia OCD GAD Anxiety Disorders: DSM-IV Classification

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Lifetime and 12-Month Prevalence of Mood and Anxiety Disorders in the National Comorbidity Survey Kessler RC et al. Arch Gen Psychiatry . 1995;52:1048-1060. Kessler RC et al. Arch Gen Psychiatry . 1994;51:8-19. Prevalence (%)

PTSD—Prevalence:

PTSD—Prevalence Kessler 1995; Kessler 1999. *From Part 2 of the NCS. A total of 5877 respondents participated in the survey, which was conducted among individuals aged 15 to 54 years, from September 1990 to February 1992. PTSD prevalence (%) Lifetime prevalence Annual prevalence Lifetime PTSD prevalence (%) Women Men A common condition—PTSD is the 5th most prevalent major psychiatric illness*

Lifetime Prevalence of PTSD in the Community (NCS):

Lifetime Prevalence of PTSD in the Community (NCS) 5% Lifetime Prevalence for Men 10.4% Lifetime Prevalence for Women Estimated Lifetime Prevalence of PTSD = 7.8% Kessler et al. Arch Gen Psychiatry. 1995;52:1048 .

Lifetime Prevalence of Common Psychiatric Disorders:

Lifetime Prevalence of Common Psychiatric Disorders Kessler 1994; Kessler 1995; DSM-IV-TR ™ 2000. *In menstruating women. Lifetime prevalence (%) 0 2 4 6 8 10 12 14 7.8% Posttraumatic stress disorder (PTSD) 5.1% Generalized anxiety disorder (GAD) 3.5% Panic disorder 2.5% Obsessive-compulsive disorder (OCD) 16 18 Alcohol dependence 14.1% Major depressive disorder 17.1% 13.3% Social anxiety disorder 5%* Premenstrual dysphoric disorder (PMDD)

PTSD as a Worldwide Problem:

PTSD as a Worldwide Problem *Percentage of women, aged 14 to 24 years, in a representative community sample (n = 3021) who qualified for a full PTSD diagnosis. de Jong TVM, et al. JAMA 2001;286:555-562. Kessler RC, et al. Arch Gen Psychiatry 1995;52:1048-1060. Perkonigg A, et al. Acta Psychiatr Scand 2000;101:46-59.

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PTSD: Underdiagnosis Professional help not sought Stigma Low awareness of PTSD in primary care High diagnostic thresholds Davidson and Connor. J Clin Psychiatry. 1999;60(suppl 18):33. Kessler. J Clin Psychiatry. 2000;61(suppl 5):4.

Presentations in Primary Care:

Presentations in Primary Care Nonspecific symptoms Palpitations, shortness of breath, tremor, nausea, insomnia, unexplained pain, mood swings Reluctance to undergo certain types of examinations Rape victims and gynecological exams Nonadherence to treatment Manifestation of avoidance Yehuda R. N Engl J Med. 2002(Jan 10);346(2):108-114

PTSD—Somatic Presentation:

PTSD—Somatic Presentation Patients with PTSD often present with somatic symptoms such as Gastrointestinal symptoms Cardiovascular symptoms Neurological symptoms Musculoskeletal symptoms Headaches Low back pain Respiratory symptoms McFarlane 1994; Irwin 1996; Shalev 1990.

Diagnosis of PTSD in Primary Care:

Diagnosis of PTSD in Primary Care Must specifically ask about trauma Assess presence of core symptoms Patient self-rated scales (eg, DTS) Assess and treat comorbidity (depression, substance use, anxiety disorders) Davidson and Connor. J Clin Psychiatry. 1999;60(suppl 18):33.

PTSD Rating Scales:

PTSD Rating Scales Clinician-Administered PTSD Scale–Part 2 (CAPS-2) Davidson Trauma Scale (DTS) Symptom cluster measurements Reexperiencing Avoidance/Numbing Hyperarousal Reexperiencing Avoidance/Numbing Hyperarousal Items measured Frequency and Intensity of 17 items in the 3 clusters Frequency and Intensity of 17 items in the 3 clusters Rater Clinician Patient Validated Yes Yes Blake 1995; Davidson 1997.

