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Welcome to this SpeechPathology.com Live Expert e-Seminar!

Working With Individuals With Post-Traumatic Stress Disorder Presented By:

Gail V. Pashek, Ph. D., CCC-SLP; Kansas City Veterans Administration Medical Center Administration Medical Center

Moderated By:

Amy Hansen, M.A.,CCC-SLP, Managing Editor, SpeechPathology.com

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Working with Individuals withWorking with Individuals with Post-Traumatic Stress Disorder

Gail V. Pashek, Ph. D., CCCGail V. Pashek, Ph. D., CCC--SLPSLP

Kansas City VAMCKansas City VAMC

Gail.Pashek@va.govGail.Pashek@va.gov

Acknowledgments

The presenter is grateful to the following membersThe presenter is grateful to the following members

of the Kansas City VAMC PCG program for sharing of the Kansas City VAMC PCG program for sharing

their clinical expertise in the preparation of thistheir clinical expertise in the preparation of this

presentation:presentation:

The PatientsThe Patients

Thomas Demark, MDThomas Demark, MD

George Dent, PhDGeorge Dent, PhD

Claude Guidry, LMSWClaude Guidry, LMSW

HemantHemant Thakur, MDThakur, MD

Disclaimer

The opinions expressed in this presentationThe opinions expressed in this presentation

and products endorsed reflect the views of and products endorsed reflect the views of

the author alone and not the official policythe author alone and not the official policythe author alone and not the official policy the author alone and not the official policy

of the Veterans Health Administration,of the Veterans Health Administration,

Department of Defense, or U.S.Department of Defense, or U.S.

Government.Government.

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Why Should We Learn About PTSD?

•• Our treatment populations are changing Our treatment populations are changing ––military and nonmilitary and non--militarymilitary

•• To understand that PTSD has aTo understand that PTSD has aTo understand that PTSD has a To understand that PTSD has a physiological basisphysiological basis

•• To help our patients understand the disorder To help our patients understand the disorder and seek appropriate helpand seek appropriate help

•• To avoid doing things that might exacerbate To avoid doing things that might exacerbate the conditionthe condition

PTSD – A Brief History

Currently known classified as an anxiety Currently known classified as an anxiety disorder, it is defined as :disorder, it is defined as :•• An emotional An emotional illnessillness that may result from witnessing or that may result from witnessing or

experiencing a terrifying situation often threateningexperiencing a terrifying situation often threateningexperiencing a terrifying situation often threatening experiencing a terrifying situation often threatening significant bodily injury or deathsignificant bodily injury or death

•• Also known as:Also known as:

•• “soldier’s heart” “soldier’s heart” –– Civil WarCivil War

•• “combat fatigue” or “shell shock” “combat fatigue” or “shell shock” –– WWIWWI

•• “battle fatigue” or “gross stress reaction” “battle fatigue” or “gross stress reaction” -- WWII WWII

•• PTSD PTSD –– Vietnam eraVietnam era

PTSD – Brief History

•• Became an official DSMBecame an official DSM--III diagnosis III diagnosis ––1980. PTSD was defined by: 1980. PTSD was defined by: •• exposure to a stressor that would evokeexposure to a stressor that would evokeexposure to a stressor that would evoke exposure to a stressor that would evoke

stress in anyonestress in anyone

•• characterized by symptoms of recharacterized by symptoms of re--experiencing experiencing the traumatic eventthe traumatic event

•• numbing of responsiveness/reduced world numbing of responsiveness/reduced world involvementinvolvement

•• two other symptomstwo other symptoms

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1987 DSM-IIIR (close to present DSM-IV)

CriteriaCriteria

A. presence of severe stressor, as previously A. presence of severe stressor, as previously defineddefined

B. one or more symptoms of reB. one or more symptoms of re--experiencing the experiencing the event (recurrent/intrusive recollections, event (recurrent/intrusive recollections, dreams, current activity as if the event were dreams, current activity as if the event were recurring)recurring)

C. Three or more avoidance symptomsC. Three or more avoidance symptoms

D. Two or more arousal symptoms (startle, D. Two or more arousal symptoms (startle, hypervigilance, or physiological reactivity) hypervigilance, or physiological reactivity)

Additional DSM-IV Criteria

•• E. Duration of the disturbance (symptoms in E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.Criteria B, C, and D) is more than one month.

•• F. The disturbance causes clinically significant F. The disturbance causes clinically significant distress or impairment in social, occupational, or distress or impairment in social, occupational, or other important areas of functioning.other important areas of functioning.

