Case 7 PTSD

What is the role of ketamine in the treatment of PTSD? a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease in the incidence of paranoia related to PTSD

a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease in the incidence of paranoia related to PTSD - Ketamine is not in any of the PTSD guidelines for treatment. - Recent PTSD studies have focused on preventing PTSD from occurring after trauma in the first place - It is primarily being studied because it may disrupt individuals from laying down memories of the traumatic event due to its antagonism of NMDA receptors

Clonidine Warnings/Precautions

Hypotension/bradycardia or cardiac conduction abnormalities Somnolence or sedation Rebound hypertension Allergic reactions

Describe how medications used for PTSD affect the course of the disease: TCAs (weren't in the list on the objectives but are in the powerpoint)

Imipramine and amitriptyline are effective in treating the core symptoms of PTSD and the quality of evidence in the literature is considered to be level I by most guidelines. - However; TCAs are not first-line therapy because of adverse effects and risk of toxicity with overdose Imipramine and amitriptyline starting dose: 25 mg at bedtime. - Dosage may be increased to 50 mg at the end of week 1, with subsequent increases of 25-50 mg every 1-2 weeks; range of 50- 300 mg/day. - More rapid titration or a higher starting dose may be appropriate in some patients

Management of Psychotic Features in a patient with PTSD

Psychotic features may be found in as many as 40% of patients with PTSD. Determine if symptoms are part of the PTSD syndrome or a comorbid psychotic disorder If psychotic symptoms are part of PTSD, treat patients with SSRIs first to target the underlying symptoms Flashbacks, hypervigilance/ paranoia, and dissociation may respond to anti-adrenergics and anticonvulsants Failure to respond to either SSRIs, anti-adrenergics, or anticonvulsant medication may indicate the need to augment with SGAs If PTSD is comorbid with a psychotic disorder, start with antipsychotics

Which benzodiazepines should be considered first line for treatment of PTSD? a. Alprazolam b. Diazepam c. Temazepam d. All of the above e. None of the above

a. Alprazolam b. Diazepam c. Temazepam d. All of the above e. None of the above All guidelines recommend against the use of benzodiazepines in PTSD. - There is no evidence that benzodiazepines reduce the core symptoms of PTSD - Use of benzodiazepines may in fact make fear response worse and worsen recovery from the trauma - Studies have shown worsening of PTSD symptoms at one and six months after benzodiazepine use

How long does it take to develop PTSD symptoms after a traumatic event? a. Usually within days to a week of the event b. Usually within 1 month of the event c. Usually within three months of the event d. Usually within a year of the event

a. Usually within days to a week of the event b. Usually within 1 month of the event c. Usually within three months of the event d. Usually within a year of the event - PTSD symptoms can occur soon after an event or take time. On average symptoms will occur within 3 months after the event. - If diagnostic criteria is not met until 6 months after the event it is called PTSD with delayed expression

Prazosin ADEs

first dose syncope, orthostatic hypotension, dizziness, somnolence, headache

Clonidine contraindications

hypersensitivity to clonidine

Prazosin Contraindications

hypersensitivity to prazosin, quinazolines, or inert ingredients

Clonidine ADEs

hypotension, rebound hypertension, bradycardia, syncope, tachycardia

Describe how medications used for PTSD affect the course of the disease: Adrenergic Inhibitors-- Clonidine *(Prazosin was listed in the objectives but Clonidine was not; Prazosin listed on a different card)

(Prazosin and Clonidine are both adrenergic inhibitors) Open-label studies in children with PTSD found clonidine decreased aggressiveness, temper outbursts, emotional lability, hyperarousal, hypervigilance, and nightmares Dosing: 0.1 mg/day with an increase of 0.1 mg every 1-2 weeks to a maximum of 0.6 mg/day

Describe how medications used for PTSD affect the course of the disease: Adrenergic Inhibitors-- Prazosin *(Prazosin was listed in the objectives but Clonidine was not, listed on a different card)

