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How to Treat PTSD in Patients with Comorbid Mood Disorders

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How to Treat PTSD in Patients with Comorbid Mood Disorders How to treat PTSD in patients with comorbid mood disorders Antidepressants may trigger hypomania in patients with bipolar spectrum disorders ajor depressive disorder (MDD) and bipolar spectrum disorders are associated with some Msymptoms of—and fully defined—posttrau- matic stress disorder (PTSD). Many traumatic experi- ences can lead to this comorbidity, the most common being exposure to or witnessing combat for men and rape and sexual molestation for women.1 Trauma has major prognostic and treatment implica- tions for affectively ill patients, including those whose symptoms do not meet PTSD’s full diagnostic criteria. This article aims to help clinicians by: • presenting evidence characterizing the overlap between affective disorders and PTSD • reviewing evidence that the bipolar spectrum © 2010 SHUTTERSTOCK may be broader than generally thought, an insight that affects PTSD treatment Steven C. Dilsaver, MD • making a case for routine PTSD screening for all Comprehensive Doctors Medical Group, Inc. Arcadia, CA patients with affective illnesses • recommending PTSD treatments tailored to the patient’s comorbid affective disorder. Overlap of trauma and affective illness PTSD is remarkably comorbid with mood disorders. Americans with MDD and bipolar disorder (BPD) are 7 and 9.4 times, respectively, more likely to meet crite- ria for PTSD than persons in the general population, according to odds ratios Kessler et al2 calculated from the National Comorbidity Survey database. I have never seen a patient with PTSD who did Current Psychiatry 48 April 2010 not also meet criteria for an affective disorder. The Table 1 Evidence of bipolar spectrum features in major depressive episodes Study Design Conclusion Akiskal and 200 community mental health clinic 50% could be classified as having a Mallya, 19874 patients diagnosed as having MDD bipolar disorder Benazzi, 19975 203 consecutively presenting 45% met criteria for bipolar II disorder patients with depression Akiskal and 563 consecutive patients presenting 58% showed features of bipolar II Benazzi, 20056 with a DSM-IV-diagnosed MDE disorder Akiskal et al, 20067 493 patients in a French national 65% were determined to fall along the study presenting with MDE ‘bipolar spectrum’ Rabakowski et al, 880 Polish outpatients presenting 40% met criteria for bipolar disorder 20058 with MDE MDD: major depressive disorder; MDE: major depressive episode concurrence of PTSD and MDD is not the Some experts believe episodes of hy- Clinical Point product of overlapping diagnostic criteria. pomania and mania frequently occur in Validation studies Rather, evidence indicates these are dis- the illness course of persons with mixed suggest that mixed tinct diagnostic entities.3 A review of diag- depression; indeed, mixed depression nostic criteria for PTSD and hypomania/ is a predictor of a bipolar course. It is depression is a mania leads to the same conclusion. observed in outpatient9 and inpatient bipolar variant settings.11 Common forms of mixed de- pression feature combinations of irritabili- Bipolar spectrum disorders ty, psychomotor agitation (mild to severe), DSM-IV-TR assumes that mood disorders increased talkativeness (which may fall fall neatly into boxes. Other data (Table 1)4-8 short of frank pressured speech), racing indicate that these disorders fall along or “crowded” thoughts (or “mental over- a continuum or—more conservatively— activity”), and distractibility. Other than that the scope of bipolarity is much wid- increased self-esteem/grandiosity, any er than DSM-IV-TR recognizes. This is a symptoms within DSM-IV-TR criterion B controversial topic, and the individual for a hypomanic or manic episode may be clinician’s position could impact how one seen in mixed depression. Psychosis is an manages PTSD patients. exclusion criterion for mixed depression. In this article, I include bipolar I dis- Mixed depression responds poorly to order, bipolar II disorder, and mixed de- antidepressant monotherapy. Validation pression within the “bipolar spectrum studies suggest that mixed depression is disorders.” If one accepts this—and I a bipolar variant, as determined by its ca- do—it follows that 50% to 70% of all major pacity to predict a bipolar course and its depressive episodes (MDEs) are bipolar in association with a family history of bipo- nature.4-9 Depending on your practice set- lar disorder and age of onset.9 ting, you may see a higher or lower base rate of bipolar spectrum disorders. PTSD risk in affective illness Mixed depression is not recognized in An adolescent sample. A preliminary DSM-IV-TR, and the