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Post-Traumatic Stress Disorder: It’s Not Just Stressed Combat Veterans
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Post-Traumatic Stress DisorderIt’s Not Just Stressed Combat Veterans
Brian Koffman, MDCM, DCFP, DABFM, MS Ed
Chief Medical Officer, CLL Society (CLLSociety.org)
Retired Clinical Professor
Department of Family Medicine
Keck School of Medicine, USC Family Practice
Learning Objectives
▪ Consider PTSD when seeing patients with anxiety,
depression, sleep disorders or substance abuse
especially when there is avoidance behavior,
hyperarousal, nightmares or intrusive thoughts
▪ Choose appropriate pharmacotherapy to match the most
disturbing symptoms
▪ Use psychotherapy to help extinguish the recurring fear
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Normal versus Pathologic Anxiety
▪ Normal anxiety is adaptive. It is an inborn response
to threat or to the absence of people or objects that
signify safety and can result in cognitive (worry) and
somatic (racing heart, sweating, shaking, freezing,
etc.) symptoms
▪ Pathologic anxiety is anxiety that is excessive,
impairs function or in the case of PTSD is unrelated
to the present circumstances
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Anxiety vs. Fear
▪ Anxiety
▪ Apprehension about a future threat
▪ Fear
▪ Response to an immediate threat
▪ Both involve physiological arousal
▪ Sympathetic nervous system
▪ Both can be adaptive
▪ Fear triggers “fight or flight”
▪ May save life
Anxiety vs. Fear
▪ Anxiety increases preparedness
▪ “U-shaped” curve (Yerkes & Dodson, 1908)
▪ Absence of anxiety interferes with performance
▪ Moderate levels of anxiety improve performance
▪ High levels of anxiety are detrimental to performance
Yerkes RM, Dodson JD (1908). "The relation of strength of stimulus to rapidity of habit-formation". Journal of Comparative Neurology and Psychology.
18 (5): 459–482. doi:10.1002/cne.920180503.
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Fear vs. Anxiety
FEAR ANXIETY
Basic Emotion Generalized mood state
Noncognitive or elementary/automatic cognitions Cognitive and complex cognitions
Brief/discrete Long/chronic
Depending on the moment Dependent on the learning experiences
Distinct physiology Diffuse physiology
Instantaneous response necessary for survival Plan and prepare for challenge and threat
Response to imminent threat Response to future threat
Intense autonomic arousal Less autonomic arousal
Visual processing/imagery Verbal processing/worry
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Anxiety Disorders (DSM-5)
▪ Specific Phobia
▪ Social Anxiety Disorder (Social Phobia)
▪ Panic Disorder
▪ Agoraphobia
▪ Generalized Anxiety Disorder
▪ Substance/Medication-Induced Anxiety Disorder
▪ Anxiety Disorder Due to Another Medical Condition
PLEASE NOTE THAT PTSD IS NOT INCLUDED
DSM-5 New Category
Trauma and Stressor - Related Disorders
▪ Post-Traumatic Stress Disorder (> 1 month)
▪ Acute Stress Disorder (< 1 month)
▪ Adjustment Disorders
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Post-Traumatic Stress Disorder
▪ Has experienced or witnessed or was confronted
with an unusually traumatic event that has both of
these elements:
▪ Event involved actual or threatened death or serious
physical injury to the person or others
▪ Felt intense fear, horror or helplessness
Old Problem - New Name
▪ PTSD - known to previous generations as nostalgia, shell
shock, soldier’s heart, battle fatigue or war neurosis
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Case Study - Susan
▪ 29 yr old female seen at the urging of her fiance. A nurse with a local Marine Reserve unit who was honorably discharged in 2018 after serving two tours of duty in Afghanistan
▪ “Not been the same” since her 2nd tour of duty and it is impacting their relationship
▪ Offers few details, but upon questioning she reports that has difficulty sleeping, “sleeps with one eye open” and she has nightmares
▪ She confirms experiencing several traumatic events during her second tour but is unwilling to provide specific details
▪ She has never spoken with anyone about them and she is not sure she ever will
Case Study - Susan
▪ Spends much of her time alone as she’s irritable with friends
▪ Easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home
▪ Intrusive memories about her traumatic experiences on a nearly daily basis but declines to share any details
▪ Avoids seeing friends from her reserve unit because seeing them reminds her of experiences
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Case Study - Susan
History of trauma
▪ Hypervigilance
▪ Intrusive thoughts
▪ Irritability
▪ Loss of interest
▪ Sleep difficulties with nightmares
A Psycho-Neuro-Endocrine Disorder
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Development of PTSD
psychscene.com; psychscenehub.com
PTSD Myths
1. You have it or you don’t
▪ There are mild and severe cases
2. Almost everyone returning from combat zone has it
▪ Most exposed to combat do not
3. Only affects those in direct combat
▪ Affect noncombat military and civilians
4. Only affects veterans
▪ Any trauma exposure is a potential trigger of PTSD
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Vets Consult Civilian PCPs
▪ PTSD in Combat Veterans
▪ 20% of ∼ 5 million or 1,000,000 PTSD patients
▪ Vietnam
▪ Middle East
▪ Others & non-combat
▪ But what about the VA?
