Provider News Summer 2015 - PTSD

Post Traumatic Stress Disorder

By Shepard Greene, MD, Chief Psychiatrist, Shasta County HHSA

About 8% of the US population will develop symptoms of Post Traumatic Stress Disorder (PTSD) at some point in their lives —usually as the result of a traumatic event, such as combat, a natural disaster, accident or physical or sexual assault. Primary care settings tend to be the principal point of contact for patients with PTSD, although such patients rarely identify themselves as suffering from the disorder.

What is PTSD?

PTSD symptoms can be grouped into three categories:

Avoidance/Negative alterations in cognitions and mood/Arousal and reactivity

  • Staying away from places, events, or objects that are reminders of the experience
  • Feeling emotionally numb
  • Feeling strong guilt, depression, or worry
  • Losing interest in activities that were enjoyable in the past
  • Having trouble remembering the dangerous event
  • Acting or feeling as if the traumatic event were recurring. This could include hallucinations and dissociative flashback episodes often misdiagnosed as schizophrenia or bipolar disorder
  • Being easily startled
  • Feeling tense or "on edge"
  • Having difficulty sleeping, and/or having angry outbursts

Primary care screen for PTSD

The PC-PTSD is a four-item screen designed for use in primary care and other medical settings, and is used to screen for PTSD in veterans at the VA. If a patient answers "yes" to any three items, those screening positive should then be assessed with a structured interview for PTSD by referring to a mental health consultant.

Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

  • Have had nightmares about it or thought about it when you did not want to?
  • Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
  • Were constantly on guard, watchful, or easily startled?
  • Felt numb or detached from others, activities or your surroundings?

PTSD differential and the brain

Although the core symptoms of PTSD differ from the core symptoms of major depression or other anxiety disorders, there is a great deal of overlap. Overlapping symptoms include problems with sleep, concentration, arousal and dysphoria. PTSD is also commonly comorbid with other conditions that include depression, panic disorder, obsessive-compulsive disorder, substance abuse disorders and many characterological disorders.

Thus, a psychopharmacological symptom-based strategy is most useful as the brain is not organized according to ICD/DSM codification. The biological disturbances in PTSD can be conceptualized as a dysregulation of the hypothalamic pituitary adrenal (HPA) axis and the balance between excitatory and inhibitory brain neurocircuitry circuitry within many different areas. The amygdala plays a central role in the fear response. Researchers have found differences between patients with PTSD and those without in both brain structures and brain circuits that process threatening input. The fear circuitry becomes hypersensitive in PTSD and is no longer integrated well with the executive planning and judgment centers in the prefrontal cortex. Even minor stresses may then trigger the "fight or flight" response, which leads to increased heart rate, sweating, rapid breathing, tremors, and other symptoms of hyperarousal in patients with PTSD.

An understanding of hypothetically malfunctioning brain circuits that are regulated by specific neurotransmitters is often useful in selecting a pharmacological treatment strategy. A conceptual understanding of these circuits can guide individual pharmacological treatment choices based upon the patient’s complaints, symptoms and presentation.

Psychotherapy

If PTSD is thought to be present, refer to a mental health professional for psychotherapy, which can be clinically effective in treating PTSD.

Medication choices

The FDA has only approved two medications for the treatment of PTSD: sertraline and paroxetine. The strongest empirical evidence for reducing PTSD symptoms are SSRIs, the preferred initial class of medications used in PTSD treatment. While not FDA approved, another first-line pharmacological option is the use of SNRIs, such as venlafaxine XR, desvenlafaxine or duloxetine. Exceptions may occur for patients based upon their histories of side effects, response, comorbidities and personal preferences. Second-line agents can include tricyclic antidepressants, benzodiazepines and alpha 2 delta ligands (gabapentin, pregabalin). Third-line agents include mirtazapine, alpha 1 antagonist such as prazosin (appears favorable for diminishing nightmares), beta blockers (pre-emptive, as strong evidence exists that the use of a beta blocker immediately subsequent to trauma exposure may prevent the onset of PTSD), and atypical antipsychotics (eg, quetiapine XR).

Reference: Stahl’s Essential Psychopharmacology, Neuroscientific Basis and Practical Applications, fourth edition, by Steven Stahl, M.D.