TREATING TRAUMA IN PRIMARY CAREIntegrated Approach to Individual and Community health

Objectives

PTSD – Rates and Presentation in Primary Care

Impacts on Health and Health Care

PTSD – Assessment in Primary Care

PTSD – Treatments in Primary Care

PTSD – Treatment Teams

Trauma is not in the event.

It is in the reaction to the event.

Post-Traumatic Stress

DSM5

PTSD

Event

Avoidance

Intrusion

Cog/Mood

Arousal

PTSD – Rates in Primary Care Nearly 70% of adults experience an event that could

be classified as traumatic Over all Rates of PTSD are 8% in America, 5% in men

and 10% in women. Close to 80% of individuals have symptoms post a

traumatic event that decrease over time. In communities with high levels of community

violence, poverty, and other forms of oppression rates are at or above combat levels 25%

34% of adolescent survivors of MVA, 48% in survivors of rape, 67% prisonors of war, 64% ICU PTs (wide rage), 15% post cartic event, 11% of all MVA.

35%-50% of Chronic Pain Patients

Comorbid Health Conditions

Heart Disease Autoimmune Disease Hyperlipidemea Interstitial Cystitis Dementia Fibromyalgia/Chronic

fatigue Chronic Pain

PTSD

Stress

Health

PTSD Comorbid Mental Health

Major Depression (35% - 50%)

Substance Abuse (21%-43% PTSD+SUD)

Generalized Anxiety

Bipolar Disorder

Borderline Personality

Resiliency Factors

Family closeness/Positive Family Relationships

School attachment Neighbor support when

parental support and monitoring were low.

Peer support/Social support Emotional regulation

skills/Amount of positive emotions.

Religiosity Achievement/Self-regard Spirituality Inner-directed locus of

control Thought-control/

cognitive strategies. Mobilization after a

threat.

PTSD is endemic but so is resiliency – 60% of people in the US have an event that could be traumatic 8-10% of individuals display symptoms of PTSD.

Allostatic Load…

Bruce McEwen, PhD Stress Researcher

Stress response is meant to be short-term and then return to homeostatic range.

Short-term Stress is beneficial to the body and mind.Long-term Stress reduces the bodies efficacy.

Trauma In The Brain and BodyHyperactivation

1. Hyperactive insula (Body Information)

2. Under-activated anterior cingulate cortex (ACC). (Regulation)

3. Under-activation medial prefrontal cortex (mPFC). (Regulation)

Dr. Lanius fMRI Study

Hypoactivation

1. Down regulation of physical sensations from the insula cortex.

2. Hyperactivation activation in the anterior cigulet cortex (ACC).

3. Hyperactivation in the medial prefrontal cortex mPFC.

Dr. Lanius fMRI Study

Y

Assessment – PC PTSD

Brief Screeni

ng

Changes

Lives

DREAMS: A Mnemonic for Screening Patients for Post-traumatic Stress Disorder

(D)etachment (R)e-experiencing the event (E)vent had emotional effects (A)voidance (M)onth in duration (S)ympathetic hyperactivity or

hypervigilance

Assess Comorbidities

PHQ9 – Assess Depression

Symptoms

GAD7 – Assess Generalized

Anx

MDQ – Assess Bipolar

SBIRT – Assess SUD (Sub Use

Diss)

Recognize the Clinical Presentation

• Isolation • Loss of

relationships• Homelessness

• Irritability• Avoidance• Non-

Compliance

• Depression• Substance

Abuse• Anxiety

• Chronic Pain/Migraines

• Multiple Complaints

• Obesity

Physical Mental

SocialBehavioral

Normal defensive responses to high threat can impact treatment and treatment adherence.

Normal Defensive Responses to High Threat

FightFligh

tFreez

e

• Irritability• Loss of

Temper• Defensivenes

s • Avoidance• Anxiety• Fear• Numbing• Detachment• Giving Up

Easily

Treatment Frame

Educate About PTSD 1. Inform, 2. Normalize, 3. Join

Treatment Options: 1. CBT, 2. EMDR 3. Pharm – PTSD, 4. Pharm - SymptDevelop Common Goals

(Rapport): 1. Identify Needs, 2. Target Sympt. (e.g. insomnia, dreams, mood)Develop Treatment Team

and Ref: 1. Beh Health, 2. Providers, 3. Pain Tx, 4. Specialty Mental Health, 5. Psychiatry, 6. Social Work

Relational Tools that Create Safety

• Creating Social Bonds: Social bonds increase the impact of the doctor/patient relationship.