▪ Not eligible
▪ No desire to go -- prior experiences, word of mouth/ finances/
appointments/ changes in staff
Ramchand R et al. J Trauma Stress. 2010;23:59-68.
Tanielian T, Jaycox LH, eds. Invisible Wounds of War Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.
Santa Monica, CA: Rand Corp.;2008.
Likelihood of Getting PTSDafter Experiencing Trauma
▪ It depends on the event and the person
▪ Men experience more traumatic events
▪ Women are more likely to develop PTSD
▪ Gender is a factor in who gets PTSD
▪ 20% of women
▪ 8% of men
Kessler RC1, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry.
1995 Dec;52(12):1048-60.
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Likelihood of PTSD (con’t)Gender is important again
▪ Rape
▪ Men 65%
▪ Women 45%
▪ Combat
▪ Men 20% returning from Iraq and Afghanistan
▪ Physical Abuse
▪ Almost 50% of women
▪ 20%+ men
What puts you at risk for PTSD?
▪ Strength or severity of the stressor
▪ Characteristics of the trauma:
▪ Greater perceived life threat
▪ Feeling helpless
▪ Unpredictable, uncontrollable
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Risk for PTSD: After the Trauma
▪ Degree of Social
Support
▪ Degree of Life Stress
More than War Veterans
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Problems in Recognizing PTSD
▪ Patients commonly report only certain symptoms
▪ Insomnia, irritability, pain, sexual dysfunction, GI distress, dizziness,
headaches, hypertension or other cardiovascular symptoms, lack of
concentration, alcohol or other substance abuse related problems...
▪ Often FAIL to report traumatic experience
PTSD: Screening with DSM-5
Description
▪ The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a 5-item screen designed to identify individuals with probable PTSD. Those screening positive require further assessment, preferably with a structured interview.
Scoring
▪ Preliminary results from validation studies suggest that a cut-point of 3 on the PC-PTSD-5 (e.g., respondent answers "yes" to any 3 of 5 questions about how the traumatic event(s) have affected them over the past month) is optimally sensitive to probable PTSD. Optimizing sensitivity minimizes false negative screen results. Using a cut-point of 4 is considered optimally efficient. Optimizing efficiency balances false positive and false negative results. As additional research findings on the PC-PTSD-5 are published, updated recommendations for cut-point scores as well as psychometric data will be made available.
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DSM-5 (con’t) If yes to a traumatic event, then ask:
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Diagnosis (modified DSM-5)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
1. Directly experiencing the traumatic event(s)
2. Witnessing, in person, the event(s) as it occurred to others
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (eg, first responders collecting human remains; police officers repeatedly exposed to details of child abuse)
Note: Criterion A4 does not apply to exposure through electronic media, television,
movies, or pictures, unless this exposure is work related.