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What is PTSD???

Posttraumatic Stress Disorder (PTSD):

Posttraumatic Stress Disorder (PTSD) Exposure to a traumatic event in which both of the following were present: Experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury to self or others Responded with intense fear, helplessness or horror DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000

DSM-IV Diagnostic Criteria for PTSD:

DSM-IV Diagnostic Criteria for PTSD Appear in 3 symptom clusters: re-experiencing, avoidance/numbing, hyperarousal Last for > 1 month Cause clinically significant distress or impairment in functioning DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000 Symptoms

PTSD Symptoms:

PTSD Symptoms Re-Experiencing Hyperarousal Emotional Numbing Active Avoidance King LA et al. J Pers Soc Psychol. 1998 (Feb);74(2):420-434 Asmundson GJ et al. Behav Res Ther. 2000(Feb);38(2):203-214

“Who Can Get PTSD?”:

“Who Can Get PTSD?” Anyone, anywhere, anytime Different from other mental illness No “age at risk” Less genetic influence Clear environmental precipitant There should be no stigma attached to being a survivor of traumatic stress

Nevertheless, There Are Risk Factors for PTSD:

Nevertheless, There Are Risk Factors for PTSD Vulnerability increased by: Female gender Prior history of psychiatric illness History of trauma or stress Family history of psychiatric illness Borderline personality disorder Neuroticism Genetic liability

Prevalence of Traumatic Events Is High :

Prevalence of Traumatic Events Is High Kessler 1995; Breslau 1991; Resnick 1993. The lifetime incidence of experiencing a traumatic event severe enough to cause PTSD is more than 50%, according to the National Comorbidity Survey (NCS)* *From Part 2 of the NCS. A total of 5877 respondents participated in the survey, which was conducted among individuals aged 15 to 54 years, from September 1990 to February 1992. Incidence of experiencing a traumatic event (%) Women Men Approximately 20% of individuals exposed to a traumatic event will go on to develop PTSD

Trauma Types Causing PTSD:

Trauma Types Causing PTSD Criminal victimization Rape, intimate-partner violence, robbery Motor vehicle accidents Childhood abuse Natural disasters Unexpected death of relative/friend Terrorism War Other

Non-Combat-Related Trauma Associated with PTSD:

Non-Combat-Related Trauma Associated with PTSD Kessler et al. Arch Gen Psychiatry. 1995;52:1048 0 10 15 20 25 30 5 Male Female Physical Abuse Physical Attack Accident Molestation Rape Incidence (%) Courtesy of: David V. Sheehan, M.D., M.B.A.

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Trauma Witness Accident Threat w/ Weapon Physical Attack Molestation Combat Rape Kessler. J Clin Psychiatry . 2000;61(suppl 5):4. Kessler et al. Arch Gen Psychiatry . 1995;52:1048. Prevalence of Trauma and Probability of PTSD

Prevalence of Traumatic Events and Rates of PTSD in Response to Such Events:

Prevalence of Traumatic Events and Rates of PTSD in Response to Such Events 16.2 12.6 59.0 61.1 Sudden death of a loved one 3.2 1.4 61.8 63.1 Learned about a trauma 2.8 9.1 18.6 40.1 Witnessed injury or death - 38.8 0 6.4 Combat 5.4 3.7 15.2 18.9 Natural disaster 1.8 6.3 13.8 25.0 Accident 21.3 1.8 6.9 11.1 Physical assault 26.5 12.2 12.3 2.8 Molestation 45.9 65.0 9.2 0.7 Rape W M W M Rate of PTSD Prevalence of Event Traumatic Event Kessler, RC, Sonnega A, Bromet E, et al. Arch Gen Psychiatry. 1995(Dec);52(12):1048-1060 Breslau N, Chilcoat HD, Kessler RC, et al. Psychol Med. 1999(July);29(4):813-821

PTSD—Certain Traumatic Events Increase Risk:

