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
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