PTSD: SYMPTOMS, TREATMENTS AND CONSIDERATIONS FOR CLINICIANS GIA SANTORO, APRN, PMHNP-BC

Transcription

1 PTSD: SYMPTOMS, TREATMENTS AND CONSIDERATIONS FOR CLINICIANS GIA SANTORO, APRN, PMHNP-BC

2 DISCLOSURES No conflicts of interest. Will be discussing off-label uses of medications.

3 OBJECTIVES Participants will be able to identify the key diagnostic features of PTSD. Participants will be able to recognize the most common pharmacological treatments for PTSD, including those used off-label, with attention to potential adverse effects, potential interactions and contraindications. Participants will be able to verbalize two types of evidence-based psychotherapy for the treatment of PTSD. Participants will be able to identify at least two ways in which PTSD can interact with medical treatment.

4 PTSD: DIAGNOSTIC FEATURES Changes from DSM-IV-TR to DSM-5 No longer found in Anxiety Disorders section. Found in a new category: Trauma- and Stressor-Related Disorders. Includes disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. Placement of chapter reflects the close relationship between trauma/stressorrelated disorders and disorders in the surrounding chapters anxiety disorders, obsessive-compulsive and related disorders, and dissociative disorders. Four main symptom clusters instead of three.

5 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. PTSD: DIAGNOSTIC FEATURES CRITERION A: TRAUMA EXPOSURE Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: Directly experiencing the traumatic event(s). Witnessing, in person, the event(s) as it occurred to others. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

6 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. PTSD: DIAGNOSTIC FEATURES CRITERION B: RE-EXPERIENCING Presence of one (or more) of the following intrusion symptoms associated with the trauma Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

7 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. PTSD: DIAGNOSTIC FEATURES CRITERION C: AVOIDANCE Persistent avoidance of stimuli associated with the traumatic event(s): One or both of the following: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

8 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. PTSD: DIAGNOSTIC FEATURES CRITERION D: CHANGES IN THOUGHTS AND MOOD New category Negative alterations in cognitions and mood associated with the traumatic event(s). Two or more of the following: Inability to remember an important aspect of the traumatic event(s). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.* Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.* Persistent negative emotional state. Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions *Reflect cognitive-behavioral theory and research on the after-effects of trauma (Cusak et al., 2016; Cox, Resnick, & Kilpatrick, 2014).

9 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. PTSD: DIAGNOSTIC FEATURES CRITERION E: HYPERAROUSAL Marked alterations in arousal and reactivity associated with the traumatic event(s) Two or more of the following: Irritable behavior and angry outbursts. Reckless or self-destructive behavior. Hypervigilance. Exaggerated startle response. Problems with concentration. Sleep disturbance.

10 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. PTSD: DIAGNOSTIC FEATURES ADDITIONAL CRITERIA Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Specify whether: With dissociative symptoms: Depersonalization Derealization With delayed expression

11 PTSD: DIAGNOSTIC FEATURES OTHER NOTABLE CHANGES IN DSM-5 No longer includes that response to trauma is fear, helplessness or horror. Avoidance is only avoidance (no longer includes diminished interest, detachment, sense of foreshortened future. ) Changes in thoughts and mood category reflects more recent research that supports trauma-focused treatment as first-line Reckless or self-destructive behavior is new Dissociative specifiers are new

12 PTSD: TREATMENTS Numerous clinical practice guidelines for the treatment of PTSD: (APA, VA/DoD, UK s NICE, ISTSS, IOM, AACAP, and the Australian NHMRC). Most guidelines identify trauma-focused psychological treatments as preferred or equal to certain medications as first-line treatments. Most guidelines also acknowledge practical considerations/limitations of trauma-focused psychotherapy: Limited availability Patient preferences Drop-out rates APA: American Psychiatric Association VA/DoD: U.S. Department of Veterans Affairs/Department of Defense NICE: National Institute for Health and Clinical Excellence ISTSS: International Society for Traumatic Stress Studies IOM: Institute of Medicine AACAP: American Academy of Child and Adolescent Psychiatry NHMRC: National Health and Medical Research Council Cusak et al., 2016