Diagnosis (con’t)
B. Presence of one or more of the following intrusive
symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories
of the traumatic event(s)
2. Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s)
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Diagnosis (con’t)
B. (con’t)
3. Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
Diagnosis (con’t)
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
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Diagnosis (con’t)
D. Negative thoughts and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or drugs)
2. Persistent and exaggerated negative beliefs or expectations about oneself, others,
or the world, for example:
- "I am bad''
- "The world is completely dangerous"
- "My whole nervous system is permanently ruined"
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others
Diagnosis (con’t)
D. (con’t)
4. Persistent negative emotional state (eg, fear, horror, anger, guilt, or shame)
5. Markedly diminished interest or participation in significant activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience positive emotions (eg, inability to experience happiness, satisfaction, or loving feelings)
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Diagnosis (con’t)
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance (eg, difficulty falling or staying asleep or restless sleep)
Diagnosis (con’t)
F. Duration of the disturbance is > 1 month
G. The disturbance is clinically significant, causes distress
and affects important functions
H. There is no other cause - medical, substance or
psychiatric
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Acute Stress Reaction
▪ Symptoms of post-traumatic stress and functional
impairment after traumatic event(s) are diagnosed
acute stress disorder (ASD) for the first 30 days
▪ Most people fully recover
▪ For those who don’t after 30 days, re-diagnosed
as PTSD
Clinician-Administered PTSD Scale(CAPS-5) for DSM-5
The CAPS is the gold standard, a 30-item structured interview to:
1. Make current (past month) diagnosis of PTSD
2. Make lifetime diagnosis of PTSD
3. Assess PTSD symptoms over the past week
Assesses the 20 DSM-5 PTSD symptoms plus targets
▪ Onset and duration of symptoms
▪ Subjective distress
▪ Impact of symptoms on social and occupational functioning, improvement in symptoms
▪ Overall response validity
▪ Overall PTSD severity
▪ Specifications for the dissociative subtype (depersonalization and derealization)
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Implications of PTSD
▪ Greater unemployment
▪ Relationships
▪ Health problems
▪ Violence
▪ Generally worse quality of life
Common Co-occurring Psychiatric Conditions
▪ 80% of people with PTSD have another diagnosis
▪ Depression
▪ Anxiety disorders
▪ Generalized, panic, social phobia
▪ Substance abuse disorders
▪ OCD variant
OCD, obsessive-compulsive disorder
Kessler R, et al. Arch Gen Psychiatry. 1995;52:1048–1060.
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PTSD and Alcohol
▪ The prevalence of comorbid alcohol misuse in those with
PTSD ranged from 9.8% to 61.3%
▪ The prevalence of comorbid PTSD in those with alcohol
misuse ranged from 2% to 63%
▪ Majority of prevalence rates were over 10%
▪ Alcohol misuse associated with
▪ Avoidance/numbing symptoms
▪ Hyperarousal symptoms
Nicola Fear et al, A systematic review of the comorbidity between PTSD and alcohol misuse, 2014.
Common Comorbid Medical Problems
▪ Cardiovascular
▪ Headaches, chronic pain
▪ Metabolic, immune disorders
▪ Traumatic brain injury (TBI)
Sareen J, et al. Psychosom Med. 2007;69:242-248.
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Suicide Risk Factors
▪ Relationship issues -- feels alone, hopeless, helpless
▪ Seeing no way out and fearing things will get worse --
family, finance, and more
▪ Person is anxious, agitated, and has severe insomnia
▪ Judgment is impaired by use of alcohol or other
substances
▪ Weapons are easily accessible
Suicide Prevention
▪ Ask about suicidal thoughts and plans and ask again
▪ Involve support system
▪ Discontinue substances of abuse
▪ Remove weapons where possible
▪ Suggest Suicide Hotline: 1-800-273-TALK/8255
▪ Written contract no self harm
▪ Refer
▪ Document
U.S. DHHS. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: HHS, September 2012.
https://www.integration.samhsa.gov/health-wellness/wellness-strategies/2012_National_Strategy_for_Suicide_Prevention.pdf Accessed February 18, 2020
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Stepwise Treatment Model:Stage 1 Safety
1. Suicide and homicide prevention
2. Harm reduction for risky behaviors
3. Teach positive coping tools
▪ Anger management
▪ Stress management
Important Reason to Treat: Condition Affects Most Areas of a Person’s Life
▪ Self esteem
▪ Relationships
▪ Employment & education
▪ Finances
▪ Legal status
▪ Health
▪ Others
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Treatment Recommendations
Types of Treatment
▪ Psychotherapy
▪ Pharmacotherapy
Foa EB, Keane TM, Friedman MJ, Cohen JA, eds. Effective treatments for PTSD: Practice guide-lines from the International Society for Traumatic Stress
Studies. 2nd ed. New York, NY: Guilford Press;2008.