(Prazosin and Clonidine are both adrenergic inhibitors) Prazosin for treatment of nightmare, insomnia, and other sleep-related symptomsterm-20 Adrenergic Inhibitors-Not FDA Approved for PTSD - Trials indicate adrenergic inhibitors may be more effective than SSRIs in combat related PTSD - Systematic review of all trials of prazosin in PTSD (dose range 1 to 16 mg/day) showed a reduced nightmare severity consistently reported in the open label trials, retrospective chart reviews, and single case reports. However, a new VA collaborative study suggest the effects of prazosin are similar to placebo Dosing: 1-2 mg/day with an increase of 1 mg every 2 weeks. Mean doses in clinical trials ranged from 2-13 mg/day - Doses are typically given at bedtime - There are limited data supporting the use of two times daily dosing which demonstrated improvement in sleep as well as CAPS scores, CAPS hyperarousal symptoms, and global functioning

Describe non-pharmacologic treatments for PTSD: (listed all of them)

- CBT - EDMR (Eye Movement Desnsitization and Reprocessing) - Exposure Therapy - Anxiety Management Techniques

Describe the pathophysiology of posttraumatic stress disorder (PTSD)

- Cortisol levels are lower than normal --> contributes to "chronic adrenal exhaustion" from inhibition of the HPA axis by persistent sever anxiety - HPA and SNS may be disscoiated in PTSD (leading to uncontrolled catecholamine release - Patients exhibit abnormal increases in SNS reactivity (i.e. fight-flight) and adrenergic dysregulaiton - Alpha 1 ans alpha 2 adrenergic postsynaptic receptors- located in various parts of the brain; alpha 1 = startle and sleep responses (PTSD=excess); alpha 2= cognitive processing and apporpriate responses to emotional stimuli - Acoustic startle response- exagerated startle response

Describe non-pharmacologic treatments for PTSD: Anxiety Management Techniques

- Includes breathing exercises, progressive muscle relaxation, and stress inoculation training - Eight to 15 sessions designated to reduce anxiety by developing patients stress management skills

Describe non-pharmacologic treatments for PTSD: Exposure Therapy

- Institute of Medicine report on treatment of PTSD found exposure therapy to be effective - Involves confrontation with trauma cues in order to address and lessen importance - Most appropriate for patients with mild symptoms, and those who refuse medications, or have a medical condition in which medications are contraindicated - Eight to 12 sessions in which patients are initially given psychoeducation and treatment rationale, then breathing and anxiety management techniques while being exposed to cues and areas that elicit distress

Treatment of PTSD in Elderly (*NOT an objective but she asked about it in her Pollev)

- PTSD is common in elderly patients (13% with higher rates in Holocaust survivors, cancer patients, and post-heart surgery) - Risk factors: elder abuse, severe accident, natural disaster, terrorist attack, rape, serious illness/surgery, war event, and criminal assault - About 40% of older Veterans are being treated for late life depression have a primary diagnosis of PTSD, regardless of their era of service - Treatment of PTSD in the elderly is consistent with that of adults with close monitoring for adverse effects and drug interactions

Develop monitoring/follow-up care plans for an older adult patient with PTSD: MAINTENANCE

- Patients who respond to pharmacotherapy should be continued at the full dosage for a minimum of 12 months - If residual symptoms persist, the medication should be continued

Develop monitoring/follow-up care plans for an older adult patient with PTSD: ACUTE PHASE

- Symptoms respond slowly and many patients will never experience full resolution - Regardless of medication selected, dose should be low at initiation with a gradual titration upward toward doses used for depression - A period of 12 weeks at maximum tolerated dosages are appropriate to determine response

Develop monitoring/follow-up care plans for an older adult patient with PTSD: DISCONTINUATION

- The decision to discontinue medication is made on the basis of many factors and many patients choose to stay on medication indefinitely (e.g. response to therapy, presence of ongoing stress, adverse effects) - Medication should be slowly tapered over a period of at least one month to reduce the potential for relapse - Patients should be seen frequently during the discontinuation phase for support and monitoring for symptoms of relapse

Describe non-pharmacologic treatments for PTSD: CBT

- Typically involves 12 weekly sessions - Patients are taught to identify and alter maladaptive or dysfunctional cognitions - May be used alone or in conjunction with other therapies or medication

