Post-Traumatic Stress Disorder

Scott Grogan, DO, MBA, FAAFP

MAJ, MC30 Aug 2013

Objectives

• Applied & interpreted screening

• Utilized PTSD diagnostic tool

• Developed comfort with initiation of therapy and care plan

Take Home Points

• “Right tool makes the job easy”

• When in doubt, Anxiety d/o NOS

• SSRIs are your friends

Your Responses

• Limited experience with PTSD

• Diagnosis challenging

• Frustrating because suspect malingering for VA rating

• Overall with PTSD: 100% uncomfy

Results

1. Principles of PTSD management

2. Screening & Dx

3. Prevention after trauma exposure

4. Pharmacotherapy

5. CBT

Case #1

• In small groups…• Read case

• Discuss and answer questions

• Be prepared to share

5 Minutes

Screening

• Who?• OTSG: All soldiers (RESPECT-Mil)

• “Ask and you shall receive!”

• What?• PC-PTSD (VA/DOD)

• 4 questions; 2+ is positive

Diagnosis

• Multiple inventories

• Primary Care: PTSD checklist (PCL)• 19 questions if screen +

PTSD Checklist (PCL)

≥ 1 Re-experiencing (intrusion)

≥ 3 Avoiding

≥ 2 Hyperarousal

• Score “Moderately” or above is +

• Cut points vary; affect sens/spec

Timing Matters

BEWARE of AD!!!

BEWARE of AD!!!

• $$ & stigma at stake; need to be sure

• 50% VA disability rating

• Anxiety d/o NOS• Assess risk, safety net, start treatment

• Then REFER to BH!

BH Diagnosis

• Mississippi Scale for Combat-Related PTSD - 35 questions

• Personality Assessment Inventory• Self-report exam (1 hr) – 344 questions

• Psych interview

Case #1 Revisited

• In small groups…• Read case AGAIN• Discuss and answer questions AGAIN• Be prepared to share AGAIN

5 Minutes

Principles of Therapy

• Support

• Risk assessment

• Support

• CBT

• Support

• Pharmacotherapy

• Support

Establishing Rapport

• Empathetic approach

• Elicit preferences, listen reflectively

• Emphasize autonomy in decisions

• Pros, cons, & barriers to treatment

• Support self-efficacy

Risk Assessment

• TBI?

• Substance abuse?

• Weapons?

• Suicidality/Homocidality?

• Enlist help of family/friends

Evidence-based CBT

• Prolonged exposure therapy (PE)

• Cognitive processing therapy (CPT)

• Eye movement desensitization and reprocessing (EMDR)

• Stress inoculation training (SIT)

Pharmacotherapy

• SSRIs most studied• Sertraline & paroxitine: FDA indications

• Helps all three symptom clusters

• DO NOT WAIT FOR PSYCH DX!!!

Adjunctive Therapies

• Trazodone

• Prazosin

• Clonidine

• Imagery Rehearsal Therapy• Reprogramming dreams

Expectation Management

• Many get better with support

• Frequent follow up

• 12 weeks for full med effect• Follow PCL scores

• Drop of ≥ 5 is adequate

• <11 considered remission

Case #2

• In small groups…• Read case

• Discuss & answer questions, role play

• Be prepared to share

10 Minutes

My Challenge

• Ask screening questions for BH disorders in clinic• “Ask and you shall receive!”

• When precepting, ask about screening

Objectives

• Applied & interpreted screening

• Utilized PTSD diagnostic tool

• Developed comfort with initiation of therapy and care plan

Take Home Points

• “Right tool makes the job easy”

• When in doubt, Anxiety d/o NOS

• SSRIs are your friends