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What Advanced Practice Nurses Need to Know About PTSD

What Advanced Practice Nurses Need to Know About PTSD. Presentation for R egional Conference: Towards Excellence in Advanced Practice Nursing. April 16, 2009 Sarah Acland MD. What is PTSD ?. Normal response to abnormal events: - fear, autonomic symptoms, numbing, dissociation

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What Advanced Practice Nurses Need to Know About PTSD

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  1. What Advanced Practice NursesNeed to Know About PTSD Presentation for Regional Conference: Towards Excellence in Advanced Practice Nursing. April 16, 2009 Sarah Acland MD.

  2. What is PTSD ? Normal response to abnormal events: - fear, autonomic symptoms, numbing, dissociation In PTSD: these reactions are abnormally prolonged and cause significant interference in any or all aspects of the person’s life. Anyone who undergoes severe enough, or prolonged enough trauma, can develop PTSD.

  3. Response - • Fight • Flight • Freeze!

  4. Acute Stress Disorder Criteria are the same as for PTSD. Fewer symptoms are needed for diagnosis DURATION: from 2 days to 4 weeks after event. Almost everyone will have to some degree. Treatment is purely supportive: Listening, validation, presence, compassion.

  5. DSM 5 Post-traumatic stress disorder A. Exposure B. Intrusion Symptoms C. Avoidance of Stimuli D. Distortions E. Arousal F. Duration G. Distress H. Exclusion

  6. Exposure to Trauma (one) Actual or threatened death, injury, or sexual violence. • Directly • Witnessed • Learning it happened to significant person • Repeated or extreme exposure to aversive details (esp. work related)

  7. Intrusion symptoms (one) • Intrusive memories • Nightmares • Dissociative reactions (flashbacks) • Intense distress at exposure to triggers • Marked reactions to cues that recall the event

  8. Avoidance (one or both) • 1. Efforts to avoid memories, thoughts or feelings associated with the event • 2. Efforts to avoid external reminders that arouse such feelings.

  9. Distortions(two) 1. Inability to remember important aspect of event 2. Persistent negative beliefs about self or world 3. Distorted beliefs about cause (blame) 4. Persistent negative emotional state 5. Diminished interest in significant activities 6. Feeling detached from others 7. Inability to experience positive emotions

  10. Arousal (two) 1. Irritability, verbal and physical aggression 2. Reckless or self-destructive behavior 3. Hypervigilance 4. Exaggerated startle response 5. Concentration problems 6. Sleep disturbance

  11. Duration More than one month

  12. Distress and Exclusion • 1. Clinically significant distress in functioning • 2. Not due to substance or other condition

  13. Dissociation • Experience“walled-off” from consciousness • Coping mechanism or symptom? • Definite risk factor for PTSD • Possibly results from increased glutamate. • May involve sensation, image, behavior, meaning, affect, or all five.

  14. How does this differ from DSM IV?

  15. Presenting Symptoms May present with one major symptom: • “phobia” – avoidance of situation or place • “panic attacks” – may be re-experiencing • “mood swings” – possibly anger outbursts • “can’t concentrate” – hyperarousal • “depression” – • “pain” • “can’t sleep” These are all real problems, but may be the tip of a PTSD iceberg.

  16. Differential Diagnosis • Anxiety disorders • Sleep disorders • Mood disorders • Somatization – “hysteria” • ADD • Substance abuse • “Schizophrenia” • Borderline personality disorder

  17. Co-existing substance abuse and PTSD • 58% of veterans in SA treatment have lifetime PTSD. • 47% - 77% of male veterans with PTSD have lifetime SA. • For civilians the rates are not as high. Indicates more severe pathology and a more chronic course. Should be treated together for best results.

  18. Trauma – Simple and Complex Simple trauma – single event eg: rape, earthquake etc, car accident Complex trauma – prolonged, inescapable. eg: torture, child abuse, war, combat Complex trauma tends to cause more severe effects, especially if perceived as malicious.

  19. “Complex PTSD” Prolonged subjection to total control and repeated abuse. • chronic suicidal thinking • amnesia • unstable relationships • episodes of rage -or hypersexuality • depression, isolation • anxiety and panic • lack of concentration

  20. And..... • guilt, shame, defilement • intrusive memories and dreams • self-mutilation • dissociation, DID • lack of trust, paranoid thinking • revenge fantasies, identification with captors • alcohol and substance abuse/addiction

  21. Morbidity and Mortality Disorders that increase in presence of PTSD: • Physical illness – even after exclusion of, for example, alcohol and drug abuse • Depression and anxiety disorders • Accidents • Pain syndromes • Alcohol and drug abuse Mortality also increases – from cardiovascular disorders, accidents and suicide

  22. PTSD– Prevalence(in USA) • DSM-IV-TR (2000) 1 – 14% • Detroit (1998) Men 10%, Women 18% • Detroit (1991) Men 6%, Women 11% • NVVRS (1980) Men 31%, Women 27% -higher in Army, & with longer exposure to combat.

  23. Prevalencein Iraq Vets The incidence increases over time, and is higher if complicated by TBI – about 7% 40% of post-9-11 vets will ultimately have PTSD. This is a total of roughly 490,000 people. After screening, 30% of vets referred to MH. After diagnosis, < 50% received treatment. Treatment leads to remission in 30 – 50 %

  24. In a population of one million, if 4% suffer from PTSD, that equals 40,000 people.

  25. PTSD : Risk Factors Development of PTSD: pre-trauma factors: PH or FH of mental illness. previous personality, and experiences. Maintenance of PTSD depends more on events during and after trauma, social support, group solidarity and attitudes. Dissociation during the event is a strong predictor of PTSD.