Basic Principles of Effective Treatment
▪ Understand and ACCEPT they have PTSD
▪ Understand and ACCEPT treatment plan
▪ Actively participate in treatment
▪ Recognize that medication alone is generally not
adequate treatment
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Treatment for PTSD
▪ Cognitive Behavioral Treatments most effective
psychotherapy treatments
▪ Medication can be an effective treatment
▪ Most evidence for Cognitive Processing Therapy (CPT)
and Prolonged Exposure (PE)
▪ Most evidence for SSRIs and prazozin
PTSD Theory Behind Psychotherapy
Most individuals have symptoms of re-experiencing, avoidance, and hyperarousal following severe trauma
For most these symptoms resolve over time
For PTSD they don’t
PTSD is a failure of fear extinction following trauma
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Cognitive Based Therapies
▪ Diminishes the link between
imposed meanings and a fearful
emotional state
▪ Changes patient’s thinking about
the trauma and themselves to be
more rational and realistic
▪ The Socratic method is used to
challenge maladaptive beliefs
and thus reduce symptoms
Exposure Based Therapies
▪ Exposure therapy involves
confronting feared memories
and situations in a safe and
therapeutic setting
▪ Re-experiencing trauma
allows it to be emotionally
processed so that it can
become less painful and
see they are not dangerous
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Virtual Exposure
Prolonged Exposure (PE)
PTSD therapy that works – therapy begins with education on PE, its goals, and what to expect at each treatment stage
▪ Learning to maintain even breathing when dealing with traumatic memories can aid treatment immensely. Deep breaths can reduce distress and anxiety
▪ Talking about traumatic memories repeatedly with a therapist can help make sense of what happened and help control emotions and thoughts linked to that trauma. A therapist might advise easing into traumatic memories by first discussing less troubling ones
▪ Repeated voluntary exposure to real-world situations that might be avoided due to trauma can lessen the distress they cause
▪ Repetitive recall of memories linked to trauma can help change reactions to traumatic memories when done in a safe place. This can help to cope with distressing memories
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CPT & PE PTSD: Long Term Effect in Female Rape Victims
0
20
40
60
80
100
Pre 5+ Years
% M
eet
ing
PTS
D D
iagn
ost
ic C
rite
ria
(CA
PS)
CPT (n=63)PE (n=64)
A Comparison of Cognitive-Processing Therapy With Prolonged Exposure and a Waiting Condition for the Treatment of Chronic Posttraumatic Stress
Disorder in Female Rape Victims Patricia A. Resick,et al.
Eye Movement Desensitization and Reprocessing (EMDR)
▪ Like CBT but also incorporates saccadic eye movements with
substituting more positive link
▪ Patient relives a scene from the trauma while the therapist
repeatedly moves two fingers across the patient’s visual field and
instructs the patient to track the fingers until anxiety decreases
▪ The patient is then instructed to generate a more adaptive thought
COCHRANE REVIEW
No difference in efficacy between CBT and EMDR and both
are effective therapies for PTSD
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Other Psychotherapies for PTSD(less data)
▪ Interpersonal psychotherapy
▪ Deals with relationships affected by PTSD
▪ Mindfulness-based therapy, yoga, stress reduction
▪ Live in the moment
▪ ACT (Acceptance and Commitment Therapy)
▪ Teaching acceptance and accompanying behavioral changes
▪ MDMA
▪ Using MDMA as a catalyst of PTSD-specific psychotherapy
MDMA = methylenedioxy-methylamphetamine
Ecstatic Segue to Pharmacotherapy
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Medications
▪ First line SSRI and SNRI
▪ FDA approved: sertraline and paroxetine
▪ Prazosin – useful for nightmares
▪ Other antidepressants
▪ Atypical antipsychotics (with care)
▪ Mood stabilizers
▪ Propranolol
Avoid Benzodiazepines if possibleMay interfere with learning from other therapies
Jeffreys M, et al. J Rehabil Res Dev. 2012;49:703-715.
SSRIs
▪ Paroxetine start at 10 - 20 mg/day
▪ If little or no response is seen after 4 weeks, increase with 10 to 20 mg/day increments with 2 weeks between increases
▪ Max 60 mg/day
▪ Sertraline start at 25 or 50 mg/day
▪ If little or no response is seen after 4 weeks, increase with 25 to 50 mg/day increments with 2 weeks between increases
▪ Max 250 mg/day
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Second-generation Antipsychotics
▪ Quetiapine may help as monotherapy
▪ Little efficacy as augmentation to SSRIs alone
▪ Serious side effects
▪ Suicidal thoughts and behavior
▪ Neuroleptic malignant syndrome
▪ Tardive dyskinesia: potentially irreversible
▪ Cerebrovascular adverse reactions, including stroke, in elderly
patients with dementia-related psychosis
Villarreal G, Hamner MB, Canive JM, et al. Efficacy of Quetiapine Monotherapy in Posttraumatic Stress Disorder: A Randomized, Placebo-Controlled
Trial. Am J Psychiatry 2016; 173:1205.