Common Cluster A Stressors

•• Involves actual or threatened death or Involves actual or threatened death or serious injury or threat to physical serious injury or threat to physical integrityintegrity

•• Involves intense fear, helplessness or Involves intense fear, helplessness or , p, phorrorhorror

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Cluster B – Re-experiencing

•• Intrusive thoughts, images and perceptionsIntrusive thoughts, images and perceptions

•• Dreams Dreams

•• Sense of reSense of re--experiencing traumaexperiencing trauma

•• Psychological distress on exposure Psychological distress on exposure y g py g pto cuesto cues

•• Physiological distress on exposure Physiological distress on exposure to cuesto cues

Cluster C – Numbing, Avoiding•• Efforts to avoid thoughts and feelingsEfforts to avoid thoughts and feelings

•• Efforts to avoid activities, people and Efforts to avoid activities, people and placesplaces

•• Inability to recallInability to recall•• Diminished interestsDiminished interests•• Diminished interestsDiminished interests•• DetachmentDetachment•• Restricted affectRestricted affect•• Sense of foreshortened futureSense of foreshortened future

Cluster D – Increased Arousal•• InsomniaInsomnia

•• IrritabilityIrritability

•• Difficulty concentratingDifficulty concentrating

•• HyperHyper--vigilancevigilance

•• Exaggerated startle responseExaggerated startle response•• Exaggerated startle responseExaggerated startle response

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Who Develops PTSD?

•• SoldiersSoldiers

•• Holocaust and other survivors of human Holocaust and other survivors of human atrocitiesatrocitiesatrocitiesatrocities

•• Victims of crime Victims of crime –– especially rape or tortureespecially rape or torture

•• Victims of accidents or disasters (natural or Victims of accidents or disasters (natural or caused by humans)caused by humans)

•• Emergency personnel and others who Emergency personnel and others who witness horrific eventswitness horrific events

However…

•• It’s important to remember that most people It’s important to remember that most people who suffer trauma recover, especially if who suffer trauma recover, especially if trauma is limited to a single incidenttrauma is limited to a single incidentgg

Differentiating Two Disorders

•• PTSD PTSD

vs.vs.

•• Acute Stress Disorder Acute Stress Disorder (ASD)(ASD)

•• Symptoms overlap with those of PTSDSymptoms overlap with those of PTSD

•• Lasts for one month or less postLasts for one month or less post--exposureexposure

•• May have “dissociative symptoms” May have “dissociative symptoms” –– e.g., not e.g., not knowing where you are, feeling one is outside knowing where you are, feeling one is outside one’s bodyone’s body

•• As many as 80% may develop PTSD As many as 80% may develop PTSD (National (National Center for PTSD)Center for PTSD)

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Incidence/Prevalence of PTSD

•• Risk for exposure to traumatic events across Risk for exposure to traumatic events across the lifespan the lifespan –– 50%50%

•• Approximately 8% of people in the U. S. Approximately 8% of people in the U. S. pp y % p ppp y % p phave had PTSD at some point in their liveshave had PTSD at some point in their lives

•• Women are more susceptible than menWomen are more susceptible than men

--Litz & Maguen, 2007Litz & Maguen, 2007

Incidence of PTSD in Recent Military Times

•• It has been estimated that 13% of Gulf War It has been estimated that 13% of Gulf War and ~20% of Iraq veterans have PTSDand ~20% of Iraq veterans have PTSD

•• 30% of Vietnam vets have been diagnosed30% of Vietnam vets have been diagnosed30% of Vietnam vets have been diagnosed 30% of Vietnam vets have been diagnosed with PTSD sometime over the course of lifewith PTSD sometime over the course of life

--National Center for PTSDNational Center for PTSD

Risk Factor Research1.1. Trauma Impact VariablesTrauma Impact Variables

•• sseverity of exposure, duration of exposure,everity of exposure, duration of exposure,

immediate reaction, resource losses, immediate reaction, resource losses, presence of TBI, acute stress disorderpresence of TBI, acute stress disorder

2.2. Personal/History VariablesPersonal/History Variables

•• gender, psychiatric history, trauma history, gender, psychiatric history, trauma history,

personality dispositionpersonality disposition

3.3. Culture & Environmental VariablesCulture & Environmental Variables

•• social support, life adversities, new social support, life adversities, new stressors, minority and socioeconomic statusstressors, minority and socioeconomic status

--Vogt, Vogt & King, 2007Vogt, Vogt & King, 2007

--LitzLitz & & MaguenMaguen, 2007, 2007

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Comorbid Disorders

80% rate of some co80% rate of some co--morbid disordermorbid disorder

•• ~30% rate of depression~30% rate of depression

•• ~15% rate of other anxiety disorder~15% rate of other anxiety disorder15% rate of other anxiety disorder15% rate of other anxiety disorder