Outline the DSM-5 criteria for PTSD

1. Exposure to threatened or actual death, sexual violence, or serious injury in one or more of the following: - Directly experiencing traumatic event(s) - Personally witnessing an event(s) as it occurred to others - Discovering a traumatic event occurred to a close family member or friend, and it there was actual or threatened death, was violent or accidental - Experiencing extreme or repeated exposure to unpleasant details of traumatic event(s) (i.e. first responders that collect human remains) 2. Presence of at least one of the intrusive symptoms associated with a traumatic event(s) and starting after the traumatic event(s) occurred 3. Consider PTSD with dissociative symptoms 4. Consider PTSD with delayed expression

In order to meet the diagnostic criteria for acute stress disorder, symptom resolution occurs by what time period? A. 3 days B. 4 weeks C. 3 months D. 1 year

A. 3 days B. 4 weeks C. 3 months D. 1 year To meet diagnostic criteria for acute stress disorder (ASD), symptoms must last for at least three days and resolve within a month.

A 29-year-old patient with PTSD is seen in the outpatient clinic for a follow-up appointment. The patient has been on venlafaxine extended-release 225 mg daily for the past 6 months, reports a 75% reduction in symptoms, and has returned to work as a schoolteacher. The patient asks how much longer they should remain on medication. Which of the following minimum durations of time should you discuss with the patient? A. 3 months B. 6 months C. 9 months D. 12 months

A. 3 months B. 6 months C. 9 months D. 12 months Since this patient has responded well to venlafaxine extended-release, treatment should continue for at least another 6 months, for a total treatment duration of 1 year. Residual symptoms persist, strengthening the recommendation to continue treatment. With the patient's return to work, additional stressors may occur, further influencing the patient's response to treatment. Once an adequate treatment period has occurred, the medication should be slowly tapered to avoid withdrawal symptoms and reduce the risk for relapse.

A 41-year-old Marine veteran from the war in Afghanistan was diagnosed with PTSD 6 months ago. The patient has had a reduction in symptoms but continues to complain about memories of witnessing the deaths of three close friends during combat and Afghani children being gunned down by the Taliban. He continually blames himself for the deaths of his friends and is estranged from his wife. He is currently on sertraline 100 mg daily and has been on this dose for a month. What is the best recommendation at this time? A. Add quetiapine 25 mg daily B. Add phenelzine 15 mg at bedtime C. Increase sertraline to 150 mg daily D. Switch to venlafaxine extended-release 37.5 mg daily

A. Add quetiapine 25 mg daily B. Add phenelzine 15 mg at bedtime C. Increase sertraline to 150 mg daily D. Switch to venlafaxine extended-release 37.5 mg daily Optimization of the effective antidepressant medication, sertraline, in this case, and titration to an effective and well-tolerated dose should occur prior to augmenting with an additional medication. Further, due to the patient's positive response to sertraline thus far, it would not be appropriate to switch to another medication at this time.

Which of the following is considered an intrusion symptom of PTSD? A. Irritability or anger outbursts B. Avoiding feelings about the trauma C. Recurrent disturbing dreams of the event D. Inability to recall an important aspect of the event

A. Irritability or anger outbursts B. Avoiding feelings about the trauma C. Recurrent disturbing dreams of the event D. Inability to recall an important aspect of the event Intrusion symptoms are characterized by distressing memories of the trauma. These can take the form of recurrent, distressing dreams or feeling that the trauma is reoccurring and may be associated with a similar physiologic reaction or psychological distress related to the trauma.

Which of the following best describes the pathophysiology of posttraumatic stress disorder (PTSD)? A. Low concentrations of cortisol B. High levels of neuropeptide Y C. Underactive autonomic nervous system D. Decreased secretion of corticotropin-releasing factor

A. Low concentrations of cortisol B. High levels of neuropeptide Y C. Underactive autonomic nervous system D. Decreased secretion of corticotropin-releasing factor There are many neuroendocrine and neurochemical abnormalities associated with PTSD. Patients with PTSD demonstrate hypersecretion of corticotropin-releasing factor but have subnormal levels of cortisol. Further, studies in nonmilitary patients have identified that lower plasma cortisol concentrations are associated with more severe PTSD symptoms