PTSD—Certain Traumatic Events Increase Risk Breslau 1998. In a study, Select traumatic events and the estimated risk for developing PTSD* *Based on results from the Detroit Area Survey of Trauma, which was a telephone survey conducted among a representative sample of 2181 individuals aged 18 to 45 years in the Detroit area in 1996. Risk of PTSD (%) Held captive/ tortured/ kidnapped Rape Severe beating Other sexual assault Serious accident or injury Shooting or stabbing Sudden unexpected death of a close friend or relative Child’s life- threatening illness Witnessing killing/ serious injury Natural disaster

Traumatic Stress:

Traumatic Stress Is always potentially harmful Threatens life Violates person Causes death Catastrophic, unexpected Beyond “normal” experiences Causes fear or horror The reaction to stress is as important as the stress itself, in determining who gets PTSD

Factors that Contribute to the Intensity of Response to a Psychological Trauma:

Factors that Contribute to the Intensity of Response to a Psychological Trauma Degree of controllability Predictability Perceived threat The relative success of attempts to minimize injury to oneself or others Actual loss If wounded, exposed to pain, or heat or cold — the biological and psychological experience can be intensified Yehuda R. N Engl J Med. 2002(Jan 10);346(2):108-114

Impaired Quality of Life with PTSD:

0 25 50 75 100 Vitality Social Function PTSD MDD OCD U.S. population Impaired Quality of Life with PTSD SF-36 = 36-item short form health survey; Lower score = more impairment; Malik ML, Connor KM, Sutherland SM, et al. J Trauma Stress. 1999(April);12(2):387-393 SF-36 Score

Economic Burden of PTSD:

Kessler. J Clin Psychiatry. 2000;61(suppl 5):4. Kessler et al. Am J Psychiatry. 1999;156:115. Average work loss = 3.6 days/month Annual productivity loss = $ 3 billion Medical utilization: mean number of past year general medical visits PTSD 5.3 Any anxiety disorder 4.4 Major depression 3.4 Economic Burden of PTSD

PTSD—Service Usage:

PTSD—Service Usage In one study, Patients with PTSD had the highest service usage among those with anxiety disorders Variable PTSD Panic disorder Agoraphobia GAD Social anxiety disorder Hospitalization   Family doctors    Psychiatrists    Psychologists  Other specialists*    Social workers   Counselors   Nurses/therapists   Work loss (absenteeism) Work cutback days     Greenberg 1999.  Indicates significantly higher utilization of variable ( P <.05 vs without disorder). *eg, gynecologists, cardiologists. Risk Factors for Service Usage and Adverse Workplace Outcomes

Impact of PTSD on Society:

Impact of PTSD on Society Patients with PTSD often exhibit significantly greater impairment than the general population in such areas as General health Role functioning Emotional health Family impact and functioning The incidence of suicide attempts in patients with PTSD has been found to be as high as 20% Warshaw 1993; Davidson 1991.

Suicidality and PTSD:

Kessler et al. Arch Gen Psychiatry. 1999;56:617. Suicidality and PTSD PTSD patients are 6 times more likely to attempt suicide than the general population PTSD has higher risk of increased number of suicide attempts than all other anxiety disorders

Risk of Suicide Attempts Among Patients with Anxiety Disorders:

Risk of Suicide Attempts Among Patients with Anxiety Disorders Kessler et al. Arch Gen Psychiatry. 1999;56:617 0 1 2 3 4 5 6 7 PTSD GAD PD SAD Any Anxiety Courtesy of: David V. Sheehan, M.D., M.B.A. Odds Ratio

Stress Reactions After the September 11, 2001 Terrorist Attacks:

Stress Reactions After the September 11, 2001 Terrorist Attacks Nationwide survey 3-5 days after 44% reported 1 or more substantial stress symptoms Manhattan survey 5-8 weeks after 7.5% current related PTSD; 9.7% current MDD National survey 1-2 months after: New York City (NYC) and Washington DC oversampling 11.2% probable PTSD in NYC and 4.0 or lower in DC and rest of country Schuster MA et al. N Engl J Med. 2001(Nov 15);345(20):1507-1512; Galea S et al. N Engl J Med. 2002(March 28);346(13):982-987; Schlenger WE et al. JAMA. 2002(Aug 7);288(5):581-588

Prevalence of Probable PTSD Post-September 11:

