What every primary care provider should know to diagnose and treat PTSD under the new DSM5.

1. REVIEW OF POSTTRAUMATIC
STRESS DISORDER
DAVID EISENMAN, MD MSHS
UCLA SCHOOL OF MEDICINE
GRAND ROUNDS
PROVIDENCE HOLY CROSS
MEDICAL CENTER
SEPTEMBER 17, 2013

2. What percent of adults in the US patients have
experienced serious traumatic events?

3. % OF US ADULTS WITH AT LEAST ONE DSM3
TRAUMATIC EVENT IN THEIR LIFE
A.
10%
B.
25%
C.
35%
D.
45%
E.
55%
Kessler 2005 Arch Gen Psych

4. IF YOU GUESSED
E. 55%

5. YOU’RE RIGHT!

6. CONDITIONAL RISK IN MEN
61% have
trauma
8% develop PTSD

7. CONDITIONAL RISK IN WOMEN
20% develop PTSD
51% have
trauma

8. CONDITIONAL RISK OF PTSD (GIVEN A QUALIFYING
TRAUMATIC EVENT)
• Overall, 20% of exposed women and 8% of exposed
men develop PTSD, but
• Rape = 40-65%
• Combat = 35%
• Violent Assault = 20%
• Sudden death of a loved one = 14%
• Witnessing a traumatic event = 7%

9. PTSD PREVALENCE IN THE U.S.
Women (%)
Population lifetime prevalence
Men (%)
10-14
5-6
Primary care prevalence
6-15
Current or recent PTSD (12mos)
3-5%
Breslau et al., 1991, 2002; Resnick et al., 1993; Kessler
et al., 1995, NVVRS, Norris 2013

10. EPIDEMIOLOGY TAKE HOMES….
• Exposure to potentially traumatic events is exceedingly
common
• Only a fraction of people exposed to a trauma develop
PTSD
• PTSD is a civilian disease
• Non-assaultive trauma is a common and real stressor in
the genesis of PTSD

11. PTSD CHANGES IN DSM 5
• Stressor criteria includes sexual assault and recurring
exposures to details
• Intense fear, helplessness or horror deleted
• 4 clusters instead of 3

12. DSM 5 POSTTRAUMATIC STRESS DISORDER
•
•
•
•
•
•
•
Stressor criterion
Intrusion symptoms
Hyperarousal symptoms
Avoidance
Cognition & mood
Duration criterion
Clinically significant impairment/distress
American Psychiatric Association (2013). Diagnostic and
Statistical Manual of Mental Disorders, 5th ed.

13. PTSD: STRESSOR CRITERION
• The person witnessed, experienced, or learned about a
traumatic event or events that involved actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others

14. PTSD CRITERION: INTRUSION SYMPTOMS
• Trauma is persistently experienced in the following
ways (needs only 1):
• Recurrent, involuntary, intrusive memories
• Traumatic nightmares
• Flashbacks
• Intense distress after reminders
• Physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect
of the traumatic event

15. PTSD CRITERION: AVOIDANCE SYMPTOMS
Persistent avoidance of stimuli associated with
the trauma (needs only 1):
Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
Efforts to avoid activities, places, or people that arouse
recollections of the trauma

16. PTSD CRITERION: NEGATIVE ALTERATIONS IN
COGNITIONS AND MOOD (NEEDS 2)
• Unable to recall key features of trauma (not due to head
injury, alcohol or drugs)
• Negative beliefs about oneself or world
(distorted/persistent)
• Blame of self or others
• Negative trauma related emotions (anger, shame)
• Diminished interest in activities
• Alienated from others
• Constricted affect

17. PTSD CRITERION: HYPERAROUSAL SYMPTOMS
Increased arousal (needs 2):
1. Sleep disturbance
2. Irritability or aggressive behavior
3. Self-destructive/reckless behavior
4. Difficulty concentrating
5. Exaggerated startle response
6. Exaggerated startle response

18. PTSD: ADDITIONAL CRITERIA
• Duration of the disturbance is more than one month.
• The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.