A 19-year-old college student was sexually assaulted at an off-campus party by an acquaintance 2 months ago. She presents to the outpatient clinic with complaints of difficulty falling and staying asleep, irritability, feeling numb, and being easily startled. She says that she has intrusive memories of the event, is missing at least 1 day of school a week, and avoids talking with her family and friends about the event. You note that on examination she has a restricted range of affect and appears nervous and refuses to talk about the details of the event. She is diagnosed with PTSD. What is the most appropriate first-line pharmacologic management of this patient? A. Paroxetine 10 mg every day B. Olanzapine 5 mg twice daily C. Diazepam 5 mg 3 times a day D. Amitriptyline 10 mg at bedtime

A. Paroxetine 10 mg every day B. Olanzapine 5 mg twice daily C. Diazepam 5 mg 3 times a day D. Amitriptyline 10 mg at bedtime This patient meets diagnostic criteria for a diagnosis of PTSD, including significant impairment; therefore, pharmacotherapy is warranted. Antidepressants, including SSRIs and venlafaxine, are first-line treatment options in PTSD. Further, paroxetine is FDA-approved for the treatment of PTSD.

Which of the following agents has the most evidence to support its use as an augmenting agent in patients with PTSD who are on antidepressant therapy and continue to complain of impulsive anger? A. Prazosin B. Zolpidem C. Clonazepam D. Lamotrigine

A. Prazosin B. Zolpidem C. Clonazepam D. Lamotrigine The addition of an anticonvulsant, such as lamotrigine or topiramate, to augment an antidepressant regimen is reasonable to target impulsive anger. Note: anticonvulsants should not be used as the sole therapeutic agent.

Which of the following nonpharmacologic treatments is the most effective in the management of PTSD? A. Relaxation training B. Deep brain stimulation C. Electroconvulsive therapy D. Trauma-focused cognitive behavioral therapy

A. Relaxation training B. Deep brain stimulation C. Electroconvulsive therapy D. Trauma-focused cognitive behavioral therapy Current guidelines emphasize the utility of trauma-focused cognitive behavioral therapy (TFCBT). Further, prolonged exposure individual trauma-focused psychotherapy in close proximity to the traumatic event resulted in lower rates of PTSD within 6 months. Data also support TFCBT is more effective than stress management or group therapy to reduce symptoms of PTSD.

Benzodiazepine Use in PTSD

All guidelines recommend AGAINST the use of benzodiazepines in PTSD. - There is no evidence that benzodiazepines reduce core symptoms of PTSD and use may potentiate the acquisition of fear response and worsen recovery from trauma. - Therefore, benzodiazepines should not be used in acute stress disorder and PTSD - No positive long term data have been reported. - Early benzodiazepine administration was associated with a higher incidence of PTSD at one and six month follow-up

Develop evidence based therapeutic plans for an older adult patient with PTSD

Current guidelines were established and studies were conducted using DSM-IV criteria. Regardless which criteria were used for diagnosis, the treatment is the same 1) First-line therapy includes trauma-focused psychotherapy (ie., exposure-based or CBT) or pharmacotherapy with an SSRI or SNRI 2) With non-response to the initial antidepressant dose, options include increasing the dose, considering a longer duration, switching to another SSRI or SNRI, or adding psychotherapy 3) With a failed second trial of antidepressant, it is recommended to switch to another SSRI or SNRI or mirtazapine. Another option includes adding psychotherapy 4) With a failure of 3 trials, including augmentation, re-evaluate the diagnosis switch to a TCA or consider use of phenelzine

Review medication lists/pertinent data to identify efficacy parameters for an older adult patient with PTSD

During the acute phase, patients should be seen weekly for 4 weeks then biweekly Evaluate on a monthly basis to monitor symptom change over time; visits can be extended to every 1 to 2 months during months 6 to 12 of therapy All three symptom domains should be evaluated using a standardized rating scale (ex: PTSD Checklist for DSM-5) Question the patient about other symptoms (e.g. sleep, anger outbursts, irritability, and disability) Assessment of response-goals of treatment - Full remission of symptoms and return to premorbid functioning - It is important to note full remission may be unrealistic for some individuals and goals will need to be tailored on an individual basis Encourage patients to keep a symptom diary - Date and presence of symptoms of intrusion, avoidance, mood, and reactivity - Include concurrent conditions such as panic attacks or suicidal thoughts

