Post-Traumatic Stress Disorder Scott Grogan, DO, MBA, FAAFP MAJ, MC 30 Aug 2013

Objectives Applied & interpreted screening Applied & interpreted screening Utilized PTSD diagnostic tool Utilized PTSD diagnostic tool Developed comfort with initiation of therapy and care plan Developed comfort with initiation of therapy and care plan

Take Home Points “Right tool makes the job easy” “Right tool makes the job easy” When in doubt, Anxiety d/o NOS When in doubt, Anxiety d/o NOS SSRIs are your friends SSRIs are your friends

Your Responses Limited experience with PTSD Limited experience with PTSD Diagnosis challenging Diagnosis challenging Frustrating because suspect malingering for VA rating Frustrating because suspect malingering for VA rating Overall with PTSD: 100% uncomfy 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… In small groups… Read case Read case Discuss and answer questions Discuss and answer questions Be prepared to share Be prepared to share 5 Minutes

Screening Who? Who? OTSG: All soldiers (RESPECT-Mil) OTSG: All soldiers (RESPECT-Mil) “Ask and you shall receive!” “Ask and you shall receive!” What? What? PC-PTSD (VA/DOD) PC-PTSD (VA/DOD) 4 questions; 2+ is positive 4 questions; 2+ is positive

Diagnosis Multiple inventories Multiple inventories Primary Care: PTSD checklist (PCL) Primary Care: PTSD checklist (PCL) 19 questions if screen + 19 questions if screen +

PTSD Checklist (PCL) ≥ 1 Re-experiencing (intrusion) ≥ 3 Avoiding ≥ 2 Hyperarousal Score “Moderately” or above is + Score “Moderately” or above is + Cut points vary; affect sens/spec Cut points vary; affect sens/spec

Timing Matters

BEWARE of AD!!!

$$ & stigma at stake; need to be sure $$ & stigma at stake; need to be sure 50% VA disability rating 50% VA disability rating Anxiety d/o NOS Anxiety d/o NOS Assess risk, safety net, start treatment Assess risk, safety net, start treatment Then REFER to BH! Then REFER to BH!

BH Diagnosis Mississippi Scale for Combat-Related PTSD - 35 questions Mississippi Scale for Combat-Related PTSD - 35 questions Personality Assessment Inventory Personality Assessment Inventory Self-report exam (1 hr) – 344 questions Self-report exam (1 hr) – 344 questions Psych interview Psych interview

Case #1 Revisited In small groups… In small groups… Read case AGAIN Read case AGAIN Discuss and answer questions AGAIN Discuss and answer questions AGAIN Be prepared to share AGAIN Be prepared to share AGAIN 5 Minutes

Principles of Therapy Support Support Risk assessment Risk assessment Support Support CBT CBT Support Support Pharmacotherapy Pharmacotherapy Support Support

Establishing Rapport Empathetic approach Empathetic approach Elicit preferences, listen reflectively Elicit preferences, listen reflectively Emphasize autonomy in decisions Emphasize autonomy in decisions Pros, cons, & barriers to treatment Pros, cons, & barriers to treatment Support self-efficacy Support self-efficacy

Risk Assessment TBI? TBI? Substance abuse? Substance abuse? Weapons? Weapons? Suicidality/Homocidality? Suicidality/Homocidality? Enlist help of family/friends Enlist help of family/friends

Evidence-based CBT Prolonged exposure therapy (PE) Prolonged exposure therapy (PE) Cognitive processing therapy (CPT) Cognitive processing therapy (CPT) Eye movement desensitization and reprocessing (EMDR) Eye movement desensitization and reprocessing (EMDR) Stress inoculation training (SIT) Stress inoculation training (SIT)

Pharmacotherapy SSRIs most studied SSRIs most studied Sertraline & paroxitine: FDA indications Sertraline & paroxitine: FDA indications Helps all three symptom clusters Helps all three symptom clusters DO NOT WAIT FOR PSYCH DX!!! DO NOT WAIT FOR PSYCH DX!!!

Adjunctive Therapies Trazodone Trazodone Prazosin Prazosin Clonidine Clonidine Imagery Rehearsal Therapy Imagery Rehearsal Therapy Reprogramming dreams Reprogramming dreams

Expectation Management Many get better with support Many get better with support Frequent follow up Frequent follow up 12 weeks for full med effect 12 weeks for full med effect Follow PCL scores Follow PCL scores Drop of ≥ 5 is adequate Drop of ≥ 5 is adequate <11 considered remission <11 considered remission

Case #2 In small groups… In small groups… Read case Read case Discuss & answer questions, role play Discuss & answer questions, role play Be prepared to share Be prepared to share 10 Minutes

My Challenge Ask screening questions for BH disorders in clinic Ask screening questions for BH disorders in clinic “Ask and you shall receive!” “Ask and you shall receive!” When precepting, ask about screening When precepting, ask about screening

Objectives Applied & interpreted screening Applied & interpreted screening Utilized PTSD diagnostic tool Utilized PTSD diagnostic tool Developed comfort with initiation of therapy and care plan Developed comfort with initiation of therapy and care plan

Take Home Points “Right tool makes the job easy” “Right tool makes the job easy” When in doubt, Anxiety d/o NOS When in doubt, Anxiety d/o NOS SSRIs are your friends SSRIs are your friends

Cardinal Sins: Do Not… Ignore it Ignore it Minimize it Minimize it Avoid a risk assessment Avoid a risk assessment Avoid questioning marital abuse/rape Avoid questioning marital abuse/rape ***Husbands, too***