13 PTSD: TREATMENTS PSYCHOTHERAPY Trauma-focused psychotherapy Cognitive behavioral treatments that involve a range of techniques that attend to the details of the trauma or associated emotions or cognitive processes (Steenkamp et al., 2015). Cognitive Processing Therapy (CPT), Prolonged Exposure (PE) and Eye Movement Desensitization and Reprocessing (EMDR) are the most widely studied. Non-trauma-focused psychotherapy Attend principally to current life stressors, reactions, goals or relationships. Stress inoculation training (SIT) gets high level evidence statements in some PTSD clinical practice guidelines (Steenkamp et al., 2015). Includes tress management skills like breathing, muscle relaxation and applying them to day to day stressors and trauma triggers.

14 PTSD: TREATMENTS PSYCHOTHERAPY: TRAUMA-FOCUSED Cognitive Processing Therapy (CPT), 12 sessions, 60 min average, HOMEWORK Disorder of non-recoveryà what got in the way? Fight/flight/freeze response Judgment for what happens during this response. The response gets paired with other cues. Reactions fade over time if you don t avoid the cues. If you avoid, reinforces fear. Just world belief à self-blame, trouble accepting, changing interpretation of event to fit belief schema, or change beliefs to fit the event so much that it changes your whole outlook. Cognitive restructuring: changing maladaptive beliefs related to the trauma by identifying, challenging and replacing them (Steenkamp et al., 2015). Must allow natural emotions to run course and work on manufactured emotions (i.e. guilt, shame) though cognitive restructuring. Goals: to help accept the reality of the event, to feel emotions about it, and develop balanced and realistic beliefs about the event, self, and others.

15 PTSD: TREATMENTS PSYCHOTHERAPY: TRAUMA-FOCUSED Prolonged Exposure (PE), sessions, 90 min average, HOMEWORK Imaginal exposureà repeatedly recount the trauma to extinguish fear responses associated with the memory (Steenkamp et al., 2015). In vivo exposureà practice facing trauma reminders and triggers in the real world (Steenkamp et al., 2015). Eye Movement Desensitization and Reprocessing (EMDR) Exposure and cognitive restructuring elements. Asks patients to maintain dual focus on an external stimulus while thinking about the trauma. Works to identify bodily sensations associated with an image, identify an aversive cognition associated with the trauma, and identify an alternate positive cognition to replace the aversive cognition (Steenkamp et al., 2015). No homework.

16 PTSD: TREATMENTS PSYCHOTHERAPY: OTHER OPTIONS High level evidence statements in PTSD clinical practice guidelines for stress inoculation training (SIT). Stress management skills like breathing and muscle relaxation applied to day to day stressors and trauma triggers (Steenkamp et al., 2015). Symptom-focused Can be effective at decreasing specific aspects of PTSD. Ex. anger management, CBT for insomnia, anxiety and/or depression, substance abuse treatments, relaxation/ stress management, emotion regulation (DBT). Supportive therapy Research does not support decrease of symptoms, but many find it helpful and meaningful. Complementary therapies Mobilizing strengths, initiative, creativity. Art, music, mindful yoga, adapted sports, transcendental meditation.

17 PTSD: TREATMENTS PHARMACOLOGICAL: ANTIDEPRESSANTS Selective Serotonin Reuptake Inhibitors (SSRIs) Recommended 1 st line agents in several treatment guidelines (Bernardy & Friedman, 2015). FDA approved: sertraline (Zoloft): DOSING à initial 25mg/day, increase to 50mg/day after 1 week, max 200mg/day paroxetine (Paxil): DOSINGà initial 20mg/day, increase by10mg/day, max 60mg/day Also studied: fluoxetine (Prozac), fluvoxamine (Luvox), citalopram (Celexa) Generally well tolerated Common adverse effects: GI upset, sexual dysfunction, black box warning for activation of suicidal ideation and behavior Medication Interactions: tramadol, TCAs, MAOIs (fatal serotonin syndrome), triptans Other considerations when using SSRIs in PTSD: May need longer trial to see efficacy. When sertraline treatment was extended from weeks, remission rates increased from 30-55% (Bernardy & Friedman, 2015; Schoenfeld, Marmar, & Neylan, 2004). Typically must be continued in order to maintain recovery; discontinuation of sertraline and fluoxetine has been associated with relapse (Bernardy & Friedman, 2015).