•• ~25% rate of alcohol dependence~25% rate of alcohol dependence

•• ~15% rate of other substance dependence~15% rate of other substance dependence

There is also a high frequency of coThere is also a high frequency of co--occurrence of occurrence of PTSD and mTBI as wellPTSD and mTBI as well

--National Center for PTSDNational Center for PTSD

Traumatic Brain Injury and PTSD

•• Individuals with mTBIIndividuals with mTBI

•• Of those with loss of consciousness, 43.9% met Of those with loss of consciousness, 43.9% met criteria for PTSDcriteria for PTSD

•• Of those with “altered mental status” 27.3% Of those with “altered mental status” 27.3% met criteria met criteria

•• Individuals with no TBIIndividuals with no TBI

•• 16.2% with other injuries met criteria16.2% with other injuries met criteria

•• 9.1% with no injury 9.1% with no injury

--Hoge et al., 2008Hoge et al., 2008

Traumatic Brain Injury and PTSD

•• Those who meet criteria for mTBIThose who meet criteria for mTBI

•• Injury may result in axonal shearing of neurons Injury may result in axonal shearing of neurons in prefrontal cortex which is important for in prefrontal cortex which is important for inhibiting fear reactions/conditioninginhibiting fear reactions/conditioning

•• Cognitive reserve for managing/overcoming the Cognitive reserve for managing/overcoming the fear reaction may be lacking if the PFC is fear reaction may be lacking if the PFC is damageddamaged

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PTSD, TBI, and Cognitive Findings

•• Individuals with PTSD often show cognitive Individuals with PTSD often show cognitive profiles similar to those of individuals with TBIprofiles similar to those of individuals with TBI

•• AttentionAttention

MM•• MemoryMemory

•• Executive FunctionsExecutive Functions

•• Brenner et al. (Brenner et al. (20092009) found NO differences in the ) found NO differences in the neuropsychological functioning of veterans with neuropsychological functioning of veterans with PTSD from those with TBI on memory or PTSD from those with TBI on memory or attention measuresattention measures

•• TBI patients were actually better on one measureTBI patients were actually better on one measure

Military: Special Considerations“Battlemind”

•• Mentality of the war zone Mentality of the war zone –– thoughts and actionsthoughts and actions

•• Inner strength to face fear and adversityInner strength to face fear and adversity

•• Mental and physical toughnessMental and physical toughness

•• Motivation to survive and complete the missionMotivation to survive and complete the mission

•• Rely on small group mentality Rely on small group mentality –– “high of battle”“high of battle”

•• 24 24 hours, hours, 7 7 days a weekdays a week

•• Alteration of circadian rhythms which allow individuals to Alteration of circadian rhythms which allow individuals to anticipate and prepare for regular environmental changesanticipate and prepare for regular environmental changes

“Battlemind” - 2

•• Emotional control is essential to survivalEmotional control is essential to survival

•• Control of weapons and gear necessary fore Control of weapons and gear necessary fore survivalsurvival

T t d i i t iT t d i i t i•• Targeted vs. inappropriate aggressivenessTargeted vs. inappropriate aggressiveness

•• Targeted aggression necessarily involves Targeted aggression necessarily involves making spilt second decisions that are lethal in making spilt second decisions that are lethal in an oftenan often--ambiguous environmentambiguous environment

•• Lack of rest is a major issueLack of rest is a major issue

•• Only Only 2525--4040% of service members with mental % of service members with mental health problems seek helphealth problems seek help

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“Battlemind” - 3

•• Chaos in combatChaos in combat

•• Deployment policies are inconsistently appliedDeployment policies are inconsistently applied

•• Combat often leads to adverse effects on mental Combat often leads to adverse effects on mental healthhealth

•• Exposes realities of injury and deathExposes realities of injury and death

•• Poses moral, ethical, and spiritual challengesPoses moral, ethical, and spiritual challenges

•• Esprit de corps Esprit de corps –– often creates alliances that are often creates alliances that are stronger than family tiesstronger than family ties

Climate in Afghanistan/Iraq

•• No front lineNo front line

•• Consistent risk when one is outside of wireConsistent risk when one is outside of wire

•• Constant threat of IEDS, VBIEDS, small arms Constant threat of IEDS, VBIEDS, small arms fire, RPGSfire, RPGS

•• Danger is unpredictable for soldiers who go Danger is unpredictable for soldiers who go outside wireoutside wire

•• No identifiable enemy until attackedNo identifiable enemy until attacked

•• Hidden enemy who keeps changing tacticsHidden enemy who keeps changing tactics

•• Threat level may vary from place to placeThreat level may vary from place to place

