Research Update: PTSD

1. Research Update:PTSD Gary H. Wynn, MD, FAPA Associate Professor / Assistant Chair Department of Psychiatry Uniformed Services University of the Health Sciences Bethesda, MD

2. Disclaimer The opinions and statements in this presentation are the responsibility of the author and such opinions and statements do not necessarily represent the policies or opinions of the Uniformed Services University of the Health Sciences, the United States Army, the Department of Defense, the United States or their agencies.

3. Agenda • Background and Current work on PTSD • Epidemiology • Stigma and Barriers to Care • Psychotherapy • Pharmacotherapy • Complementary and Alternative Medicine • Future Directions for Research

4. Epidemiology

5. Community First Responders Loved Ones Individual

6. DSM-IV-TR DSM-V Broadened definition A: Event A: Event Very similar B: Re-experiencing (Intrusion) B: Intrusion (Re-experiencing) Effectively Split in Two C: Avoidance C: Avoidance D: Negative Alterations in Cognitions/Mood Very similar D: Arousal E: Arousal Identical E: Duration F: Duration Identical F: Clinically Significant Distress G: Clinically Significant Distress H: Not attributable to substance/medical

7. DSM-IV-TR DSM-V EVENT A: Exposure to actual or threateneddeath, serious injury, or sexual violence in one (or more) of the following ways: A: The person has been exposedto a traumatic event whichboth of the following were present: A1: experienced, witnessed, or was confronted with events that involved actual or threatened death/serious injury A1: Directly experiencing the traumatic event(s) A2: Witnessing, in person, the event(s) as it occurred to others A2: response involved intense fear, helplessness, or horror A3: Learning that the traumatic event(s) occurred to a close family member or close friend A4: Experiencing repeated or extremeexposure to aversive details of the traumatic event(s)

8. DSM-IV-TR DSM-V C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsivenessas indicated by 3 or more of the following: C: Persistent avoidance of stimuli associated with the traumatic event as evidenced by on or both of the following: C1: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings C2: Avoidance of or efforts to avoid external reminders C1: Efforts to avoid thoughts, feelings, or conversations D: Negative alterations in cognitions and mood associated with traumatic event(s) C2: Efforts to avoid activities, places, or people D1: Inability to remember an important aspect of the traumatic event(s) C3: Inability to recall an important aspect of the trauma D2: Persistent exaggerated negative beliefs about oneself, others, or the world C4: Markedly diminished interest in significant activities D3: Persistent, distorted cognitions that leadthe individual to self blame C5: Feeling of detachment or estrangement from others D4: Persistent negative emotional state D5: Markedly diminished interest in significant activities C6: Restricted range of affect D6: Feelings of detachment or estrangement from others C7: Sense of foreshortened future D7: Persistent inability to experience positive emotions

9. DSM-IV-TR DSM-V Specifiers Acute (<3 months) With Dissociative Symptoms - Depersonalization Chronic (>3 months) - Derealization With Delayed Onset With Delayed Expression Subthreshold PTSD Adjustment Disorder Adjustment Disorder Anxiety Disorder NOS Other Specified Trauma- and Stressor-Related Disorder Unspecified Trauma- and Stressor-Related Disorder

10. DSM Discordance Hoge CW, Riviere L, WilkJ et al. The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-V versus DSM-IV-TR symptom criteria with the PTSD checklist. Lancet Psychiatry Aug 2014

11. Extreme Stress Pre-Stress Stress Post-Stress PTSD Depression Substance Use Disorders Chronic Pain Somatic Disorders Other Psychiatric Disorders Genetics Subjective Response And Recovery Prior Stress And Stress Prep Adapted from John Krystal (APA 2013)

12. Responses to Trauma • Change in Sleep • Decrease in • Feeling Safe • Isolation Distress Responses Health Risk Behaviors (changed behavior) Mental Health • Anxiety • PTSD • Depression • Resilience • Smoking • Alcohol • Over dedication • Change in travel • Separation anxiety

14. Benedek DM and Wynn GH. Clinical Manual for Management of PTSD. American Psychiatric Press, Inc 2010

15. Stigma and Barriers to Care

16. From the 2010 National Survey on Drug Use and Health

17. Stigma Lack of perceived need 66 60 Perceived lack of effectiveness 66 40 54 Want to solve on own 68 40 Unsure where to go 49 35 Fear of forced hospitalization Men 22 Women 23 Stigma 24 17 0 10 20 30 40 50 60 70 80 Agree or Strongly Agree, % Kessler RC. J Clin Psychiatry. 2000;61(suppl 5):4-12.