18 PTSD: TREATMENTS PHARMACOLOGICAL: ANTIDEPRESSANTS Serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine ER (Effexor): DOSINGà Initial 37.5mg/day, increase no faster than 75mg/day every 4 days, max dose 225mg/ day Two large multisite trials showed PTSD symptom improvements using total CAPS scores compared to placebo (one maintained for 12 weeks and one for 6 months (Bernardy & Friedman, 2015). Common adverse effects: GI upset, sexual dysfunction, sweating, dose-dependent increase in BP, black box warning for activation of suicidal ideation and behavior Medication interactions: tramadol, MAOIs, cimetidine Meta-analyses have generally confirmed efficacy of SSRI/SNRIs for PTSD and most clinical practice guidelines recommend these agents as first line treatment options, particularly if no access to psychotherapy or for patients who do not want to engage in trauma-focused psychotherapy (Bernardy & Friedman, 2015). Medication is generally recommended for people with PTSD who have concurrent moderate to severe depression (Bernardy & Friedman, 2015).

19 PTSD: TREATMENTS PHARMACOLOGICAL: ANTIDEPRESSANTS Other antidepressants Mirtazapine (Remeron) 15-45mg Shows promise as for PTSD in patients with comorbid anxiety disorders May be helpful to target insomnia Common adverse effects: weight gain, dry mouth, constipation, sedation, hypotension, black box warning for activation of suicidal ideation and behavior Medication interactions: tramadol, MAOIs Bupropion (Wellbutrin) Has not shown statistically significant improvements in PTSD symptoms (Schoenfeld et al., 2004). May increase anxiety and panic. May be beneficial for sexual dysfunction from SSRIs, smoking cessation, depression, attention/ concentration

20 PTSD: TREATMENTS PHARMACOLOGICAL: ANTIDEPRESSANTS Other antidepressants, continued: Tricyclic antidepressants (TCAs) Amitriptyline, imipramine, and desipramine have all be tested in controlled trials using relatively small samples (Schoenfeld et al., 2004). Modest symptom improvements from imipramine and amitriptyline (Schoenfeld et al., 2004). No improvement with desipramine (Schoenfeld et al., 2004). Adverse effects: blurred vision, dry moth, constipation, sedation, weight gain, cardiac arrhythmias and seizures, especially in overdose, black box warning for suicidality Medication Interactions: anticholinergic agents, tramadol, CYP450 inhibitors, cimetidine Monoamine oxidase inhibitor (MAOI) Phenalzine Use particularly for pts with co-occurring major depressive disorder that does not respond to SSRIs (Bernardy & Friedman, 2015). Have a more complicated side effect profile and require closer monitoring. Dizziness, sedation, headache, sweating, blurred vision, constipation, orthostatic hypotension, hypertensive crisis with tyramine containing foods/drugs, activation of suicidality, seizures, hepatotoxicity, diet restrictions Nefazodone Less sexual dysfunction than SSRIs (Schoenfeld et al., 2004). Hepatotoxicity and liver failure black box warning.