The Onset and Course of PTSD

•• Onset may occur even years after the initial Onset may occur even years after the initial traumatrauma

•• In fact Wolfe et al (1999) demonstratedIn fact Wolfe et al (1999) demonstratedIn fact, Wolfe et al. (1999) demonstrated In fact, Wolfe et al. (1999) demonstrated that the incidence of PTSD doubled within that the incidence of PTSD doubled within 2 years after combat in 2,900 Gulf War 2 years after combat in 2,900 Gulf War veteransveterans

•• Course may worsen without treatment (i.e., Course may worsen without treatment (i.e., consider the course of avoidance behaviors)consider the course of avoidance behaviors)

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Assessment for PTSD

•• Many Scales are available (see website)Many Scales are available (see website)•• Most frequently used Most frequently used Clinician Administered PTSD Scale Clinician Administered PTSD Scale

(CAPS;(CAPS; Blake et al, 1995)Blake et al, 1995)•• Designed for professionals including clinicians and Designed for professionals including clinicians and

researchers with PTSD knowledgeresearchers with PTSD knowledge•• But can be administered by paraprofessionals with trainingBut can be administered by paraprofessionals with training•• 4545 60 min to administer60 min to administer•• 4545--60 min. to administer60 min. to administer•• 17 PTSD symptoms17 PTSD symptoms•• Impact Impact –– social, vocational social, vocational •• SeveritySeverity•• Response validityResponse validity•• Can assess for current or lifetime presence of PTSDCan assess for current or lifetime presence of PTSD

Source: National Center for PTSDSource: National Center for PTSD

The Psychobiology of PTSD

Neurocircuits of Fear inThe Limbic System

•• Sensory Sensory –– thalamus to primary thalamus to primary sensory cortex to association sensory cortex to association cortexcortex

•• Association cortex to Association cortex to amygdala entorhinal cortexamygdala entorhinal cortexamygdala, entorhinal cortex, amygdala, entorhinal cortex, orbitofrontal area, cingulate orbitofrontal area, cingulate gyrusgyrus

•• Amygdala Amygdala –– projects to the projects to the most of striatum and most of striatum and hypothalamus as well as hypothalamus as well as medial prefrontal cortexmedial prefrontal cortex

•• Amygdala exerts a powerful Amygdala exerts a powerful influence over the response influence over the response systemsystem

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Neurocircuits Involved in Re-experiencing Trauma

•• Amygdala integrates both conditioned and Amygdala integrates both conditioned and unconditioned stimuli in fear responseunconditioned stimuli in fear response

Aff h h d l i ll lAff h h d l i ll l•• Afferents reach the amygdala via two parallel Afferents reach the amygdala via two parallel neural circuits neural circuits –– a rapid subcortical path and a a rapid subcortical path and a longer loop through the cortex and hippocampuslonger loop through the cortex and hippocampus

•• Amygdala connections to hippocampus Amygdala connections to hippocampus implicated in strong emotional memoryimplicated in strong emotional memory

Neurocircuitry of Inhibition of the Amygdala

•• Medial prefrontal cortex and the anterior cingulate Medial prefrontal cortex and the anterior cingulate believed to have an inhibitory function on believed to have an inhibitory function on amygdala activation amygdala activation

--image courtesy of Dr. Rand Swensonimage courtesy of Dr. Rand Swenson

https://www.dartmouth.edu/~rswenson/Nehttps://www.dartmouth.edu/~rswenson/NeuroSci/chapter_9.html#chapter_9_amyguroSci/chapter_9.html#chapter_9_amygdaladala

Neuroimaging Studies of PTSD1.1. Neuroimaging of the HippocampusNeuroimaging of the Hippocampus

•• Multiple studies since 1995 Multiple studies since 1995 –– smaller smaller hippocampal volumes found in individuals hippocampal volumes found in individuals with PTSDwith PTSDwith PTSDwith PTSD

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Neuroimaging Studies2. Neuroimaging of the Amygdala (cont’d)2. Neuroimaging of the Amygdala (cont’d)

•• Study of Study of activation of the amygdala in fear activation of the amygdala in fear conditioningconditioning

•• Animal literature Animal literature –– cell death following cell death following prolonged stressprolonged stress

•• Functional but not structural differences Functional but not structural differences found in persons with and without PTSDfound in persons with and without PTSD

--Rauch et al. 2000Rauch et al. 2000

Neuroimaging Studies

3. Neuroimaging of Medial Prefrontal Cortex3. Neuroimaging of Medial Prefrontal Cortex

•• Anterior cingulate found to be smaller in Anterior cingulate found to be smaller in individuals with PTSD (individuals with PTSD (Morgan & Romanski, & Morgan & Romanski, &