Treatment in Pregnancy and Lactation (*NOT an objective but she asked about it in her Pollev)

In civilians, the lifetime rate of PTSD is higher in women (18.3%) vs. men (10.2%), most likely because of higher rates of sexual trauma in women During the childbearing years, pregnancy may increase the risk of trauma exposure and PTSD or may rekindle/exacerbate the disorder. Traumatic childbirth may be a stressor of severity and intensity enough to cause PTSD. Women with PTSD have a 4-fold longer illness than men (48 vs 12 months) and women have a higher burden of medical illness and attempted suicides. Few studies have examined gender differences in efficacy with antidepressants in PTSD Direct evidence of untreated PTSD on fetal development is lacking CBT should be offered as first-line option to pregnant and lactating women with PTSD

Management of Insomnia and Nightmares in a patient with PTSD

Insomnia and nightmares are symptoms of PTSD that may respond to first-line therapy; however, these symptoms often persist despite treatment and can be made worse by SSRI therapy - Assess lifestyle factors and sleep hygiene - Limit caffeine, nicotine, and over-the-counter stimulant use - Rule out sleep apnea, periodic limb movement disorder - Addition of prazosin may be efficacious for nightmares and insomnia however, recent VA guidelines recommend neither for nor against prazosin use of nightmares of sleep based on a recent study - Trazodone, nefazodone, mirtazapine, olanzapine, quetiapine, low dose TCAs, and zolpidem have shown some efficacy in sleep problems with PTSD

Describe how medications used for PTSD affect the course of the disease: NaSSA

Mirtazapine-starting dose is 15 mg at bedtime with increases of 15 mg every two weeks to maximum dose of 60 mg/day (exceeds approved recommended maximum dose). 45 mg/day showed improvement on some measures, but global improvement was not shown on all scales

Describe non-pharmacologic treatments for PTSD: EDMR (Eye Movement Desensitization and Reprocessing)

Multistage treatment that entails 8 stages - History gathering - Treatment planning - Patient preparation - Systematic assessment of trauma-relevant target(s) - Desensitization and reprocessing - Installation of alternative positive cognitions - Body scan for continuing discomfort or trouble spots - Closure designed to address constructive coping needs for future use

Describe how medications used for PTSD affect the course of the disease: SARIs

Nefazodone has also demonstrated mixed results in clinical trials. - Short- term effects appear to be most pronounced. - Starting dose is 100 mg twice daily with increase by 100mg every 4 days as tolerated up to a maximum of 600 mg/day divided twice daily. - The risk of liver failure limits its use. Trazodone may be used for sleep problems with PTSD

Describe how medications used for PTSD affect the course of the disease: Second generation antipsychotics (SGAs)

Not FDA Approved for PTSD Efficacy: Guidelines recommend SGA augmentation as second or third line therapy, however, recent evidence supporting use in PTSD is limited. SGAs should not routinely be recommended in the treatment of PTSD

Describe how medications used for PTSD affect the course of the disease: Anticonvulsants (weren't in the list on the objectives but are in the powerpoint)

Not FDA Approved for PTSD Open-label studies of divalproex sodium, carbamazepine, and topiramate have demonstrated mixed or limited efficacy with regard to specific symptom clusters of PTSD. These studies, as well as a single controlled trial of lamotrigine, indicate benefit with regard to treating symptoms of re-experiencing. Anticonvulsants are typically used as adjunctive agents with antidepressant agents

Treatment of PTSD in Children (*NOT an objective but she asked about women and elderly in her Pollev)

Of children and adolescents who have experienced a trauma, 3% to 15% in girls and 1% to 6% of boys could be diagnosed with PTSD. Rates are much higher in at risk samples (i.e. witnessing a parental homicide) and in sexually abused children, or those with exposure to a school shooting or community violence Adolescents present like adults. Children can have: - Generalized fears - Avoidance of situations - Sleep disturbance - Preoccupation with words/symbols - Post-traumatic play reenactment - Loss of acquired skills - Flashbacks/amnesia CBT is the treatment of choice in children with psychoeducation and parental involvement. Medications may be used to treat target symptoms, but there is sparse data