21 PTSD: TREATMENTS PHARMACOLOGICAL: ANTIPSYCHOTICS Risperidone and olanzapine are the only atypical antipsychotics (AAPs) to have RCTs investigating their efficacy as adjunctive treatment for PTSD (Bernardy & Friedman, 2015). Risperidone: 5 RTCs with 3 noting positive effects (on aggression, hyperarousal and re-experiencing) and 2 showing no benefit. Krystal et al. s RCT (N: 247) showed no significant difference in treatment response between risperidone and placebo à change in the VA/DoD treatment guidelines which now recommend against the use of risperidone for SSRI nonresponders (2011). The use of AAPs as adjunctive treatment for PTSD is only recommended for those patients who exhibit psychotic features, or: Severe cases of PTSD with disorganized behavior and marked dissociative symptoms as an adjunct, or: Instances of explosive, aggressive or violent behavior (Schoenfeld et al., 2004). Quetiapine monotherapy trialà decrease in total CAPS score, improvement in depression, sleep (Villarreal et al., 2016) Monitor weight, lipids, hemoglobina1c, risk for akathisia, tardive dyskinesia, EPS, NMS, black box warning for mortality risk in elderly dementia patients.

22 PTSD: TREATMENTS PHARMACOLOGICAL: MOOD STABILIZERS Carbamazepine (Tegretol): several small open clinical trials showed reductions in intrusive traumatic memories and flashbacks and improvements in insomnia, irritability, impulsivity and violent behavior (Schoenfeld, et al., 2004). Valproic Acid (Depakote): 10 of 16 patients showed improvement in arousal and avoidance not intrusion symptoms (Schoenfeld et al., 2004). Topiramate (Topamax): was associated with reductions in PTSD symptoms in an open trial among 35 patients unresponsive to previous pharmacotherapy when administered alone or as adjunctive treatment (Schoenfeld et al., 2004). May be helpful for reducing alcohol consumption/craving and PTSD symptoms in patients with co-morbid alcohol use disorder (Bernardy & Friedman, 2015). Lamotrigine (Lamictal): some improvements in PTSD symptoms in a small sample, not significant (Schoenfeld et al., 2004 ). Lithium: two small open trials showed improvement in the hyperarousal cluster of symptoms; may be helpful for reducing anger and irritability per case studies (Schoenfeld et al., 2004). Gabapentin: In a retrospective review as adjunctive treatment was found to reduce insomnia and nightmares (Schoenfeld et al., 2004). Not considered efficacious as monotherapy, but may be necessary in patients with co-morbid bipolar disorder, or when there is a concern that adding an antidepressant for PTSD symptoms could precipitate a manic episode.

23 PTSD: TREATMENTS PHARMACOLOGICAL: OTHER Alpha adrenergic antagonist: Prazosin (Minipress): DOSINGà initial 1-2mg qhs, increase steadily up to 10-15mg qhs Has proven effective for PTSD-related nightmares In a RCT with military personnel, had positive results on both daytime and sleep-associated PTSD symptoms when administered BID (Raskind et al., 2013). Adverse effects: hypotension, dizziness, lightheadedness, priapism Medication interactions: other antihypertensives Alpha-2 receptor agonists: Clonidine (0.1mg BID-TID)> guanfacine in clinical practice (Belkin & Schwartz, 2015). May he helpful for hyperarousal symptoms. Evidence base for both is still quite limited (Belkin & Schwartz, 2015).

24 PTSD: TREATMENTS PHARMACOLOGICAL: SLEEP Eszopiclone (Lunesta) DOSING: 2-3mg qhs or qhs PRN In a small cohort was shown to significantly improve PTSD measures and sleep over placebo in a 3 week trial (Bernardy & Friedman, 2015; Pollack et al., 2011). Same results have not been shown for zolpidem or other sedative-hypnotics. Trazodone mg qhs or qhs PRN Adverse effects: priapism, sedation hang-over, headache Limited efficacy as monotherapy for PTSD Effective sedating actions; recommended/often used adjunctively with SSRIs to address PTSDrelated sleep disorders (Bernardy & Friendman, 2015).

25 PTSD: TREATMENTS PHARMACOLOGICAL: ANXIOLYTICS Benzodiazepines NO EVIDENCE of efficacy in PTSD Increasing evidence of risks May interfere with the ability to desensitize fear responses to trauma cues: By altering optimal levels of working anxiety necessary for desensitization By interfering with cognitive processing (Bernardy & Friedman, 2015; Schoenfeld et al., 2004). NOT recommended Buspirone (Buspar) Efficacy is not established but can be a useful alternative for anxiety related symptoms (Schoenfeld et al., 2004). Recommend psychotherapy plus pharmacotherapy for co-occurring anxiety disorders (Schoenfeld et al., 2004).