LeDoux, 1993; and othersLeDoux, 1993; and others))LeDoux, 1993; and othersLeDoux, 1993; and others))

•• Study Study of activation of the prefrontal cortex to of activation of the prefrontal cortex to fearful fearful faces in subway fire survivors with faces in subway fire survivors with PTSDPTSD

•• The PFC is less active in response to emotional The PFC is less active in response to emotional faces than normals (Kim et al., 2008)faces than normals (Kim et al., 2008)

A Simplified Discussion of the Neurochemistry of PTSD

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PTSD Pathophysiology -Neuroendocrine and

Neurotransmitter Systems

•• Hyperarousal and hypervigilance in PTSD Hyperarousal and hypervigilance in PTSD ––heart rate changesheart rate changes

•• Numerous neurotransmitters implicated inNumerous neurotransmitters implicated in•• Numerous neurotransmitters implicated in Numerous neurotransmitters implicated in arousal including glutamate, norepinephrine, arousal including glutamate, norepinephrine, dopamine, acetylcholine, & serotonin in varying dopamine, acetylcholine, & serotonin in varying degreesdegrees

•• Chronic arousal system alterations appear to Chronic arousal system alterations appear to involve longinvolve long--term changes in neural functionterm changes in neural function

The Adrenergic System:Norepinephrine in PTSD

•• Norepinephrine (NE) and “fight or flight” Norepinephrine (NE) and “fight or flight” reactionreaction

•• Enhances fear conditioning in the amygdalaEnhances fear conditioning in the amygdalaEnhances fear conditioning in the amygdalaEnhances fear conditioning in the amygdala

Corticotrophin Releasing Factor & Glucosteroids

•• As a neurotransmitter , CRF promotes release of As a neurotransmitter , CRF promotes release of norepinephrine enhancing amygdala activationnorepinephrine enhancing amygdala activation

•• Norepinephrine and glucosteriods appear to Norepinephrine and glucosteriods appear to reinforce each otherreinforce each other

•• Glucosteroids impair prefrontal cortical functionGlucosteroids impair prefrontal cortical function

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GABA, Glutamate and the Amygdala

•• GABA inhibits the release of glutamate in the GABA inhibits the release of glutamate in the thalamus and amygdala (glutamate can increase thalamus and amygdala (glutamate can increase dissociative symptoms)dissociative symptoms)

•• However, excitation in stress/danger, rapid release However, excitation in stress/danger, rapid release of glutamate may overcome GABA inhibitionof glutamate may overcome GABA inhibition

•• Glutamate elevations allow for rapid responses to Glutamate elevations allow for rapid responses to danger, but also can lead to neural toxicity and cell danger, but also can lead to neural toxicity and cell death (Ding et al., death (Ding et al., 20102010))

•• Low plasma levels of GABA found in individuals Low plasma levels of GABA found in individuals with PTSD (Vaiva et al., with PTSD (Vaiva et al., 20042004) )

Serotonin Levels in PTSD

•• Serotonin (Serotonin (55--HT) monoamine synthesized HT) monoamine synthesized from tryptophan (depletion can increase from tryptophan (depletion can increase aggression)aggression)

•• Released from neurons in the brainstemReleased from neurons in the brainstemReleased from neurons in the brainstemReleased from neurons in the brainstem

•• Implicated in many functions, including Implicated in many functions, including mood and memorymood and memory

•• Preclinical studies suggest that Preclinical studies suggest that 55--HT levels HT levels are reduced when an organism is stressedare reduced when an organism is stressed

•• Reduced Reduced 55--HT appears to be related to the HT appears to be related to the release of cortisolrelease of cortisol

The Dopaminergic System and PTSD

•• In uncontrollable stress, the amygdala In uncontrollable stress, the amygdala produces dopamine release in the PFCproduces dopamine release in the PFC

•• Excessive dopamine release is believed toExcessive dopamine release is believed toExcessive dopamine release is believed to Excessive dopamine release is believed to contribute to hyperarousalcontribute to hyperarousal and and hypervigilance hypervigilance

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Treatment of PTSD by Mental Health Professionals

At present, two major approaches have been At present, two major approaches have been researched extensively:researched extensively:

•• Pharmacological TreatmentsPharmacological TreatmentsPharmacological TreatmentsPharmacological Treatments

•• Cognitive Behavioral TreatmentsCognitive Behavioral Treatments

PharmacotherapyAntidepressants

•• SSRIs have received the most attention. Two medications SSRIs have received the most attention. Two medications have FDA approval:have FDA approval:•• SertralineSertraline•• ParoxetineParoxetine