purpose of this ar- cross-sectional study conducted by our ticle is not to defend its inclusion as a bi- group indicates that adolescents with af- polar spectrum phenomenon. A proposed fective disorders may have a much higher definition of mixed depression9 requires risk of developing PTSD than psychiatric the presence of an MDE contaminated by comparison subjects.12 We used modules ≥3 features of hypomania or mania, with- from the Structured Clinical Interview for out euphoria or inflated self-esteem/gran- DSM-IV (SCID) to screen for intra-episode Current Psychiatry diosity (Table 2, page 50).10 psychopathology (as opposed to lifetime Vol. 9, No. 4 49 Table 2 Diagnostic characteristics of a hypomanic episode, DSM-IV-TR criteria A and B A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. B. During the period of mood disturbance, 3 or more of the following symptoms have persisted PTSD and (4 if the mood is only irritable) and have been present to a significant degree: mood disorders 1) inflated self-esteem or grandiosity 2) decreased need for sleep (eg, feels rested after only 3 hours of sleep) 3) more talkative than usual or pressure to keep talking 4) flight of ideas or subjective experience that thoughts are racing 5) distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) 6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, the person engages in unrestrained buying sprees, sexual indiscretions, Clinical Point or foolish business investments). Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric In our study, an Association; 2000 adult patient with bipolar disorder was 5 times more likely prevalence of disorders) in 79 adolescents trauma leading to PTSD was sexual moles- to have PTSD than with MDD, 34 with BPD as defined in the tation or rape as a child or adolescent in this one with MDD DSM-IV-TR, and 26 with neither affective predominantly female Latino population. disorder (psychiatric controls). We found: • 38.2% of subjects with BPD met crite- ria for PTSD, compared with 13.9% of Populations at risk for PTSD those with MDD (OR 4.9; P = .001) The prevalence of PTSD in clinical sam- • 3.8% of adolescents without a mood ples varies, depending on the population disorder met criteria for PTSD. studied. For instance, women are at much We also found that comorbid PTSD was higher risk for developing PTSD than associated with a 4.5-fold higher risk of a men, even in comparisons where men are suicide attempt, even after we controlled exposed to a greater number of traumatic for BPD diagnosis. When we controlled for events and analyses control for differenc- the presence of other concurrent anxiety es in the prevalence of sexual abuse. The disorders, the likelihood of an adolescent gender difference is greater if the trauma with PTSD having attempted suicide re- occurs during childhood.14 Essentially all mained significant (OR 3.4; P = .023). This patients in our adolescent and adult stud- finding suggests that PTSD is an indepen- ies developed PTSD in response to child- dent risk factor for a suicide attempt. hood or adolescent sexual trauma.12,13 A population exposed to a high rate of An adult sample. We then focused on violent crime would be expected to show a adults meeting criteria for MDD or BPD. higher PTSD prevalence than one exposed ONLINE In a study of 187 consecutively presenting to substantially less violence. The base rate ONLY affectively ill patients, we used the SCID of PTSD also is much higher in affectively Discuss this article at to screen for multiple anxiety disorders ill patients than in the general population. http://CurrentPsychiatry. including PTSD.13 Lifetime—as opposed An analysis by Otto et al15 found a 16% blogspot.com to intra-episode—PTSD prevalence was lifetime prevalence of concomitant PTSD in 23.8% among the 118 patients with MDD 1,214 persons with BPD (not the manifold and 62.3% among the 69 patients with BPD. forms within the bipolar spectrum). Oquen- A patient with BPD was 5 times more likely do et al16 reported a 25.7% lifetime preva- to have PTSD than a patient with MDD (OR lence of PTSD in 230 patients with a history Current Psychiatry 50 April 2010 5.3; P < .0001). The most common cause of of MDD. Other epidemiologic2 and clinical Checklist DSM-IV-TR diagnostic criteria for posttraumatic stress disorder Criterion A. The person has been exposed to a traumatic event in which both of the following have been present: ☐ 1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others ☐ 2. The person’s response involved intense fear, helplessness, or horror Criterion B. The traumatic event is persistently re-experienced in at least 1 of the following ways: ☐ 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions ☐ 2. Recurrent distressing dreams of the event ☐ 3.
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