Prevalence of Probable PTSD Post-September 11 Schlenger 2002. Web-based epidemiologic survey of a nationally representative cross-sectional sample using the PTSD checklist and the Brief Symptom Inventory, administered 1 to 2 months following the attacks; defined as “probable” because diagnoses were made using screening instruments, not comprehensive clinical evaluations. Prevalence (%) NYC metropolitan area District of Columbia metropolitan area Other major metropolitan areas Remainder of US US total (n=777) (n=247) (n=536) (n=704) (n=2264)

3 Target Symptoms of PTSD:

3 Target Symptoms of PTSD Numbing Intrusive Hyperarousal Trauma Courtesy of: David V. Sheehan, M.D., M.B.A.

DSM-IV Diagnostic Criteria for PTSD Re-experiencing:

American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders, 4th ed . 1994 . DSM-IV Diagnostic Criteria for PTSD Re-experiencing Persistent re-experiencing of  1 of the following: recurrent distressing recollections of event recurrent distressing dreams of event acting or feeling event was recurring psychological distress at cues resembling event physiological reactivity to cues resembling event

DSM-IV Diagnostic Criteria for PTSD Avoidance/Numbing:

* Related to the trauma. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed . 1994. DSM-IV Diagnostic Criteria for PTSD Avoidance/Numbing Avoidance of stimuli and numbing of general responsiveness indicated by  3 of the following: avoid thoughts, feelings, or conversations* avoid activities, places, or people* inability to recall part of trauma  interest in activities estrangement from others restricted range of affect sense of foreshortened future

DSM-IV Diagnostic Criteria for PTSD Hyperarousal:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994 . DSM-IV Diagnostic Criteria for PTSD Hyperarousal Persistent symptoms of increased arousal (  2): difficulty sleeping irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response

Increased Morbidity with PTSD:

Increased Morbidity with PTSD PTSD (%) Non-PTSD (%) Psychiatric GAD 53 9 Major depression 30 4 Somatization 12 0 Drug abuse/dependence 9 1 Medical Bronchial asthma 13 5 Peptic ulcer 13 4 Hypertension 31 18 Davidson JR, Hughes D, Blazer DG, George LK. Psychol Med. 1991(Aug);21(3):713-721

Psychiatric Comorbidity in PTSD:

Comorbidity (%) Psychiatric Comorbidity in PTSD Major Depressive Episode GAD Panic Disorder Social Anxiety Disorder Agoraphobia Alcohol Abuse/ Dependence Drug Abuse/ Dependence Kessler et al. Arch Gen Psychiatry . 1995;52:1048.

PTSD—Comorbidity (cont’d):

PTSD—Comorbidity (cont’d) Lifetime histories of PTSD comorbid with other psychiatric disorders Kessler 1995. Responders (%) Percent Women Men Percent Lifetime PTSD and 1 or more psychiatric disorders Women Men Lifetime PTSD and 3 or more psychiatric disorders

Lifetime Comorbidity of PTSD With Major Depressive Disorder:

Lifetime Comorbidity of PTSD With Major Depressive Disorder 48% PTSD Major Depression Kessler 1995.

RISK FACTORS FOR DEPRESSION AND ANXIETY (including PTSD):

RISK FACTORS FOR DEPRESSION AND ANXIETY (including PTSD) GENETIC SOMATIC PSYCHOLOGICAL ENVIRONMENTAL e.g.,SYSTEMIC ILLNESS CHRONIC PAIN, ENDOCRINE DISORDER FAMILY HISTORY e.g., LOW SELF-ESTEEM, POOR COPING SKILLS e.g., UNEMPLOYMENT, DIVORCE, ABUSE, BEREAVEMENT,TRAUMA,COMBAT

Treatment Requires Understanding:

Neurotransmitters offer a crucial conceptual bridge between the mind and the brain . Treatment Requires Understanding

Axon Terminals Of Serotonergic Neurons Project To Virtually All Portions Of The Brain:

