2/10/2020 POST‐TRAUMATIC STRESS SYNDROME (PTSD) The Rage of Achilles Margaret Wheeler MD Shell‐shock , Battle‐fatigue…. PTSD: It’s Not Only for Vets anymore…. 1 2/10/2020 CASE PTSD Often Missed • 60‐90% of the time diagnosis is Ms. N presents with intermittent episodes of SOB, palpitations and missed sweats. • Missed in all ages, illnesses, comorbidities and settings She has an extensive work up, including EKGs, Ziopatch x2, echo, • Most often missed exercise treadmill, CXR, HRCT, VQ scan, sleep study, TSH, CBC, • in women, metabolic panel, cortisol CRP/ESR all of which are negative. She has • people with lower income and been referred to cardiology and pulmonology • Lower education • Few seek help PTSD is COMMON Should We Care? • 7.8 % of all in US • 88 % have comorbid conditions • 10% in women • Depression • Substance Use Disorder • 16.5% in under < 125% FPL • Anxiety Disorder • 20% in recent combatants • Higher rates of • 40% in homeless women; 30% homeless men • Insulin resistance; • Autoimmune disease; • 24% Homeless adolescents • Hyperlipidemia • Refugees 10X rate of pop. where resettled • Dementia • Parto, 2011, Whitbeck, 2015,Bender, 2010,Fzzel, 2005 • Sleep Disorders 2 2/10/2020 DSM‐ 5 Criteria: Step 1 Screen • Exposure to death, serious injury, or sexual violence • Direct experience • Witnessing • Learning of accidental or violent death in a someone close • Experiencing repeated or extreme exposure to aversive details of trauma (e.g. first responders) Screening Step 1: Exposure YES OR NO? DSM‐5 Diagnostic Clusters • Re‐experiencing the trauma (1) • Avoidance (1) • Arousal ( sleep disturbances; hypervigilance; irritability)( 2) • Negative thoughts (2) • cognitions (disillusionment, guilt, shame, blame) • mood ( emotional numbing, estrangement, inability to experience positive emotions) • At least 1 month’s duration (o/w Acute Stress Disorder) • Significant distress or impairment in social, occupational,or other functioning • American Psychiatric Association. DSM‐ 3 2/10/2020 Screening Step 2: The Clusters Diagnosis and Monitoring: >3– probable PTSD PCL‐5 ( think PHQ‐9) • Use for screening/diagnosis‐ • Monitoring symptoms • 5‐10 reliable change • 10‐20 significant change • https://www.ptsd.va.gov/profes sional/assessment/documents/P CL5_Standard_form.PDF Weathers, 2013 CASE Treatment • Ms. N is screened for PTSD • Most effective– CBT exposure; CBT mixed • Moderately effective: Cognitive processing; cognitive • She is from Rwanda therapy, narrative exposure therapy, Eye movement desensitization and reprocessing (EMDR); • fluoxetine, parotexine, venlafaxine • She was there during the genocide • Low effectiveness : Psychotherapy, Imagery rehearsal; seeking safety; trauma regulation; • sertraline; prazosin; topiramate; olanzapine; risperidone • AHRQ 2018; VA PTSD Practice Guidelines 4 2/10/2020 Prevention: Limited Evidence PTSD • Primary prevention: Upstream work– housing policies,gun control, anti‐war; policing and sentencing; antipoverty, resilience training (no evidence) Remember to Ask • Secondary: Immediately after– very limited evidence: • + early CBT/ exposure therapy; pain control; ??hydrocortisone • ‐ beta‐blockers; gabapentin; benzos; escitalopram; early psychotherapeutic interview References References • Finkelhor, D., Vanderminden, J., Turner, H., Hamby, S., & Shattuck, A. • Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P. , & (2014). Upset among youth in response to questions about exposure to Schnurr, P. P. (2013). The PTSD Checklist for DSM‐5 (PCL‐5) – Standard violence, sexual assault and family maltreatment. Child Abuse & Neglect, [Measurement instrument]. Available from https://www.ptsd.va.gov/ 38(2), 217‐223. • National Center for PTSD https://www.ptsd.va.gov/index.asp • Lewis C, Raisanen L, Bisson JI, Jones I, Zammit S (2018). Trauma exposure and undetected posttraumatic stress disorder among adults with a mental • Psychological and Pharmacological Treatments for Adults with disorder. Depression & Anxiety 35:178‐184 Posttraumatic Stress Disorder (PTSD): A Systematic Review AHRQ • Miele, D., & O'Brien, E.J. (2010). Underdiagnosis of posttraumatic stress https://effectivehealthcare.ahrq.gov/products/ptsd‐adult‐treatment‐ disorder in at risk youth. Journal of Traumatic Stress, 23(5), 591‐598. update/research‐protocol • van Zyl, M., Oosthuizen, P. P. , & Seedat, S. (2008). Post traumatic stress • Parto JA, Evans MK, Zonderman AB. Symptoms of posttraumatic disorder: Undiagnosed cases in a tertiary inpatient setting. African Journal stress disorder among urban residents. J Nerv Ment Dis. of Psychiatry, 11, 119‐122. 2011;199(7):436–439. doi:10.1097/NMD.0b013e3182214154 5 2/10/2020 References • Fazel, M., Wheeler, J., &Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365(9467), 1309–1314. https://doi‐ org.ucsf.idm.oclc.org/10.1016/S0140‐6736(05)61027‐6 6.