STEPS: 1. Create Safety (eye contact – upper face working) 2. Approach Proximity (physical/ emotional closeness)3. Establish Contact (physical/ emotional contact)

• Self-Empowerment: Uses positive emotions to build on existing patient strengths.

How: Identify successful coping, positive support, nurturing self care,and current strengths. This helps you get more mileage and impact when teaching new information.

Map for safe containment in clinical contact

To establishsafety:

Orient: Direct

attention outward

through the senses

Joining / Resource

Stressful Content

Joining / Resource

Orient: Direct

attention outward

through the senses

Treatment Process Overview

Psychopharmacological Treatment of PTSD

The only two FDA approved medications for the treatment of PTSD are sertraline (Zoloft) and paroxetine (Paxil).

There is also strong evidence for: SSRI fluoxetine (Prozac), SNRI venlafaxine (Effexor) which are considered first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD.

Other Antidepressants: There have been smaller RCTs with mirtazapine as well as open trials.

(Mirtazapine may be particularly helpful for treatment of insomnia in PTSD).

Trazodone is also commonly used for insomnia in PTSD even though there is little empirical evidence available for its use.

Nefazodone (serazone) Is still available in a generic form but carries a black box warning regarding liver failure.

Depression is one of the major comorbidities (above medications are effective in comorbid depression). Bupropion is useful in treating comorbid MDD (not PTSD)

Psychopharmacological Treatment of PTSD

Mood stabilizers These medications, also known as anticonvulsants or anti-epileptic drugs, either block glutamate or potentiate GABA or do both.

Topiramate has demonstrated promising results in randomized controlled trials with civilians and Veterans with PTSD.

Despite some promising open label studies, other RCTs have been negative for this group of medications in treating PTSD

Psychopharmacological Treatment of PTSD

Small single-site studies suggested that atypical antipsychotic agents were effective adjunctive treatment for PTSD patients who had poor responses to first-line SSRIs or SNRIs

A recent large-scale multi-site trial of risperidone as an adjunctive agent for SSRI poor/partial responders showed that there was no benefit (in comparison with a placebo group).

VA/DoD PTSD Clinical Practice Guideline has been revised as follows: Atypical antipsychotics are not recommended as mono-therapy for PTSD. Risperidone (Risperdal) is contraindicated for use as an adjunctive agent

- potential harm (side effects) exceeds benefits. There is insufficient evidence to recommend any other atypical

antipsychotic as an adjunctive agent for PTSD.

Psychopharmacological Treatment of PTSD

Prazosin has been found to be effective in RCTs in decreasing nightmares in PTSD. It blocks the noradrenergic stimulation of the alpha 1 receptor. Its effectiveness for PTSD symptoms other than nightmares has not been determined at this time.

The tricyclic antidepressants and MAOIs act on a number of neurotransmitters. While there are RCTs supporting their use, these medications are not used as first line agents due to their safety and side effect profiles

The tricyclics have quinidine like effects on the heart and can cause ventricular arrhythmias especially in overdose.

The MAOI phenezine has been shown to be effective in PTSD. Careful management of the MAOIs and strict dietary controls are important because they can cause potentially fatal reaction.

Psychopharmacological Treatment of PTSD

Buspirone is sometimes used adjunctively in treatment of hyperarousal symptoms.

Beta blockers also have been used to treat hyperarousal. Beta blockers block the effects of adrenalin (epinephrine) on organs such as the heart, sweat glands, and muscles. The evidence is not definitive at this time. It is thought to re-wire the memories with out fight/flight response. This is a neuroplastic based treatment.

Benzodiazepines act directly on the GABA system which produces a calming effect on the nervous system. This is the only potentially addictive group of medications discussed. Studies have not shown them to be useful in PTSD treatment as they do not work on the core PTSD symptoms. Also these medications are addictive.

Questions???

Thank You!