Develop monitoring/follow-up care plans for an older adult patient with PTSD OVERVIEW

Onset of Action: - Acute Phase - Continuation Phase Duration of Therapy: - Maintenance - Discontinuation

· Explain the use of rating scales for assessment of PTSD o **Know the names of the 2 rating scales administered for PTSD:

PTSD Checklist & Clinician Administered PTSD Scale (CAPS)

Describe how medications used for PTSD affect the course of the disease: SSRIs

Paroxetine and sertraline are first-line pharmacotherapy agents for PTSD and are FDA approved acute treatment of PTSD. Sertraline is also indicated for long term therapy Fluoxetine is listed as a first-line agent, but is not FDA indicated for PTSD Other SSRIs may also be beneficial; however, there is insufficient evidence for recommendation as first-line agents (i.e. citalopram, fluvoxamine, and escitalopram have open trials) One meta-analysis supports there are no treatment differences between combat and non-combat related PTSD

Review medication lists/pertinent data to identify safety parameters for an older adult patient with PTSD

Patients with PTSD are sensitive to the adverse effects of medications Monitor carefully for any adverse reaction that can delay an increase in dosage or cause the patient distress

Describe how medications used for PTSD affect the course of the disease: MAOIs

Phenelzine demonstrated mixed results in clinical trials. - Starting dose is 30 mg with increase to 45 mg after one week; subsequent increases of 15 mg every 2 weeks to maximum of 90 mg/day. - The risk of adverse effects and toxicity make MAOIs last line agents

Patient Education for patient with PTSD

Promote healthy behaviors-exercise, good sleep hygiene, and the need for decreased use of caffeine, nicotine, alcohol, and stimulants Education about Treatment - When and how to take the medication - Expected time interval before beneficial effects of treatment may be noticed - Necessity to take medication even after feeling better - Need to consult with the prescriber before discontinuing medication - Steps to take if problems or questions arise

Describe how PTSD presents clinically & Describe the usual time course of symptoms for a patient with PTSD (1c, 1f)

Prospective studies suggest symptomatic distress peaks in the days and weeks after a trauma and then gradually declines over the course of the year after the trauma Age at onset and course of PTSD are variable - Can occur at any age - Presentation is not predictable because symptoms are related to duration and intensity of trauma, presence of other psychiatric disorders, and how the patient deals with the trauma Most are 3 months after trauma if its after 6 that's considered delayed Duration of illness - Average duration of symptoms in patients undergoing treatment is approximately 36 months - Average duration of symptoms in patients not treated is 5 years (60 months) - One-third of persons who develop PTSD will develop chronic symptoms that do not remit Rates of recovery from PTSD vary by gender - Women are less likely to recover. Personality often changes with problems of impaired affect modulation; self- destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness, or feeling that they have been permanently damaged; a loss of previously supportive beliefs; hostility; social withdrawal; feeling constantly threatened and being in an alert status; and impaired relationships with others Symptoms of PTSD are associated with functional impairment and diminished QOL Prevalence of concurrent conditions: depression (80%), alcohol or substance use disorder (50%), attempted suicide (20%)

Identify barriers to follow-up for an older adult patient with PTSD

Some barriers to follow-up for patients with PTSD include: - Concerns about the effect of disclosure on employment - A perception that mental health care is ineffective - A lack of information on resources for care - Financial concerns - Logistical problems such as travel distance

Management of Substance Use Disorders in a patient with PTSD

Substance use disorders are common in patient with PTSD; the International Psychopharmacology Algorithm Project (IPAP) algorithm requires patients to undergo withdrawal from substance of abuse/dependence Patients should be abstinent for one week before beginning treatment for PTSD. However, substance use disorder should not prevent concurrent treatment for PTSD Treatment algorithm is the same for these patients after abstinence is attained Benzodiazepines are contraindicated in patients with substance use disorder

Develop monitoring/follow-up care plans for an older adult patient with PTSD: CONTINUATION PHASE

Symptoms continue to improve and maximal drug benefit (i.e. functional improvement or QOL) may be seen