26 PTSD: TREATMENTS SUMMARY Offer trauma focused psychotherapy +/- SSRI (sertraline, paroxetine) or SNRI (venlafaxine). Can try other SSRIs, SNRIs, mirtazapine, if first option ineffective or has adverse effects. For treatment refractory co-occurring depression may try amitriptyline, imipramine, phenalzine, nefazodone with careful consideration of risk/benefit. Benzodiazepines and bupropion do not have evidence for efficacy, and carry risks. For co-occurring anxiety disorders, consider buspirone, CBT for anxiety. Adjunctive risperidone or olanzapine for PTSD with psychotic features or with co-occurring psychotic disorder. Limited evidence for mood stabilizers, but they may be needed with co-occurring bipolar disorder. For PTSD related insomnia, prazosin (for nightmares), Lunesta, trazaodone may be best options.

27 PTSD: THE FUTURE OF HEALTHCARE MEDICAL MARIJUANA? Rapidly changing legal environment surrounding cannabis Still illegal under federal law. 23 states have approved for medical use. Approval of marijuana as a medication is done under state authority by ballot or state legislature approval without approval of the FDA. In Connecticut, one of the indications is PTSD. In states that allow use for PTSD, it is listed as the primary indication in 38.5% of users (Yarnell, 2015). Evidence of efficacy? +/- For sleep, may be helpful in short-term but may interfere with long-term sleep structure (Yarnell, 2015). Cannabis has been shown to have anxiolytic AND anxiogenic properties depending on primary cannabinoid (Yarnell, 2015). Neurobiological and animal studies suggest potential underlying mechanisms consistent with some findings suggesting it may have effect on decreasing PTSD symptoms (Yarnell, 2015). To date, no large scale RCT has shown efficacy (Yarnell, 2015).

28 PTSD: THE FUTURE OF HEALTHCARE MEDICAL MARIJUANA? Evidence of efficacy? (continued) Marijuana use linked with impaired short-term memory, learning difficulties, impaired motor coordination, altered judgment, and, in high doses, paranoia and psychosis (Ragen et al., 2015; Volkow et al., 2016). Longer-term or heavy use linked to elevated risk of: addiction to marijuana as well as other drugs of abuse altered brain development, cognitive impairment, poor educational outcomes, diminished life satisfaction and achievement chronic bronchitis increased risk of motor vehicle accidents increased risk of depression and anxiety as well as psychotic disorders among those predisposed (Ragen et al., 2015; Volkow et al., 2016). Need to use clinical judgement on case by case basis.

29 PTSD: THE FUTURE OF HEALTHCARE Treatment trends: Continued studies of existing medications (i.e. clonidine, guanfacine) Use of medication to enhance psychotherapy ketamine during exposure therapy Secondary prevention Medications used shorty after a significant traumatic exposure to prevent memory consolidation from taking place (Thomas & Stein, 2017). Propranolol Morphine *addictive potential

30 PTSD: THE FUTURE OF HEALTHCARE Treatment trends, continued: Novel Agents: Endocannabinoids CB1 agonists (e.g. nabilone) (Ragen et al., 2015 ) Ketamine: Evidence for rapid reduction in symptom severity (Bernardy & Friedman, 2015) NMDA receptor antagonist Infusions associated with significant and rapid reduction of core PTSD symptom severity and comorbid depressive symptoms. Well tolerated. Long term safety and efficacy to maintain initial response (Thomas & Stein, 2017). Addictive potential Oxytocin Intranasal infusion promising for augmentation of PTSD treatment response during psychotherapy (Thomas & Stein, 2017). Glucocorticoids (e.g. hydrocortisone) Omega-3 PUFAs Neuropeptides-NPY agonist agents in development