•• Initially, in large, multiInitially, in large, multi--site industrysite industry--sponsored trials with sponsored trials with mostly mostly civilian civilian participants, positive findings have been participants, positive findings have been obtained with sertraline (Davidson et al., 2000; Friedman obtained with sertraline (Davidson et al., 2000; Friedman et al., 2000) et al., 2000)

•• PParoxetine has been shown to be effective in managing aroxetine has been shown to be effective in managing PTSD symptoms (Marshall et al., 2001; Tucker et al., PTSD symptoms (Marshall et al., 2001; Tucker et al., 2001)2001)

PharmacotherapyAntidepressants - Sertraline

•• However, sertraline was not demonstrated to be However, sertraline was not demonstrated to be efficacious in the treatment of PTSD in a placeboefficacious in the treatment of PTSD in a placebo--controlled double blind multicontrolled double blind multi center VA cliniccenter VA cliniccontrolled, double blind multicontrolled, double blind multi--center VA clinic center VA clinic study (Friedman et al, 2007)study (Friedman et al, 2007)

•• Yet, Rothbaum et al. (2006) showed that SSRI Yet, Rothbaum et al. (2006) showed that SSRI partial responders achieved further improvement partial responders achieved further improvement after medication treatment was augmented by after medication treatment was augmented by prolonged exposure therapyprolonged exposure therapy

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PharmacotherapyParoxetine

•• Marshall et al. (2001) concluded “Doses of 20 and Marshall et al. (2001) concluded “Doses of 20 and 40 mg/day of paroxetine are effective and well 40 mg/day of paroxetine are effective and well tolerated in the treatment of adults with chronic tolerated in the treatment of adults with chronic PTSD” (as measured on the CAPS)PTSD” (as measured on the CAPS)

•• Vermetten et al (2003) presented preliminaryVermetten et al (2003) presented preliminary•• Vermetten et al. (2003) presented preliminary Vermetten et al. (2003) presented preliminary evidence that paroxetine:evidence that paroxetine:

•• May help prevent decreases in hippocampal May help prevent decreases in hippocampal volumevolume

•• May result in improvements in verbal memory May result in improvements in verbal memory (but not figural memory) (but not figural memory)

PharmacotherapyOther Antidepressants

•• Other SSRI agents:Other SSRI agents:•• FluoxetineFluoxetine --NefazodoneNefazodone

•• FluvoxamineFluvoxamine --TrazedoneTrazedoneFluvoxamineFluvoxamine TrazedoneTrazedone

•• CitalopramCitalopram

•• Tricyclic Antidepressants/MAOIsTricyclic Antidepressants/MAOIs

•• Antidepressants can be useful for treating Antidepressants can be useful for treating associated depression and anxiety symptoms. The associated depression and anxiety symptoms. The choice is made based upon side effects profile. choice is made based upon side effects profile.

Other Agents Target Different Mechanisms

•• Antiadrenergic agents Antiadrenergic agents -- Prazosin, an alphaPrazosin, an alpha--1 1 postpost--synaptic receptor antagonist, has shown synaptic receptor antagonist, has shown consistent efficacy in preventing traumatic consistent efficacy in preventing traumatic i h (K l & D id 2007)i h (K l & D id 2007)nightmares (Krystal & Davidson, 2007)nightmares (Krystal & Davidson, 2007)

•• However, inconsistent success was found in However, inconsistent success was found in reducing PTSD symptoms (possibly because it reducing PTSD symptoms (possibly because it was only administered once a day, at bedtime) was only administered once a day, at bedtime) (Raskind et al., 2007). (Raskind et al., 2007).

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Other Agents Target Different Mechanisms

•• Antiadrenergic agents (cont’d)Antiadrenergic agents (cont’d)

•• Propranolol, a postPropranolol, a post--synaptic beta receptor synaptic beta receptor antagonist has shown promise inantagonist has shown promise inantagonist, has shown promise in antagonist, has shown promise in preventing PTSDpreventing PTSD--related related psychophysiological arousal but not psychophysiological arousal but not PTSD among emergency room patients PTSD among emergency room patients who received the medication within six who received the medication within six hours of their traumatic event (Pitman et hours of their traumatic event (Pitman et al., 2002).al., 2002).