Axon Terminals Of Serotonergic Neurons Project To Virtually All Portions Of The Brain Thalamus Ventral Striatum Amygdaloid Body Hypothalamus Olfactory And Entorhinal Cortices Hippocampus Rostral Raphe Nuclei Striatum Neocortex Cingulum To Hippocampus Cerebellar Cortex Intracerebellar Nuclei Caudal Raphe Nuclei To Spinal Cord Cingulate Gyrus

Kaplan and Sadock. Synopsis of Psychiatry, Behavioral Sciences, Clinical Psychiatry. 6th ed. 1991 (revised).:

Kaplan and Sadock. Synopsis of Psychiatry, Behavioral Sciences, Clinical Psychiatry . 6th ed. 1991 (revised). Norepinephrine Innervation Of The CNS Cerebral Cortex Fornix Nucleus Accumbens Amygdala Hypothalamus Dorsal Bundle Ventral Bundle Stria Terminalis Hippocampus Projection Thalamic Projection Locus Ceruleus Medullary Cell Bodies And Spinal Pathways

Dopamine Neurotransmission :

Dopamine Neurotransmission Enhances signal Improves attention Focus On-task behavior On-task cognition Solanto. Stimulant Drugs and ADHD. Oxford; 2001. Nigrostriatal Pathway Mesolimbic Pathway Substantia nigra Ventral tegmental area Mesocortical Pathway Dopamine Relative to ADHD

Neurotransmitters and normal behavior:

MOOD MODULATION IMPULSE CONTROL PLEASURE DRIVE LIBIDO APPETITE AGGRESSION Neurotransmitters and normal behavior ADAPTED FROM HEALY AND MCMONAGLE (1997) ACTIVATION AFFECT COGNITION ENERGY ATTENTION MOTIVATION STRESS TOLERANCE MODULATION SEROTONIN NOREPINEPHRINE DOPAMINE

Reduced neurotransmission and neural adaptability:

SEROTONIN NOREPINEPHRINE DOPAMINE IMPAIRED MODULATION IMPAIRED ACTIVATION DEPRESSION Anxiety Irritability Hostility Hypochondriasis Impulsivity Agitation Suicidality Fatigue Apathy Lack of initiative Hypersomnia Decreased productivity Inability to concentrate Anhedonia Reduced neurotransmission and neural adaptability

Normal release and reuptake of GABA:

Normal release and reuptake of GABA

HYPOTHESIS OF STRESS & DEPRESSION:

Normal Stress Antidepressants Glucocorticoids BDNF Serotonin and NE BDNF Glucocorticoids Normal survival and growth Atrophy/death of neurons Increased survival and growth Genetic factors Other Neuronal Insults : Hypoxia-ischemia Hypoglycemia Neurotoxins Viruses HYPOTHESIS OF STRESS & DEPRESSION

Response to Stress: Normal, MDD, PTSD:

Response to Stress : Normal, MDD, PTSD Yehuda R. N Engl J Med. 2002(Jan 10);346(2):108-114

Biological Aspects of PTSD:

Biological Aspects of PTSD Patients with chronic PTSD have:  increased circulating levels of NE  reactivity of  2 -adrenergic receptors  levels of thyroid hormone (at times) Neuroanatomical studies have revealed:  reactivity of amygdala and anterior paralimbic areas to trauma-related stimuli  reactivity of the anterior cingulate and orbitofrontal areas Yehuda R. N Engl J Med. 2002(Jan 10);346(2):108-114

HPA Axis Abnormalities:

HPA Axis Abnormalities Cortisol levels lower than normal Corticotropin-releasing factor (CRF) increased Sensitivity of the negative-feedback system is increased Exaggerated suppression of cortisol in response to dexamethasone Increased sensitivity of lymphocyte glucocorticoid receptors Yehuda R. N Engl J Med. 2002(Jan 10);346(2):108-114

Persons Who Develop PTSD:

Persons Who Develop PTSD Attenuated levels of cortisol in the immediate aftermath Higher heart rates in the ER and 1 week later Exaggerated startle response takes a month to develop Adrenergic activation in the face of low cortisol facilitates learning in animals Memories are strongly encoded and associated with strong, subjective feelings of distress Yehuda R. N Engl J Med. 2002(Jan 10);346(2):108-114

Management of PTSD:

Management of PTSD

Recognition:

Recognition

Healthcare Professionals:

Healthcare Professionals Ask about trauma history Incorporate screening questions in evaluation Assess and treat comorbidity (depression, substance use, anxiety disorders)

Screening Questions for PTSD:

Screening Questions for PTSD “What’s the worst thing that ever happened to you?” How did you react when it happened? “Do memories of _______ still bother you? Did you get over it?” “Do you avoid situations that might remind you of ____? Have your relationships suffered because of ____?” “Have you become more nervous since ___? Is it hard for you to relax because of ____?”