19. PHYSICAL EXAM
• Evaluate possible medical sequelae of the trauma
• 10-15% of mild TBI develop post-concussive symptoms
(somatic, cognitive, and emotional) that overlap with
PTSD symptoms
• Rule out medical causes of PTSD symptoms
• No medical illnesses can produce all 4 types of PTSD
symptoms simultaneously; Focus the medical H&P on
the dominant PTSD symptom, e.g. sympathetic
hyperactivity

20. LABORATORY STUDIES
• TSH: Consider for all patients. Restlessness, insomnia,
and autonomic hyperactivity are common to both PTSD
and hyperthyroid states.
• T3 and T4 levels have been found to be elevated in
patients with PTSD. TSH levels are unaffected.
• Drug Screen: Consider for all patients. Substancerelated disorders are highly comorbid with PTSD.

21. LABORATORY STUDIES
• CT/MRI of head: Consider for patients with cognitive
deficits.
• Sleep Studies: Consider for patients with sleep symptoms
predating trauma exposure and patients with other
symptoms suggesting a primary sleep disorder (e.g., loud
snoring, excessive daytime sleepiness)

22. PATIENTS WHO HAVE EXPERIENCED A TRAUMA AND
HAVE SUFFICIENT SYMPTOMS ARE LIKELY TO HAVE
PTSD
• Exposure: “have you had any experience that was so frightening or
upsetting that it haunts you still?
• Physical reactions, nightmares, unwanted memories—resembles
acute anxiety
• Avoidance—they try not to think about it or go out of their way to
avoid reminders
• Numb or detached feeling—resembles depression
• Constantly on guard, watchful, startled easily—resembles
“paranoia” to the patient
PIER, ACP Online http://pier.acponline.org/physicians/public/d251/tables/d251-thp.html

23. The most common diagnosis missed is the second
diagnosis.
Sir William Osler

24. COMORBIDITY OF PTSD
• Majority w/PTSD have other diagnoses:~80-90%
• Depression
• Panic attacks and GAD
• Substance abuse (mostly men)
• Physical symptoms (somatization)
Brown et al., Journal of Abnormal Psychology, 2001
Hamner at al., Journal of Nervous and Mental Disease, 2000
Kessler et al., Archives of General Psychiatry, 1995

25. DEPRESSION AND PTSD
• Posttraumatic depression may occur without PTSD
• Depression more likely later in the course of PTSD
• Later in the course the patient may no longer meet criteria for
PTSD but may still have major depression

26. SUBSTANCE ABUSE AND PTSD
• At least 2 possible courses:
• PTSD before the Substance Abuse
• PTSD after the Substance Abuse
• Substance Abuse and PTSD likely to be hospitalized
more than Substance Abuse alone
• In veterans the incidence of concurrent substance
abuse is 60-80%

27. SUICIDE ASSESSMENT
• Particularly important in older adults, males, and
Veterans
Module 1:
Trauma,
PTSD, and
Health-27

28. DIAGNOSIS BULLETS
• Consider head trauma
• Consider the second diagnosis
• Ask about suicidal thoughts

29. IF IT APPEARS THAT A PATIENT DOES HAVE PTSD
•
Let the patient know that your evaluation does not mean that he or she definitely has PTSD,
but that you think further evaluation is needed.
•
Encourage the patient to voice any reservations or concerns he or she might have about
evaluation or treatment. You may be able to facilitate treatment by listening to these
concerns, acknowledging their validity, and addressing some of the patient's questions
about what to expect during mental health evaluation and treatment.
•
Make sure the patient understands that he or she is not crazy.
•
Normalize the idea of treatment. Explain that treatment involves common sense activities
that include learning more about PTSD, finding and practicing ways of coping with traumarelated symptoms and problems, taking steps to improve relationships with family and
friends, and making contact with other patients who experience similar problems.
•
Provide the patient with a written referral to a mental health professional
National Center for PTSD: PTSD Screening and Referral,
http://www.ptsd.va.gov/professional/pages/assessments/assessment.a
sp

30. TREATMENT CHOICES: MEDICATION,
PSYCHOTHERAPY, OR BOTH
• Initial treatment can be either pharmacotherapy or
psychotherapy
• Both approaches are efficacious, and each has
advantages and disadvantages

31. PSYCHOTHERAPIES
• Education and supportive
• Privacy, confidentiality
• Distress from traumas can effect the body, health
and mental health
• Caution before eliciting detailed trauma story
• Assess current safety
• Cognitive Processing Therapy
• Exposure-based treatments
• EMDR (eye movement desensitization reprocessing)

32. Patients with PTSD who are going to be treated with
medication should, with few exceptions, be prescribed
an SSRI or SNRI as their first medication.