Other Agents Target Different Mechanisms

•• Benzodiazepines and Mood StabilizersBenzodiazepines and Mood Stabilizers

•• Hypothesis Hypothesis –– benzodiazepines may enhance benzodiazepines may enhance neurotransmission of inhibitory GABAergic neurotransmission of inhibitory GABAergic neurons to effectively treat PTSDneurons to effectively treat PTSDneurons to effectively treat PTSDneurons to effectively treat PTSD

•• Unfortunately, studies to date have not been Unfortunately, studies to date have not been able to demonstrate this with medications tried:able to demonstrate this with medications tried:--alprazolam, tiagabin, valproatealprazolam, tiagabin, valproate

•• However, these medications may aid in However, these medications may aid in panic panic attacksattacks, severe , severe anxiety anxiety and and sleep disorderssleep disorders

•• Recommend limited use Recommend limited use –– abuse potentialabuse potential

Medication and Sleep Disorders

•• Insomnia can cause further problems with Insomnia can cause further problems with fatigue, poor concentration (and thus fatigue, poor concentration (and thus memory difficulty), irritability, anxiety, etcmemory difficulty), irritability, anxiety, etc

•• Trazodone (Deseryl)Trazodone (Deseryl)

•• Zolpidem (Ambien)Zolpidem (Ambien)

•• BenadrylBenadryl

•• Short acting benzodiazepines if Short acting benzodiazepines if associated anxiety and other medications associated anxiety and other medications failfail

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Psychotherapeutic ApproachesTo PTSD Treatment

•• Early Cognitive Behavior InterventionsEarly Cognitive Behavior Interventions

•• TraumaTrauma--Focused Cognitive Behavior Focused Cognitive Behavior Therapy (TFTherapy (TF--CBT)CBT)Therapy (TFTherapy (TF CBT)CBT)

•• Exposure TherapyExposure Therapy

•• Eye Movement Desensitization (EMDR)Eye Movement Desensitization (EMDR)

•• Cognitive RestructuringCognitive Restructuring

•• Group TherapiesGroup Therapies

Cognitive Behavioral Approaches -Exposure Therapies

•• Theoretical Background Theoretical Background –– Mowrer’sMowrer’s ((19601960) theory ) theory ––fear conditioning and learning of avoidancefear conditioning and learning of avoidance

•• ElementsElements•• Breathing trainingBreathing training•• RelaxationRelaxation•• ExposureExposure

•• ImaginedImagined•• Directed therapeuticDirected therapeutic•• InteroceptiveInteroceptive//•• In vivoIn vivo

Cognitive Restructuring (Beck, 1976)

•• Theoretical Background Theoretical Background –– it is the person’s it is the person’s iinnterpretation terpretation of the traumatic event that is of the traumatic event that is causing them distresscausing them distress

•• ElementsElements•• Identification of automatic thoughts the Identification of automatic thoughts the

pt has in relation to the traumapt has in relation to the trauma•• Pt is challenged in regard to their Pt is challenged in regard to their

dysfunctional thoughts and beliefsdysfunctional thoughts and beliefs•• Focus on relearningFocus on relearning

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Eye Movement Desensitizationand Reprocessing (EMDR)

(Shapiro, 1989; 1995)

•• Theoretical Background Theoretical Background –– assertion that assertion that traumatic memories can be processed traumatic memories can be processed neurophysiologicallyneurophysiologically in dual tasks (adaptive in dual tasks (adaptive information processing theory)information processing theory)p g y)p g y)

•• ElementsElements•• Rapid eye movements & other sensory Rapid eye movements & other sensory

stimulationstimulation•• Guided Guided imaginalimaginal exposureexposure•• Cognitive restructuringCognitive restructuring

Other Psychotherapeutic Variants

•• Training coping skillsTraining coping skills

•• Lifestyle managementLifestyle management

•• StressStress innoculationinnoculation/management/management•• Stress Stress innoculationinnoculation/management/management

•• Group TherapyGroup Therapy

Other Experimental/Emerging PTSD Therapies

•• Imagery Based TreatmentsImagery Based Treatments

•• Systems Approaches (e.g., Family)Systems Approaches (e.g., Family)

•• HypnosisHypnosis•• HypnosisHypnosis

•• Technological Based TreatmentsTechnological Based Treatments

•• Internet BasedInternet Based

•• Video ConferencingVideo Conferencing

•• Virtual RealityVirtual Reality

--Cukor et al., 2009Cukor et al., 2009

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Efficacy of Treatments for PTSD

•• IssuesIssues

•• Dropout rateDropout rate

•• UnblindedUnblinded administrationadministration

•• UnblindedUnblinded assessmentassessment

•• Duration of treatmentDuration of treatment

•• Lack of followLack of follow--upup

•• Little data on combination therapiesLittle data on combination therapies

•• ComorbidComorbid disordersdisorders

Efficacy of Treatments for PTSD

•• There is strong evidence to There is strong evidence to toto support support cognitivecognitive--behavior therapies in both early behavior therapies in both early and later intervention approachesand later intervention approaches

•• There is also support for pharmacological There is also support for pharmacological approaches approaches –– the best evidence is for SSRI’s the best evidence is for SSRI’s as“frontas“front line” treatmentsline” treatments

•• Though still controversialThough still controversial, there appears to , there appears to be growing support for efficacy of EMDRbe growing support for efficacy of EMDR

Efficacy Data - Conclusions

“Although there are some systematic “Although there are some systematic comparisons of different treatment comparisons of different treatment modalities…we have not reached the point modalities…we have not reached the point ppwhere we can predict which treatments are where we can predict which treatments are most suitable for which patients under most suitable for which patients under which conditions.”which conditions.”