PTSD—Effective Treatment Is Available:

PTSD—Effective Treatment Is Available Effective treatments may include Medication Individual or group psychotherapy targeting the precipitating traumatic event, utilizing cognitive-behavioral techniques such as exposure or cognitive restructuring Simulated Exposure therapy The combination of medication and psychotherapy is often recommended, particularly in moderate to severe PTSD Sutherland 1999; Marshall 1998.

PTSD Treatment Options :

PTSD Treatment Options Pharmacological TCAs MAOIs SSRIs Mood Stabilizers Anti-anxiety Agents Psychosocial Exposure Therapy Cognitive Therapy Anxiety Management Desensitization Hypnotherapy

Psychotherapy:

Psychotherapy

Fluoxetine*(Prozac) Treatment of PTSD:

Fluoxetine*(Prozac) Treatment of PTSD Clinician- Administered PTSD Scale Total Baseline Week 5 Baseline Week 5 Baseline Week 5 Baseline Week 5 Fluoxetine Placebo Fluoxetine Placebo * Not FDA approved for treatment of PTSD. VA OPC = Veterans Affairs Outpatient Clinic. No significant differences between groups; OC dataset; mean fluoxetine dose = 40 mg. Adapted with permission from van der Kolk et al. J Clin Psychiatry. 1994;55:517. Copyright 2001, Physicians Postgraduate Press. Trauma Clinic (N=23) VA OPC (N=24)

PTSD Fluoxetine vs. Placebo:

PTSD Fluoxetine vs. Placebo *p=0.03; **p<0.01; DTS = Davidson Trauma Scale; Connor et al. Br J Psychiatry. 1999;174:1 0 5 10 15 20 Placebo Fluoxetine Final DTS Score Intrusive* Avoidance Numbing Hyperarousal 17.3 9.0 6.2 15.1 3.0 6.3 6.7 13.5 Courtesy of: David V. Sheehan, M.D., M.B.A.

Sertraline (Zoloft) Flexible-Dose PTSD Study:

Sertraline (Zoloft) Flexible-Dose PTSD Study Adjusted Mean Change in CAPS-2 Total Score * P <.001 at week 12. Mean dose for completers = 151.3 mg. Brady et al. JAMA . 2000;283:1837. *

Paroxetine (Paxil) Treatment of PTSD Psychiatric Comorbidity Analysis:

* P <. 001; N=1180. Data on file. GlaxoSmithKline; 2001. Beebe et al. Presented at the annual meeting of APA; May 5-10, 2001; New Orleans LA. Paroxetine (Paxil) Treatment of PTSD Psychiatric Comorbidity Analysis -45 -40 -35 -30 -25 -20 -15 -10 -5 0 Total Without Comorbidity With Comorbidity Change from Baseline in Total CAPS-2 Score (  2SE) Placebo Paroxetine * * *

Treatment Guidelines for PTSD:

Treatment Guidelines for PTSD Recommended duration of treatment after response The efficacy of sertraline in PTSD has been demonstrated for up to 28 weeks following 24 weeks of open-label treatment (52 weeks total) In patients receiving sertraline for extended periods, its usefulness should be reevaluated periodically. * Acute PTSD is defined as 1 to 3 months’ duration of symptoms. † Chronic PTSD is defined as ≥ 3 months’ duration of symptoms. DSM-IV- TR ™ 2000; Expert Consensus Panels for PTSD 1999. Months Acute* PTSD (6-12 months) Chronic † PTSD (12-24 months) Chronic PTSD with residual symptoms (24 months) 0 6 12 18 24

Dosing Strategy for Antidepressants in the Treatment of Depression and Anxiety:

