1. Post-Traumatic Stress Disorder (PTSD) A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for the Students of Ohio University Heritage College of Osteopathic Medicine Kendall L. Stewart, MD, MBA, DFAPA November 29, 2011

2. Why is this important? Terrible things happen. People cope with these things in different ways. When exposed to trauma, some people 1,2 will develop Posttraumatic Stress Disorder, a potentially disabling affliction involving feelings of helplessness, fear and dread that result in avoidance and isolation. Posttraumatic Stress Disorder The lifetime prevalence in the general population is 1 to 3- percent. It can occur at any age, but it is more common in adults. Full recovery is the rule for acute PTSD, but chronic PTSD is much more difficult to treat. After mastering the information in this presentation, you will be able to –Describe how patients with Panic Disorder often present, –Detail the diagnostic criteria, –Describe some of the associated features, –List some differential diagnoses, –Write a preliminary treatment plan, and –Identify some of the frequent treatment challenges. 1 People vary greatly in their reactions to trauma. A woman struck while sleeping in a car developed full-blown PTSD. 2 A mother lost two sons to drunk drivers and moved on.

3. How might a patient with PTSD present? This is a truck driver with a 21- year history of accident-free driving. “Four years ago I was involved in an accident.” “The other truck driver was trapped and burned to death” “I tried to get him out but I couldn’t.” “I started having nightmares right away.”nightmares “I was afraid to go to sleep and I didn’t want to talk about what happened.” “My family says I have been irritable and detached ever since.” “When I was released to return to work, I couldn’t bring myself to drive again.” “I tried counseling but it didn’t help.” “I took medication but it just made my sleepy.” “I mostly just stay at home.” “I don’t drive and I don’t get into a car if I can’t help it.” “It still upsets me to watch accidents on TV.” “This has ruined my life.” 1,2 1 Some of these patients become negative, bitter and difficult. Know when to say “no” to difficult patients. 2 A patient threatened to sue me, but I helped his lawyer with a crazy neighbor.

4. What are the diagnostic criteria for PTSD? The person has been exposed to a traumatic event in which both of the following were present: –The person experienced, witnessed or was confronted with an event that involved actual or threatened death, serious injury or loss of physical integrity of self or others –The person’s response involved intense fear, helplessness 1,2,3 or horror. The traumatic event is persistently re-experienced in one (or more) of the following ways: –Recurrent and inclusive recollections –Recurrent distressing dreams –Acting or feeling as if the traumatic event were reoccurring –Intense psychological distress at exposure to internal or external cues –Physiological reactivity to exposure to cues 1 Pay careful attention when any complainer insists that the problem is always someone’s else’s fault. 2 A physician was sure that I was refusing to let people work with him in surgery. 3 Understand the concept of “locus of control.” Slide 1 of 2

5. What are the diagnostic criteria for PTSD? Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by three or more of the following: –Efforts to avoid thoughts, feelings or conversations about the trauma –Efforts to avoid activities, places or people that trigger recollections of the trauma –Markedly diminished interest or participation in significant activities –Feeling of detachment or estrangement from others –Restricted range of affect –Sense of foreshortened future Persistent symptoms of increased arousal (since the trauma) as indicated by two (or more) –Difficulty falling or staying asleep –Irritability or outbursts of anger –Difficulty concentrating –Hypervigilance –Exaggerated startle response Duration of more than one month 1,2,3 Clinically significant distress or impairment You can listen to a patient’s story here. here 1 Acute=duration < one month 2 Chronic=duration> three months 3 With Delayed Onset=symptoms begin > six months after the trauma Slide 2 of 2

6. What associated features might you see? “Survival guilt” is not uncommon.Survival guilt Avoidance behaviors may trigger work problems, marital problems or other interpersonal problems. Auditory hallucinations and paranoia can be present. The following constellation of symptoms is more common following child physical or sexual abuse or domestic battering: –Impaired affect modulation 1affect –Self-destructive and impulsive behavior –Dissociative symptomsDissociative –Somatic complaints –Feelings of ineffectiveness, shame, despair or hopelessness –And so on PTSD is associated with increased rates of psychiatric comorbid conditions. Increased autonomic functioning may be found. 2,3 Physical injuries may be present. 1 “Splitting” normally occurs in early childhood, but persists in Borderline Personality Disorder. 2 I was amazed at the level of arousal during the prison riot. 3 The calm medical student I left behind diagnosed a heart attack clinically.

7. What other diagnoses might you include in the differential diagnosis? 1 I once treated a man who engaged in “burn parties” with his friends. He even burned his penis. Normal anxiety –Discomfort following a stressor that is not extreme (spouse leaving, being fired) –Adjustment disorder (not coded as a mental disorder but sufferers make seek treatment)Adjustment disorder Other anxiety disorders –Comorbid and preexisting disorders should be considered. Anxiety secondary to a general medical condition –Comorbid and preexisting disorders should be considered. Substance-induced anxiety –Substance abuse often complicates the picture. 1Substance abuse Anxiety secondary to other psychiatric disorders –Any of them might be present.

8. What might a typical treatment plan look like? Acute anxiety –Provide reassurance. –Provide support. –Avoid sedation. –Discourage adoption of the patient role. –Arrange for graduated reexposure. 1graduated reexposure. 1 Chronic anxiety –Real or fantasy graduated exposure in safe environment may be helpful. –(It may also be overwhelming.) –Antidepressant medications should be considered. –Prescribe benzodiazepines routinely with great caution. –Beta-blockers may be helpful with tremor.Beta-blockers –Unstructured psychotherapy is only temporarily helpful. Generalized anxiety –Consider buspirone 15 mg twice per day.buspirone Other comorbid disorders –Diagnose and treat these conditions vigorously. Maladaptive attitudes and behaviors –Consider cognitive behavioral psychotherapy (CBT)cognitive behavioral psychotherapy (CBT) –Set and pursue incremental, realistic goals. 2 Education and self help –Provide educational resources. –Recommend a daily exercise regimen. –Recommend a healthy diet. –Suggest healthy distractions. 3 –Recommend meditation. –Recommend online resources with caution. –Recommend self help groups with caution. 1 Graduated exposure to traumatic environment can be very helpful. 2 Your patients’—and your own—lack of motivation will drive you nuts. Remember whose life it is, anyway. 3 It does not help to shame, preach or nag. I relearned that with my sons.

9. What are some of the treatment challenges you can expect? These patients are often sullen, resistant and noncompliant. They are often suspicious and unable to build and sustain a therapeutic relationship. The trauma may become the organizing principle of their lives. 1 They often complain that the medicine the physician has prescribed is ineffective, but they are unwilling to taper it. 2 They are often miserable and they make those around them miserable. Persuading them to adopt healthy distractions is one of the most helpful strategies. These people tolerate confrontation very poorly. 3confrontation 1 Mothers who have lost children may become bitter, lifelong activists who are more annoying than effective. 2 Taking the same approach you take with chronic pain patients is sometimes helpful. 3 A patient once told me that my role was to listen and accept, never to challenge or confront.

10. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

11. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

12. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

13.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Justin Greenlee, DO OUCOM 2004 Jeffrey Hill, DO OUCOM 1987