33. SSRI AND SNRI
• SSRIs
• Paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac),
and citalopram (Celexa)
• Effective for comorbid depression, anxiety, insomnia,
social phobias
• SNRIs
• Venlafaxine
• May exacerbate hypertension
• Duloxetine

34. SSRI
• Some patients may demonstrate an initial worsening when
starting treatment
• In some cases, this may be due to activating/ anxiogenic
effects of the SSRIs (e.g., insomnia, agitation,
gastrointestinal distress)
• In other instances, it may be related to discussion of the
trauma and uncovering heretofore unaddressed feelings
and thoughts

35. MEDICATION TRIAL
• Start low and go slow: Begin with low doses with gradual dose increases
in the first few weeks, since initial high doses can exacerbate
anxiety/arousal symptoms
• Week 3–4: Increase the dose if excellent response is not achieved
• If only partial response, push to maximal dose tolerated by patient
• E.g., sertraline: 25mg increase to 50mg in 1 week, then up by
25/50mg every 1–2 weeks to maximum 200mg
• E.g., paroxetine: 10–20mg up by 10–20mg every 2 weeks to
maximum 60mg

36. MEDICATION TRIAL
• Continue at maximal dose for 4–6 more weeks for a total of 8–12
weeks
• Treat for a minimum of one year
• If no response, then try another antidepressant
• If partial response, add other medications

37. WHAT TO TELL PATIENTS ABOUT ANTIDEPRESSANTS
• They are not like antibiotics
• They are not addictive
• The response is gradual
• Take the medications daily (don’t double up if you miss a day)
• Keep taking the medications even if you feel better
• Keep track of side effects, and discuss these with health care
providers

38. AVOID BENZODIAZEPINE MONOTHERAPY
• They do not control or eliminate the core features
of PTSD
• They can interfere with the cognitive processing of the trauma necessary for
psychotherapy to be successful
• No demonstrated benefit over placebo for PTSD-related sleep dysfunction
• Can produce dependence in PTSD patients who are prone to addiction
• Withdrawal may exacerbate PTSD symptoms
• Not recommended by VA/DoD Clinical Practice Guideline
Bernardy, N., PTSD Research Quarterly, 2013

39. MANAGING PTSD-RELATED INSOMNIA
• Sleep hygiene: Decrease caffeine, alcohol, etc.
• Antihistamines: Diphenhydramine (25–50mg)
• Antidepressants: Low dose trazodone 50mg to 100mg
after 1 week, up to 200mg
• Alpha-blocker: Prazosin, titrated up from 1–15mg, may
reduce nightmares and insomnia; monitor BP and pulse
• Non-BZD: Zolpidem

40. SIDE EFFECTS AND MANAGEMENT*
Side effect
Probability
Management
Sedation
+/-
Bedtime dosing; caffeine
Anticholinergic
(dry mouth/eyes,
constipation)
+/-
Hydration; sugarless gum;
artificial tears; fiber
GI distress
++
Improves in 1–2 weeks; take
with meals; try antacids or
H2 blockers
*Adapted from RESPECT-Mil Primary Care Clinician’s Manual.

41. SIDE EFFECTS AND MANAGEMENT
Side effect
Probability
Management
Restlessness/
jitters
+
Start low; reduce dose
temporarily; propranolol
10mg b.i.d. or t.i.d.
Headache
+
Lower dose; Tylenol
Sexual
dysfunction
++
Reduce dose; Viagra
Insomnia
+
Take in a.m.; low dose
trazodone; zolpidem

43. MANAGEMENT BULLETS
• SSRIs are the first line treatment
• Start low and go slow
• Combine other medications as needed

44. David Eisenman, MD, MSHS
Director, UCLA Center for Public Health and Disasters
Associate Professor Medicine/Public Health at UCLA
RAND Associate Natural Scientist
Preparedness Science Officer, Los Angeles County
Department of Public Health
deisenman@mednet.ucla.edu

45. PC-PTSD: 4 ITEM SCREENER USED IN PRIMARY CARE
AND AT THE VA
• In your life, have you had any experience that was so frightening,
horrible, or upsetting that in the past month you:
• Had nightmares about it or thought about it when you didn’t
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 or activities or
surroundings?
• “Positive” if answers yes to any three.
Prins, Primary Care Psychiatry, 2003