Post-Traumatic Stress Disorder

Presentation by: Eric Nielsen 2012 PharmD Candidate Preceptor: Andrea Mason, PharmD Presented on Friday March 11, 2011

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prevalence. theories of origin ‡ Diagnosis of PTSD: ± Criteria according to DSM-IV ‡ Treatment of PTSD ± Cognitive-Behavioral therapy ± Medication therapy 2 .Objectives ‡ Introduce Post-Traumatic Stress Disorder: ± Signs/symptoms.

What is PTSD? ‡ Post-Traumatic Stress Disorder is thought to be a poorly-contained recovery from stressful events ‡ PTSD is an anxiety disorder that develops after exposure to real or threatened death. show signs of hyper-arousal. killing. or display avoidance of situations that remind them of previous trauma 3 . or natural disasters. violent encounters. ‡ The PTSD patient will frequently: re-experience the unpleasant emotions associated the traumatic event.

hypervigilant. activities or people who remind patient of the traumatic event ± Inability to remember event.conversations about. thoughts about. losing sleep 4 . now ‡ Avoidance behaviors in PTSD: ± Avoiding . loss of pleasure from normal personal & family activities ‡ Hyperarousal: easily startled. distressing dreams about the event ± Strong feelings that the event is happening again.More about PTSD ‡ Typical of post-traumatic stress syndrome signs: ± Recurrent & intrusive distressing memories of event ± Recurring.

20% of women will develop PTSD ‡ Environmental. genetic factors: no strong correlations ± Causes vs Effects are still debated among researchers 5 .6% ‡ PTSD always associated with traumatic event. ± About 50% men and 60% women experience such events ‡ Among those with traumatic experience: ± About 8% of men.Epidemiology of PTSD ‡ Prevalence in the general population = 3.

in adrenal gland activity ± Including cortisol. high CRF 6 . epinephrine output [theory] ‡ Trends found in PTSD patients include: high proportion of NorEpinephrine to Cortisol. in levels of neurotransmitters (NE).Etiology of PTSD ‡ Physical or emotional trauma (or both): ± Military service. tsunami. foster care. tornado. child abuse ‡ Abnormalities: in brain function. low levels of neuronal DA & NE ± Thought to contribute to altered recovery from stress ± Patients often show low brain-catecholamines.

outburst of anger. low interest ‡ D: Hyperarousal . selective forgetfulness. intense response to reminders ‡ C: Persistent avoidance and numbing of responsiveness ‡ Presence of at least 3/7 avoidance criteria such as avoidance of people. concentrating. excessive vigilance. thoughts.Diagnosis of PTSD ‡ DSM-IV criteria for PTSD (all must be met): ‡ A: Exposure to traumatic event ‡ Risk of serious injury/death AND a response of fear or horror ‡ B: Persistent re-experiencing of traumatic event ‡ Flashbacks. excessive startle response ‡ E: Duration of Symptoms = more than 1 month ‡ F: Significant Impairment of daily living & activities 7 . distressing dreams. places.difficulty sleeping.

with use of antidepressants (SSRIs) where indicated ‡ CBT for post-traumatic stress often includes Exposure Therapy (1st line in US Military and VA) ‡ Mixed evidence for the effectiveness of EMDR: ± Eye Movement Desensitization and Reprocessing 8 .Treatment of PTSD ‡ Current First-line therapy: ± Cognitive Behavioral Therapy (CBT).

± Reduction in startle response. hyper-arousal effects ‡ Anti-convulsive and mood agents ± Evidence for preservation of REM sleep with reduction in frequency/severity of nightmares 9 . Venlafaxine ‡ Pressor agents: Alpha-blocking agents.Pharmacotherapy for PTSD ‡ Selective Serotonin Reuptake Inhibitors ± 1st line med therapy ‡ Mixed-action Antidepressants: ± Lowest drop-out rates = Bupropion.

diazepam.Pharmacotherapy cont d ‡ Some evidence for benefit of B-blocker propranolol. ± Thought to interfere with brain s process of reinforcing (patient s traumatic) memory ‡ Given just before Exposure Therapy ‡ Poor evidence for use of benzodiazepines ± (lorazepam. etc) ‡ Proven risk of BDz dependence. withdrawal symptoms 10 . used during CBT.

HA. others (Rx s for anxiety & depressive disorders) OCD (Rx s for several anxiety & depressive disorders. somnolence. sexual sideFx Nausea. sexual sideFx Nausea. HA. OCD.Treatment: SSRIs Medication citalopram (Celexa) paroxetine (Paxil) fluoxetine (Prozac) fluvoxamine (Luvox) sertraline (Zoloft) Class SSRI FCA Indications MDD (Rx s for several anxiety & depressive disorders. sexual sideFx Nausea. panic (Rx s for anxiety & depressive disorders) MDD. typically) MDD. sexual sideFx Nausea. typically) PTSD. somnolence. somnolence. MDD. panic Dosing 20-60 mg per day 20-50 mg per day 10-80 mg per day 100-250 mg per day 50-200 mg per day Side Effects Nausea. sexual sideFx SSRI SSRI SSRI SSRI 11 . OCD. OCD. HA. somnolence. HA. somnolence. HA.

bulimia (Rx s for refractory PTSD) Hypertension (Rx s common for anxiety & panic disorders) Dosing 37-225mg per day 50-300mg per day 15-45mg at bedtime 15-90mg at bedtime 6-10mg at bedtime Side Effects Nausea. headache Hypotension. panic Depression. nausea. somnolence. dry mouth. dizziness. appetite incr. weight gain Hypotension. HA. SAD. chronic pain (common Rx for mod-severe PTSD) MDD (common Rx for modsevere PTSD) Depression. GAD.Treatment: SSRIs Medication venlafaxine ER (Effexor) Amitryptaline (Elavil) mirtazepine (Remeron) phenelzine (Nardil) prazosin (Minipress) Class SNDRI FCA Indications MDD. dizziness. HA. orthostasis Dry mouth. sexual sideFx Dry mouth. impotence 12 TCA tetracyclic MAOI alphablocker .

recent review of research suggests its use of standard CBT elements may produce most benefits. recognize maladaptive thoughts ‡ PTSD therapy emphasizes gradual exposure to perceived traumatic situation & thoughts (desensitization ‡ EMDR: Eye Movement Desensitization and Reprocessing ‡ Used by VA and Military.Non-drug Therapy ‡ Cognitive-Behavioral Therapy: ± Therapist guides individual to be aware of their thought patterns . versus actual effectiveness of eye-movement elements 13 .

Summary ‡ Post-Traumatic Stress Disorder is. 14 . Correlations between altered stress response and non-typical levels of neuronal NE & DA. ‡ Self-treatment with drugs and alcohol is widespread. ‡ Research to find definitive causes may result in more effective treatments in the future. ‡ Origins and causes of PTSD are not definitively known. as is misdiagnosis and under-treatment by clinicians. and altered levels of cortisol have been noted in patients.

1002/hup. North CS.Peris J. DiPiro R.ufl.Shad MU. PhD.1171/pdf 2. et al: Pharmacotherapy: A Pathophysiologic Approach. Feb 2011 (ePub ahead of publication). University of Florida College of Pharmacy. Pharmacology lecture notes.Joseph T. 7e. http://onlinelibrary. Hum Psychopharmacol Clin Exp.lp. Oct 2009 15 . Talbert GC.wiley. Suris AM. Novel combination strategy to optimize treatment for PTSD.com. Chapter 74: Anxiety Disorders II: Posttraumatic Stress Disorder and ObsessiveCompulsive Disorder 3.References 1.hscl.edu/doi/10.