Prazosin Warnings/precautions

Syncope or sudden loss of consciousness Priapism

T/F: PTSD is common in elderly patients

True - PTSD is common in elderly patients (13%) - Higher rates in Holocaust survivors, cancer and post-heart surgery patients - Risk factors: elder abuse, severe accidents, natural disasters, terrorist attacks, rape, serious illness or surgery, war events, criminal assaults - About 40% of older veterans that are treated for late life depression also have a primary diagnosis of PTSD, regardless of their era of service

Describe the etiology for PTSD

Unknown- investigators believe a personal predisposition is necessary for symptoms to develop after a traumatic event

Describe how medications used for PTSD affect the course of the disease: SNRIs

Venlafaxine XR-recommended as a first-line treatment option in some guidelines on the basis of evidence in the literature - Venlafaxine (37.5-300 mg/day) was effective for acute and long-term treatment (24 weeks) in 329 patients with moderate to severe PTSD compared with placebo - Mean max dose was 221.5 mg/day - Only symptoms of re-experiencing and avoidance/numbing improved, not hyper-arousal Starting dose: 37.5 mg/day; the IPAP algorithm recommends to increase the dose to 75 mg in the first week, then increase by 37.5 mg or 75 mg every 2 weeks

What gender is at the greatest risk of developing PTSD in the civilian population? a. Men b. Women

Women - In civilians, the lifetime rate of PTSD is higher in women (18.3%) vs men (10.2%) most likely due to the higher rates of sexual trauma in women. - Women have a 4-fold longer illness than men (14 mos vs 12 mos). Women have a higher burden of medical illness, and attempted suicides - Women are less likely to recover from symptoms of PTSD. They are more likely to have personality changes and other symptoms that lead to impaired relationships with others

How long should you treat an individual with PTSD after full remission of their symptoms? a. 4 to 6 weeks b. 6 to 8 weeks c. 4 to 9 months d. 12 months

a. 4 to 6 weeks b. 6 to 8 weeks c. 4 to 9 months d. 12 months - Patients who respond to pharmacotherapy should continue to receive treatment at the full dosage of medication for a minimum of 12 months - If residual symptoms persist, continue the medication - The decision to discontinue medication is made on the basis of a number of factors and many patients choose to stay on medication indefinitely

Which SSRIs are FDA approved to treat PTSD? a. Fluoxetine b. Sertraline c. Citalopram d. Paroxetine

a. Fluoxetine b. Sertraline c. Citalopram d. Paroxetine The only SSRI's FDA approved to treat PTSD are: 1. Sertraline 2. Paroxetine Fluoxetine is also listed (as treatment option in guidelines) but it is not indicated (FDA approved) for PTSD Other SSRI's may help but have not been studied sufficiently: 1. Citalopram - open trials only 2. Escitalopram - open trials only 3. Fluvoxamine - open trials only

What is the role of second generation antipsychotics in the treatment of PTSD? a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease in the incidence of paranoia related to PTSD

a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease in the incidence of paranoia related to PTSD - SGA's are considered to be a second or third line treatment for PTSD unless the PTSD is comorbid with a psychotic disorder - If psychotic symptoms are part of PTSD, try SSRI's first, and then anti-adrenergics and anticonvulsants - If those treatments fail, then consider using an SGA for PTSD related psychosis

What is the role of prazosin in the treatment of PTSD? a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease paranoid related to PTSD

a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease paranoid related to PTSD - Prazosin can be used for treatment of nightmares, insomnia, and other sleep-related symptoms - Prazosin has been primarily studied in combat related PTSD rather than civilian related PTSD.