31 PTSD: INTERACTIONS WITH MEDICAL TREATMENT A CASE STUDY 56 yo AA male Army veteran, 2x divorced, currently living with female partner in a rented house, 5 children (one under 18 years of age). Cook in the Army and experienced MST by a supervisor (does not remember full account, possibly in part due to intoxication during the event). Was active for 1 year and honorably discharged. 100% SC for PTSD. Psychiatric diagnosis: PTSD, MDD, recurrent, alcohol use disorder. Smokes 1 PPD. History of learning disability with difficulty reading and writing. History of presentations to PER for alcohol intoxication, residential programs for both alcohol use disorder and PTSD, outpatient groups (including Men s MST support group), work therapy programs, medication management. Has never been able to completed trauma focused psychotherapy (avoidance, etc.) but has participated in in vivo exposure when in residential tx.

32 PTSD: INTERACTIONS WITH MEDICAL TREATMENT A CASE STUDY Symptoms: Trauma related nightmares and intrusive thoughts, psychological and physiological reactivity especially on the bus and in crowds ( anxious ) Depressed mood, shame, change in thoughts about himself and others Avoidance of crowds, certain people, trauma reminders, talking about trauma Poor sleep, hypervigilance, irritability, decreased motivation AH of voice behind him; will turn around to see no one is there--no other psychotic symptoms, no history of manic episode No history of drug dependence but of alcohol use disorder with occasional flare ups

33 PTSD: INTERACTIONS WITH MEDICAL TREATMENT A CASE STUDY Medical co-morbidities: Type 2 DM, ED, HLD On metformin 1000mg BID and glipizide 20 BID; adamantly refuses insulin (probably needs it) Has refused colonoscopy, only moderate compliance with medical medications (also include atorvastatin, sildenafil) Psychiatric medications: bupropion 100mg BID (for depression) sertraline 150mg daily (for PTSD) trazodone 50mg qhs (for insomnia) PSA rising in 2015à veteran repeatedly no-showed to scheduled biopsy. Eventually agreed to 6-week residential stay in PTSD program to provide support for getting biopsy and deal with issues related to MST triggered by needing/getting biopsy

34 PTSD: INTERACTIONS WITH MEDICAL TREATMENT A CASE STUDY Feb 2016: Diagnosed with Gleason 7 (3+4) prostate carcinoma s/p biopsy and chose active surveillance, verbalizing understanding of other options (radiation, surgery). Began no-showing 6 month f/u MRI and Artemis biopsy as well as MH appointments. Obtained a service dog in this time period, which was his preferred focus when he did come to see MH. Eventually disclosed in MH appointment that he wasn t willing to do any more procedures d/t triggering of PTSD symptoms, difficulty dealing with bleeding and pain after last biopsy (refuses narcotics), mistrust of providers, fear that procedure will cause cancer to spread, misunderstanding of why they couldn t just take the cancer out when they did the biopsy. Called MD during MH appointment and set up meeting to discuss above.

35 PTSD: INTERACTIONS WITH MEDICAL TREATMENT A CASE STUDY Per MD, if vet chose active surveillance would facilitate an MRI with an rx for lorazepam and for biopsy to be done under sedation. (*more triggering given nature of MST). Given his ethnicity, young age (56), high PSA of 10.73, PSAD of 0.35 and biopsy proven Gleason 7 (3+4) prostate adenocarcinoma other treatment options were discussed. Agreed to radiation, with Eligard injections, set up closer to home given high anxiety. Discussed potential worsening of PTSD sx s with Eligard injections; psych and medical providers working together to monitor veteran, therapy dog as added support.