Dosing Strategy for Antidepressants in the Treatment of Depression and Anxiety Titrate to mg dose to therapeutic effect to side effects “Maintenance dose”

Dosing Strategy for Antidepressants in the Treatment of Depression and Anxiety:

Dosing Strategy for Antidepressants in the Treatment of Depression and Anxiety Slowly Gently start low increase by small increments Relentless pursuit of remission don’t just move away from pathology move towards remission

Other Pharmacological options? (not FDA approved):

Other Pharmacological options? (not FDA approved) Second Generation Antipsychotics (SGA)eg Risperdal,Seroquel etc. Anti-Convulsants and Mood-Stabilizing medications eg depakote,Lamictal etc. Beta-blockers eg propronalol,atenolol etc. Other Anti-depressants(SNRI,NDRI,NASA etc.) eg Cymbalta,Effexor,Wellbutrin Anti-Anxiety meds. (Buspirone,Benzos)

OTHER OPTIONS:

OTHER OPTIONS Family Therapy Couple’s Therapy Relaxation Therapies,hypnosis,biofeedback,yoga etc.. EMDR Diet (limiting Caffeine,alcohol) Exercise Support Groups Other……

Internet Resources for Patients:

Internet Resources for Patients www.nimh.nih.gov www.nami.org www.depression.org www.adaa.org www.ndmda.org www.medem.com www.paxil.com

PTSD Summary:

PTSD Summary High lifetime prevalence Often undiagnosed Highly comorbid Highest rate of suicide attempts of all anxiety disorders SSRIs recommended as first-line therapy Expert Consensus Panels for PTSD. J Clin Psychiatry . 1999;60(suppl 16).

References:

References 1. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry . 1995;52:1048-1060. 2. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry . 1991;48:216-222. 3. Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol . 1993;61:984-991. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:463-468. 5. Kessler RC, Zhao SJ, Katz SJ, et al. Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. Am J Psychiatry . 1999;156:115-123. 6. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA . 2002;288:581-588. 7. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry . 1998;55:626-632. 8. Davidson JRT, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med . 1991;21:713-721. 9. Beckham JC, Moore SD, Feldman ME, Hertzberg MA, Kirby AC, Fairbank JA. Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry . 1998;155:1565-1569. 10. Warshaw MG, Fierman E, Pratt L, et al. Quality of life and dissociation in anxiety disorder patients with histories of trauma or PTSD. Am J Psychiatry . 1993;150:1512-1516. 11. Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E. Traumas and posttraumatic stress disorder in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry . 1995;34:1369-1380.

References:

References 12. Samson AY, Bensen S, Beck A, Price D, Nimmer C. Posttraumatic stress disorder in primary care. J Fam Pract . 1999;48:222-227. 13. Blank AS Jr. Clinical detection, diagnosis, and differential diagnosis of post-traumatic stress disorder. Psychiatr Clin North Am . 1994;17:351-383. 14. McFarlane AC, Atchinson M, Rafalowicz E, Papay P. Physical symptoms in post-traumatic stress disorder. J Psychosom Res . 1994;38:715-726. 15. Irwin C, Falsetti SA, Lydiard RB, Ballenger JC, Brock CD, Brener W. Comorbidity of posttraumatic stress disorder and irritable bowel syndrome. J Clin Psychiatry . 1996;57:576-578. 16. Shalev A, Bleich A, Ursano RJ. Posttraumatic stress disorder: somatic comorbidity and effort tolerance. Psychosomatics . 1990;31:197-203. 17. Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry . 1999;70:427-435. 18. Sutherland SM, Davidson JRT. Pharmacological treatment of posttraumatic stress disorder. In: Saigh PA, Brenner JD, eds. Posttraumatic Stress Disorder: a Comprehensive Text . Boston, Mass: Allyn & Bacon; 1999: 327-353. 19. Marshall RD, Davidson JRT, Yehuda R. Pharmacotherapy in the treatment of posttraumatic stress disorder and other trauma-related syndromes. In: Yehuda R, ed. Psychological Trauma . Washington, DC: American Psychiatric Press, Inc; 1998:133-177.

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