What is the role of antidepressants in the treatment of PTSD? a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease paranoid thinking

a. Decrease reexperiencing and arousal b. Decrease memory formation c. Decrease incidence of nightmares d. Decrease paranoid thinking - Serotonergic antidepressants can decrease symptoms of re-experiencing, numbness, and arousal - The more noradrenergic antidepressants (venlafaxine, TCAs) can decrease the hyperactivity of the sympathetic nervous system

What other psychiatric disorders occur most frequently in conjunction with PTSD? a. Depression b. Substance use disorder c. Generalized anxiety d. Suicide attempts

a. Depression b. Substance use disorder c. Generalized anxiety d. Suicide attempts - The most common concurrent conditions with PTSD are: 1. Depression (80%) 2. Alcohol or substance use disorders (50%) 3. Attempted suicide (20%)

According to the American Psychiatric Association which SNRI can be used first line to treat PTSD? a. Duloxetine b. Desvenlafaxine c. Venlafaxine d. Levomilnacipran

a. Duloxetine b. Desvenlafaxine c. Venlafaxine d. Levomilnacipran The only SNRI approved to treat PTSD according to the American Psychiatric Association is venlafaxine ER - Venlafaxine ER was studied in 329 patients and was effective for core symptoms of re-experiencing, and avoidance, numbing (now in mood/cognitive) - Venlafaxine ER does not treat hyperarousal

????????? According to the American Psychiatric Association what drugs are first line for the treatment for PTSD? a. Fluoxetine b. Paroxetine c. Sertaline d. Venlafaxine e. Prazosin

a. Fluoxetine b. Paroxetine c. Sertaline d. Venlafaxine e. Prazosin Pollev response history shows all responses as correct Her Pollev Powerpoint lists the following (excludes venlafaxine): According to the APA the following drugs are considered first line for PTSD: - Fluoxetine - Paroxetine - Sertraline - Prazosin (for nightmares due to combat related PTSD, not civilian PTSD) BUT her slides later on also say: "The only SNRI approved to treat PTSD according to the American Psychiatric Association is venlafaxine ER" so venlafaxine is right

What are three core areas of PTSD? a. Intrusion, avoidance, reactivity b. Depression, paranoia, gambling c. Mood, memory, numbness d. Nightmares, cognition, anxiety

a. Intrusion, avoidance, reactivity b. Depression, paranoia, gambling c. Mood, memory, numbness d. Nightmares, cognition, anxiety

AB has had depression since she was 16 years old and 2 years ago she was diagnosed with PTSD. She has been successfully treated with escitalopram for the past four years. AB recently found out that she is 6 weeks pregnant. What do you recommend? a. Stop the escitalopram immediately to avoid teratogenic effects on the fetus b. Taper the escitalopram off over the next four weeks c. Stop escitalopram and add paroxetine since it is a safer antidepressant d. Continue the escitalopram since the benefit to the baby outweighs the risks

a. Stop the escitalopram immediately to avoid teratogenic effects on the fetus b. Taper the escitalopram off over the next four weeks c. Stop escitalopram and add paroxetine since it is a safer antidepressant d. Continue the escitalopram since the benefit to the baby outweighs the risks - Similar to other disorders that use antidepressants, SSRI's should be continued unless there is a risk that outweighs the benefit of treatment. - It is likely that treating depression in light of a long history of both depression and PTSD will benefit mom and baby, including improving her mood, having better nutrition, and less risk of harm to herself and the baby. - Antidepressants should not be discontinued quickly if it can be avoided. - Escitalopram is not known to be teratogenic, but paroxetine is, so this would not be a safe medication change

How long does it take for treated PTSD symptoms to resolve *Depends on whether or not patient is being treated* a. Three months b. Twelve months c. Thirty six months d. Sixty months

a. Three months b. Twelve months c. Thirty six months d. Sixty months - The average duration of symptoms in patients undergoing treatment is approximately 36 months - The average duration of symptoms in untreated patients is approximately 5 years (60 months) - One-third of individuals that develop PTSD will develop chronic symptoms that do not remit.

Which of the following would be the primary goal of treating PTSD? a. Treating symptoms of depression b. Treating patient nightmares and psychosis c. Treating individuals with substance use issues by sending them to rehabilitation d. Treating core symptoms of PTSD

a. Treating symptoms of depression b. Treating patient nightmares and psychosis c. Treating individuals with substance use issues by sending them to rehabilitation d. Treating core symptoms of PTSD - The primary goal of treating PTSD is to reduce the core symptoms of the illness and to prevent relapse. - Other goals include: 1. Preventing or reducing comorbidities of depression, anxiety, or substance use 2. Improve the individuals ability to function