Second-generation Antipsychotics
Serious side effects (con’t)
▪ Metabolic
▪ Hyperglycemia
▪ Increased cholesterol and triglycerides
▪ Weight gain
▪ Orthostatic hypotension and falls
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Second-generation Antipsychotics
Serious side effects (con’t)
▪ Leukopenia, Neutropenia, and Agranulocytosis
▪ Cataracts
▪ Seizures
▪ QT Prolongation
▪ Dysphagia and dysarthria
▪ Anticholinergic (antimuscarinic) effects
Prazozin
▪ Alpha 1 blocker used mainly for sleep and nightmares
▪ Meta-analysis showed benefit effects in reducing overall
PTSD symptoms and nightmares and improving sleep
▪ Start at 1 mg hs and slowly increase
▪ Max 15 mg
▪ Side effects include orthostatic hypotension
▪ Taper off to avoid rebound hypertension
Khachatryan D, Groll D, Booij L, et al. Prazosin for treating sleep disturbances in adults with posttraumatic stress disorder: a systematic review and meta-
analysis of randomized controlled trials. Gen Hosp Psychiatry 2016; 39:46.
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Other Medication (less data)
▪ Propranolol for revived memories
▪ Promising early results
▪ TCAs, trazadone and mirtazapine
▪ Little data
▪ Mood stabilizers
▪ Topiramate or tiagabine or divalproex not better than placebo
▪ Ketamine
▪ Clinically meaningful reduction in PTSD
▪ Cannabis
▪ Associated with worse treatment outcomes
Steenen SA, et al. Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis. J Psychopharmacol 2016; 30:128. Davidson JR, et al.
The efficacy and tolerability of tiagabine in adult patients with post-traumatic stress disorder. J Clin Psychopharmacol 2007; 27:85. Tucker P, et al. Efficacy and safety
of topiramate monotherapy in civilian posttraumatic stress disorder: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry 2007; 68:201. Lindley SE,
Carlson EB, Hill K. A randomized, double-blind, placebo-controlled trial of augmentation topiramate for chronic combat-related posttraumatic stress disorder. J Clin
Psychopharmacol 2007; 27:677.
Possible Causes of Treatment Resistance
▪ Inadequate dosage
▪ Side effects
▪ Poor compliance
▪ Adverse life events
▪ Ongoing or re-traumatization
▪ Loss of social support
▪ Drug interactions
Jackson C, et al. Treatment for complex PTSD. In: Sookman D, Leahy RL, eds. Treatment resistant anxiety disorders. New York, NY:
Taylor & Francis Group;2010.
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VA/DoD PTSD Treatment Guidelines
Pharmacotherapy Interventions for Treatment of PTSD: Balance of Benefit and Harm
SR (Strength of Recommendation Rating)
A(Strong Recommendation)
B (Fair Evidence)
C(No Recommendation)
D(Ineffective or Harmful)
I(Insufficient Evidence)
Significant Benefit
• SSRIs–Fluoxetine
Sertraline
Paroxetine
• SNRI–Venlafaxine
Some Benefit
• Mirtazapine
• Prazosin
(Use For sleep/
nightmares)
• TCAs
• Nefazodone
[Use caution]
• MAOIs
(Phenelzine –
attention to drug-
drug and dietary
interactions)
Some Benefit
• Citalopram
Unknown
• Prazosin
(For global PTSD)
No Benefit
Benzodiazepines
(Harm)
Tiagabine
Guanfacine
Valproate
Topiramate
Risperidone
Unknown
• Olanzapine and
Quetiapine
• Conventional
antipsychotics
• Buspirone
• Non-Benzodiazepine
sedative/hypnotics
• Bupropion
• Trazodone (Adjunctive)
• Gabapentin
• Lamotrigine
• Propranolol
• Clonidine
Dept Veteran Affairs. VA/DoD Clinical Practice Guidelines. http://www.healthquality.va.gov/post_traumatic_stress_disorder_ptsd.asp Accessed February 4, 2020.
“And Finally, I Want You to Know...”
▪ The condition from which you suffer has a name -- PTSD -- and it is as
real as any other injury
▪ It has a biological basis, and is not something about which you should
be ashamed
▪ You were not born with it, nor did you bring it on yourself
▪ You cannot -- think it, self-talk it, or pray it away
▪ But you can recover from it by getting a realistic understanding of what it
is, and by participating fully in valid and effective treatment
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