36 PTSD: INTERACTIONS WITH MEDICAL TREATMENT Reacting to trauma triggers (sedation, nature of biopsy, authority?) Avoidance!!! (no-shows, poor compliance with medications, refusing treatment) Pain (lower pain threshold?, less ability to cope) Substance Abuse (fear of taking narcotics, previous/current alcohol use worsening MH symptoms) Stigma (disclosing PTSD/MST to providers, If my hair fall out others will think I m taking crack. ) Anxiety (contributes to knowledge deficit, avoidance, inability to tolerate procedures, travel) Medication interactions (with psychiatric medications or symptoms)

37 THANK YOU! QUESTIONS?

38 REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Bernardy, N.C., & Friedman, M.J. (2015). Psychopharmacological strategies in the management of posttraumatic stress disorder (PTSD): What have we l earned? Disaster Psychiatry: Trauma, PTSD, and Related Disorders, 17(4), 564. doi: /s Cox, K.S., Resnick, H.H., & Kilpatrick, D.G. (2014). Prevalence and correlates of posttrauma distorted beliefs: Evaluating DSM-5 PTSD expanded cognitive symptoms in a national sample. Journal of Traumatic Stress, 27(3), doi: /jts Cusak, K., Jonas, D.E., Forneris, C.A., Wines, C., Sonis, J., Middleton, J.C., Feltner, C., Brownley, K.A., Olmsted, K.R., Greenblatt, A., Weil, A., & Gaynes, B.N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, doi: /j.cpr Krystal, J.H., Rosenheck. R.A., Cramer, J.A., Vessicchio, J.C., Jones, K.M., Vertrees, J.E., Horney, R. A., Huang, G.D., Stock, C., Veterans Affairs Cooperative Study No. 504 Group. (2011). Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: A randomized trial. JAMA, 306(5), doi: /jama Pollack, M.H., Hoge, E.A., Worthington, J.J., Moshier, S.J., Wechsler, R.S., Brandes, M., & Simon, N.M. (2011). Eszopiclone for the treatment of posttraumatic stress disorder and associated insomnia: A randomized, double-blind, placebo-controlled trial. Journal of Clinical Psychiatry,, 72(7), /JCP.09m05607gry doi: Ragen, B.J., Seidel, J., Chollak, C., Pietrzak, R.H., & Neumeister, A. (2015). Investigational drugs under development for the treatment of PTSD. Expert Opinion on Investigational Drugs, 24(5), doi: /

39 REFERENCES Raskind, M.A., Raskind, M.A., Peterson, K., Williams T., Hoff, D.J., Hart, K., Holmes, H., Homas, D., Hill, J., Daniels, C., Calohan, J., Millard, S.P., Rohde, K., O'Connell, J., Pritzl, D., Feiszli, K., Petrie, E.C., Gross, C., Mayer, C.L., Freed, M.C., Engel, C., & Peskind, E.R. (2013). A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. American Journal of Psychiatry, 170(9), doi: /appi.ajp Schoenfeld, F.B., Marmar, C.R., & Neylan, T.C. (2004). Current Concepts in Pharmacotherapy for Posttraumatic Stress Disorder. Psychiatric Services, 55(5), doi: /appi.ps Steenkamp, M.M., Litz, B.T., Hoge, C.W., & Marmar, C.R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA, 314(5), doi: /jama Thomas, E. & Stein, D.J., (2017). Novel pharmacological treatment strategies for posttraumatic stress disorder. Expert Review of Clinical Pharmacology, 10(2), doi: / Villarreal, G., Hamner, M.B., Canive, J.M., Robert, S., Calais, L..A., Durklaski, V., Zhai, M.S., & Qualls, C. (2016). Efficacy of quetiapine monotherapy in posttraumatic stress disorder: A randomized, placebo-controlled trial. American Journal of Psychiatry, 173(12), doi: /appi.ajp Volkow, N.D., Swanson, J.M., Evins, A.E., DeLisi, L.E., Meier, M.H., Gonzalez, R., Bloomfield, M.A., Curran, H.V., & Baler, R.I. (2016). Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: A Review. JAMA Psychiatry, 73(3), doi: /jamapsychiatry Yarnell, S. (2015). The use of medicinal marijuana for posttraumatic stress disorder: A review of the current literature. The Primary Care Companion for CNS Disorders, 17(3). doi: /pcc.15r01786