--Friedman, Cohen, Friedman, Cohen, FoaFoa & Keane (2009) p. 617& Keane (2009) p. 617

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Recommendations for Non-mental Health Professionals

Education

•• Become educated about the physiological Become educated about the physiological basis for PTSDbasis for PTSD

•• ChemicalChemicalChemicalChemical

•• NeuroanatomicalNeuroanatomical

•• Research current therapies and medicationsResearch current therapies and medications

•• Educate your patients and their familiesEducate your patients and their families

About Identifying PTSD

•• If you are the person screening an individual for If you are the person screening an individual for PTSD, gently and carefully screen the PTSD, gently and carefully screen the patient/client for PTSD with 4 questions about:patient/client for PTSD with 4 questions about:

•• moodmoodmood mood

•• sleepsleep

•• nightmaresnightmares

•• problem with angerproblem with anger

•• Positive responses warrant referral to a mental Positive responses warrant referral to a mental health professional health professional who has experience in who has experience in dealing with PTSDdealing with PTSD

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About Traumatic Incidents

•• Don’t bring them upDon’t bring them up

•• You may wish to gently redirect the pt if You may wish to gently redirect the pt if s/he initiates discussion of traumatic s/he initiates discussion of traumatic incidents incidents

•• Avoid discussing death/killingAvoid discussing death/killing

•• A person’s PTSD triggers may not be A person’s PTSD triggers may not be knownknown

•• Autobiographical review may trigger Autobiographical review may trigger unpleasant memoriesunpleasant memories

About Cognitive Symptoms

•• Use caution when attributing cognitive symptoms to Use caution when attributing cognitive symptoms to traumatic brain injury traumatic brain injury

•• Educate patients that cognitive problems may be Educate patients that cognitive problems may be related to PTSDrelated to PTSD

•• One study demonstrated that mTBI effects on One study demonstrated that mTBI effects on multiple health problems have been shown to be multiple health problems have been shown to be nonsignificant once postnonsignificant once post--traumatic stress disorder traumatic stress disorder (PTSD)(PTSD) and depression were controlled forand depression were controlled for

•• Consider also limitations of sleep disorders and Consider also limitations of sleep disorders and

chronic painchronic pain

About Sensory Stimuli

•• Avoid surprising the trauma survivorAvoid surprising the trauma survivor

e.g., e.g.,

•• Loud noisesLoud noises

•• Approaching from behindApproaching from behind

•• Tapping the pt on the shoulderTapping the pt on the shoulder

•• Some traditional targets of treatment may not Some traditional targets of treatment may not be appropriate (e.g., promoting eye contact)be appropriate (e.g., promoting eye contact)

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About Dealing with Symptoms

•• Acknowledge validity of the pt’s distress and Acknowledge validity of the pt’s distress and emotionsemotions

•• Keep your back to the door Keep your back to the door –– remember that remember that symptoms have a physiological basissymptoms have a physiological basis

•• Keep calm if pt becomesKeep calm if pt becomes hyperarousedhyperarousedKeep calm if pt becomes Keep calm if pt becomes hyperarousedhyperaroused

•• Obtain help from mental health professionals Obtain help from mental health professionals when possiblewhen possible

•• Screen for suicide ideationScreen for suicide ideation

•• It may be appropriate to gently challenge It may be appropriate to gently challenge distorted thinking distorted thinking –– but be cautiousbut be cautious

•• Don’t take it personally Don’t take it personally

Encourage and Support Treatment Seeking Behavior

•• It is often difficult for patients to seek It is often difficult for patients to seek appropriate helpappropriate helpappropriate helpappropriate help

•• Confer with coConfer with co--treating mental health treating mental health providers on appropriate treatment providers on appropriate treatment strategies for the patientstrategies for the patient

National Center for PTSD

Website: Website: http://www.ptsd.va.gov/http://www.ptsd.va.gov/

•• For veterans, their families and the publicFor veterans, their families and the public

•• For clinicians and researchersFor clinicians and researchers•• For clinicians and researchersFor clinicians and researchers

•• Additional references Additional references –– separate handoutseparate handout