Post-Traumatic Post-Traumatic Stress Disorder Stress Disorder

(PTSD)(PTSD)A Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Diagnostic and Treatment Process

A Presentation for the Students of Ohio University A Presentation for the Students of Ohio University Heritage College of Osteopathic MedicineHeritage College of Osteopathic Medicine

Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPANovember 29, 2011November 29, 2011

Why is this important?

• Terrible things happen.• People cope with these things in

different ways.• When exposed to trauma, some

people1,2 will develop Posttraumatic Stress Disorder, a potentially disabling affliction involving feelings of helplessness, fear and dread that result in avoidance and isolation.

• 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. 2A mother lost two sons to drunk drivers and moved on.

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.”

• “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.

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, helplessness1,2,3 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

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 month1,2,3

• Clinically significant distress or impairment

• You can listen to a patient’s story here.

1 Acute=duration < one month2 Chronic=duration> three months3 With Delayed Onset=symptoms begin > six months after the trauma

Slide 2 of 2

What associated features might you see?

• “Survival guilt” is not uncommon.• 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 modulation1

– Self-destructive and impulsive behavior– Dissociative symptoms– 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.

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)• 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.1

• Anxiety secondary to other psychiatric disorders– Any of them might be present.

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.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.– Unstructured psychotherapy is only

temporarily helpful.• Generalized anxiety

– Consider buspirone 15 mg twice per day.

• Other comorbid disorders– Diagnose and treat these conditions

vigorously.• Maladaptive attitudes and behaviors

– Consider 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.

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.3

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.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008

• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,

January 2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

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.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice 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.

• 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.

• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.

• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.

• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

How can you contact me?1

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center

Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.

1805 27th Street1805 27th StreetWaller BuildingWaller Building

Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662

740.356.8153740.356.8153

StewartK@somc.org StewartK@somc.org KendallLStewartMD@yahoo.comKendallLStewartMD@yahoo.com

www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com

1Speaking and consultation fees benefit the SOMC Endowment Fund.

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Are there other questions?

Justin Greenlee, DOJustin Greenlee, DOOUCOM 2004OUCOM 2004

Jeffrey Hill, DOJeffrey Hill, DOOUCOM 1987OUCOM 1987