  26. PTSD Risk Factors • Younger age, female gender, minority status, poor education, previous trauma, childhood adversity. - all depending on which population. • Stronger factors: psych. history, childhood abuse, family psych. history. • More important: factors during & after event: severity & duration, lack of support, additional life stress.

  27. HISTORY W. H.R. Rivers 1864 – 1922 First effective treatment of “Shell-Shock”. After him, soldiers were no longer shot for “cowardice”.

  28. Neurobiology of PTSD • PTSD is a physical illness, an exaggeration of normal response: • Threat is perceived by sensory neurons, registered in the cortex, • proceeds to the limbic system of the mid-brain, • specifically the hypothalamus, • and from there the reaction is mediated by the autonomic nervous system.

  29. Autonomic Nervous System Sympathetic N. S. Parasympathetic N.S. pallor rapid breathing rapid heartbeat sweating tremor enlarged pupils increased BP and temp gut and bladder overactivity fear flushing slow breathing slowed heartbeat warm,dry skin slowed gut activity small pupils normal BP and temp calm exterior

  30. The Limbic System

  31. In PTSD the sympathetic symptoms persist, and are not balanced by the parasympathetic system. At the same time the memory of trauma remains subcortical and is not fully integrated into normal event memory.

  32. Normal Response to Threat • Fight! • Flight! • F-r-e-e-z-e

  33. Hypothalamic-pituitary-adrenal Axis Normal Situation – alarm spreads from amygdala to hypothalamus, triggers the SNS, releasing nortriptyline, and starts off the flight/fight reaction. The pituitary stimulates the adrenals to release cortisol - a slower reaction - and this brings the alarm reaction gradually to an end. In PTSD, cortisol release is blocked or deficient.Alarm reaction continues, leading to re-experiencing. Holocaust survivors and others with PTSD have been found to have low urinary cortisol excretion.

  34. Neurotransmitters • Catecholamines: Epinephrine and NE: sympathetic activators. Urinary excretion is increased • Cortisol and CRH (HPA): modulate SNS. CRH is increased, whereas cortisol may be increased or decreased. May inhibit PFC memory. • Glutamate/GABA: Excitatory/inhibitory. Glutamate flooding initially, with imbalance. Low GABA may lead to helplessness. • Serotonin (5-HT): Low, increasing amygdala activity. Increased fear behaviors, decreased memory trace.

  35. STRE--E—E—E--TCH!

  36. Pharmacological Treatment Serotonin – SSRIs • Improve symptoms • Improve anxiety • Promote GABA and calm down amygdala, reducing rage, aggression, impulsivity, SI. • Promote neurogenesis (as do all anti-depressants.)

  37. Pharmacological Treatment 5HT / noradrenaline enhancers. • Effexor, Cymbalta, both effective but not as anxiolytic as one hoped. • Tricyclics – Elavil, Sinequan, effective and cheap; also sedative. 5-HT • Monamine oxidase inhibitors – Phenelzine, effective but risky, esp in alcohol abusers. None is as effective for PTSD as the SSRIs

  38. Pharmacological Treatment Adrenergic System: • Beta-blocks: propranolol etc. • Alpha-1 block: prazocin • Alpha-2 agonist: clonidine All these anti-adrenergic agents reduce arousal & re-experiencing Prazocin: nightmares, also in daytime for flashbacks.

  39. Pharmacological Treatment Gaba/glutamate system: mainly anti-convulsants • Depacote : increases GABA • Tegretol : increases GABA • Lamictal : inhibits glutamate • D-Cycloserine: enhances glutamatergic function: neuroplasticity & new memory formation. Adjunct to CBT

  40. Pharmacological Treatment Atypical anti-psychotics: Dopamine, serotonin blockade: • Risperdal • Seroquel – Seroquel XR • Abilify • Zyprexa Useful for aggression, nightmares, some hyperarousal. Best as adjuncts.

  41. Pharmacological Treatment Glucocorticoids: hydrocortisone. Given in high doses in the acute situation, for septic shock or cardiac surgery, it seems to prevent the later development of PTSD. (also, possibly, beta-blockers and morphine)

  42. Pharmacological Treatment GABA agonists: Benzodiazepines:. Not recommended because: • Sedation, memory impairment, ataxia • Risk of dependency • Exacerbation of depression • Cause rebound anxiety. (Alprazolam) • May be useful short-term for sleep.

  43. Psychological Treatment • “Exposure is the only modality for which evidence is sufficient…..” • Aim is to replace negative repeating circuits with positive memories and ideas. • The unmodified sensory memories then can be released into the pre-frontal cortex, where they are available to normal cognition and increased understanding.

  44. Treatment Principles • Establish therapeutic alliance • Establish safety • Assist patient in own recovery • Use “safe places” • Validate the experience • Celebrate progress

  45. Do no harm • re-traumatizing – eg premature questions • triggering flashbacks, panic attacks • ignoring therapeutic boundaries • dis-empowering – eg making decisions • colluding in unhealthy behavior • pathologizing

  46. AVOID: • rescue – making decisions for patient • advice • closed questions • filling-in memories • high expectations

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