18. 100 95% 94% 90% 88% 90 86% Patients Making Treatment Contact, % 80 65% 70 60 GAD PTSD Lifetime Probability of Treatment Contact 7% contact within year of PTSD onset and12-year median delay to first treatment contact PanicDisorder DysthymicDisorder BipolarDisorder MajorDepression Wang PS, et al. Arch Gen Psychiatry. 2005;62:603-613.

19. Lu MW, Duckart JP, O’Malley JP et al. Correlates of Utilization of PTSD Specialty Treatment Among Recently Diagnosed Veterans at the VA. Psychiatric Services 2011

20. Psychotherapy

21. Psychotherapies From VA/DoD Clinical Practice Guideline for The Management of Post-Traumatic Stress (2010)

22. Level A Psychotherapy Choices Patients should be offered one of the evidence-based trauma-focused psychotherapeutic interventions that include components of exposure and/or cognitive restructuring; ORstress inoculation training. Choice should be based on symptom severity, clinician expertise, and patient preference, and may include: Exposure therapy (e.g., Prolonged Exposure) Cognitive therapy (e.g., Cognitive Processing Therapy) Stress management therapy (e.g., SIT) or Eye Movement Desensitization & Reprocessing (EMDR)

23. VA/DoD Guideline: Therapy Selection • Explain the range of available and effective therapeutic options for PTSD to all patients with PTSD • Patient education is recommended as an element of treatment of PTSD for all patients and family members • Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidence-based pharmacotherapy as 1st line treatment • Psychotherapies should be provided by practitioners who have been trained in that particular method • A collaborative care approach to therapy administration, with care management, may be considered

24. Adapted from Watts BV, Schnurr PP, Mayo L et al.Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry 2013

25. Prolonged Exposure in Veterans Yoder M, Tuerk PW, Price M et al. Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars. Psychological Services 2012

26. PCL Score Chard KM, Ricksecker EG, Healy ET et al. Dissemination and experience with cognitive processing therapy. J Rehabil Res Dev 2012

27. Cognitive Behavioral Conjoint Therapy for PTSD Improves PTSD Symptoms Adapted from Monson CM, Fredman SJ, Macdonald A et al. Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial. JAMA 2012 (Adapted with permission from Schnurr, APA 2012)

28. The Benefits of Cognitive Behavioral Therapy for PTSD Persist Long-Term CAPS PTSD Severity 126 female sexual assault survivors with PTSD, followed 6.2 years after treatment (range = 4.5-10 years) • Comparable to 171 initial participants Remission at follow up: 77.8% Cognitive Processing Therapy 82.5% Prolonged Exposure Adapted from Resick PA, Williams LF, Suvak MK et al. Long-Term Outcomes of Cognitive-Behavioral Treatments for Posttraumatic Stress Disorder Among Female Rape Survivors, J Consult ClinPsychol 2012 (Adapted with permission from Schnurr, APA 2012)

29. Pharmacotherapy

30. Adapted from VA/DoD Clinical Practice Guideline for The Management of Post-Traumatic Stress (2010)

31. * - including sertraline v PEx v combination study

33. Venlafaxine ER • 12-week • Flexible dose • 538 randomized • 350 completers • ~10% difference in remission Davidson J, Rothbaum BO, Tucker P et al. Venlafaxine extended release in posttraumatic stress disorder: a sertraline- and placebo-controlled study. J ClinPsychopharmacol2006

37. Complementary and Alternative Medicine

38. What is CAM? A group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medical. National Center for Complementary and Alternative Medicine Natural Products Herbal medicines, dietary supplements, probiotics Mind and Body Medicine Meditation, Acupuncture, Yoga, Progressive Relaxation Manipulative and Body-Based Practices Massage therapy, Spinal Manipulation NCCAM website: nccam.nih.gov

39. Other ways to Organize CAM Based on validity of proposed mechanism: 1) Consistent with current medical perspectives and understanding of pathophysiology 2) Unsure of mechanism for perceived benefit 3) Violates basic laws of physics/chemistry/biology Or Based on Modality Type: 1) Interventions (e.g. Acupuncture) 2) Care Delivery Method (e.g. Computer Based Therapy) 3) Personal Activities (e.g. Recreational Therapy)

40. Why is CAM Research so complicated? • Hypothesis development Design believable studies • Definition and Validation of Diagnosis Define PTSD using validated instruments Establish Chronicity of symptoms • Treatment Design Standardize the intervention • Measuring outcome Use established assessment tools to evaluate Include follow-up assessments • Interpreting Results Identify primary and secondary outcome measures prior to the trial

43. Future Directions