This slide show explores key aspects of treating PTSD in primary care. It explored assessing for symptoms of trauma, flow chart for treatment and collaborative team development and psychopharmachology.

1. TREATING TRAUMA IN
PRIMARY CARE
Integrated Approach to
Individual and Community health

2. Objectives
PTSD – Rates and Presentation in Primary
Care
Impacts on Health and Health Care
PTSD – Assessment in Primary Care
PTSD – Treatments in Primary Care
PTSD – Treatment Teams

3. Trauma is not in the event.
It is in the reaction to the event.
Post-Traumatic Stress
DSM5
PTSD
Event
Avoidance
Intrusion
Cog/Mood
Arousal

4. PTSD – Rates in Primary Care
 Nearly 70% of adults experience an event that could be
classified as traumatic
 Over all Rates of PTSD are 8% in America, 5% in men
and 10% in women.
 Close to 80% of individuals have symptoms post a
traumatic event that decrease over time.
 In communities with high levels of community violence,
poverty, and other forms of oppression rates are at or
above combat levels 25%
 34% of adolescent survivors of MVA, 48% in survivors of
rape, 67% prisonors of war, 64% ICU PTs (wide rage),
15% post cartic event, 11% of all MVA.
 35%-50% of Chronic Pain Patients

5. Comorbid Health Conditions
 Heart Disease
 Autoimmune Disease
 Hyperlipidemea
 Interstitial Cystitis
 Dementia
 Fibromyalgia/Chronic
fatigue
 Chronic Pain
PTSD
Stress
Health

6. PTSD Comorbid Mental Health
Major Depression
(35% - 50%)
Substance Abuse
(21%-43% PTSD+SUD)
Generalized Anxiety
Bipolar Disorder
Borderline Personality

7. Resiliency Factors
 Family closeness/Positive
Family Relationships
 School attachment
 Neighbor support when
parental support and
monitoring were low.
 Peer support/Social support
 Emotional regulation
skills/Amount of positive
emotions.
 Religiosity
 Achievement/Self-regard
 Spirituality
 Inner-directed locus of
control
 Thought-control/cognitive
strategies.
 Mobilization after a threat.
PTSD is endemic but so is resiliency – 60% of people in the US have an
event that could be traumatic 8-10% of individuals display symptoms of
PTSD.

8. Allostatic Load…

9. Bruce McEwen, PhD
Stress Researcher

10. Stress response is meant to be short-term and then
return to homeostatic range.
Short-term Stress is beneficial to the body and mind.
Long-term Stress reduces the bodies efficacy.

11. Trauma In The Brain and BodyHyperactivation
1. Hyperactive
insula (Body
Information)
2. Under-activated
anterior
cingulate cortex
(ACC).
(Regulation)
3. Under-activation
medial
prefrontal cortex
(mPFC).
(Regulation)
Dr. Lanius fMRI Study
Hypoactivation
1. Down regulation
of physical
sensations from
the insula cortex.
2. Hyperactivation
activation in the
anterior cigulet
cortex (ACC).
3. Hyperactivation in
the medial
prefrontal cortex
mPFC.
Dr. Lanius fMRI Study
Y

12. Assessment – PC PTSD
Brief
Screening
Changes
Lives

13. DREAMS: A Mnemonic for Screening Patients
for Post-traumatic Stress Disorder
 (D)etachment
 (R)e-experiencing the event
 (E)vent had emotional effects
 (A)voidance
 (M)onth in duration
 (S)ympathetic hyperactivity or
hypervigilance

14. Assess Comorbidities
 PHQ9 – Assess Depression Symptoms
 GAD7 – Assess Generalized Anx
 MDQ – Assess Bipolar
 SBIRT – Assess SUD (Sub Use Diss)

15. Recognize the Clinical Presentation
• Isolation
• Loss of
relationships
• Homelessness
• Irritability
• Avoidance
• Non-Compliance
• Depression
• Substance Abuse
• Anxiety
• Chronic
Pain/Migraines
• Multiple
Complaints
• Obesity
Physical Mental
SocialBehavioral

16. Normal defensive responses to high threat can
impact treatment and treatment adherence.
Normal Defensive Responses to High Threat
Fight
Flight
Freeze
• Irritability
• Loss of Temper
• Defensiveness
• Avoidance
• Anxiety
• Fear
• Numbing
• Detachment
• Giving Up Easily

17. Treatment Frame
Educate About PTSD
1. Inform, 2. Normalize, 3. Join
Treatment Options: 1. CBT, 2. EMDR
3. Pharm – PTSD, 4. Pharm - Sympt
Develop Common Goals (Rapport):
1. Identify Needs, 2. Target Sympt.
(e.g. insomnia, dreams, mood)
Develop Treatment Team and Ref:
1. Beh Health, 2. Providers, 3. Pain Tx, 4. Specialty
Mental Health, 5. Psychiatry, 6. Social Work

18. Relational Tools that Create Safety
• Creating Social Bonds: Social bonds increase the impact of the
doctor/patient relationship.
STEPS:
1. Create Safety (eye contact – upper face working)
2. Approach Proximity (physical/ emotional closeness)
3. Establish Contact (physical/ emotional contact)
• Self-Empowerment: Uses positive
emotions to build on existing
patient strengths.
How: Identify successful coping,
positive support, nurturing self care,
and current strengths. This helps
you get more mileage and impact
when teaching new information.

19. Map for safe containment
in clinical contact
To establish
safety:
Orient:
Direct attention
outward through
the senses
Joining /
Resource
Stressful
Content
Joining /
Resource
Orient:
Direct attention
outward through
the senses

20. Treatment Process Overview

21. Psychopharmacological Treatment of PTSD
 The only two FDA approved medications for the treatment of PTSD
are sertraline (Zoloft) and paroxetine (Paxil).
 There is also strong evidence for: SSRI fluoxetine (Prozac), SNRI
venlafaxine (Effexor) which are considered first-line treatments in the VA/DoD
Clinical Practice Guideline for PTSD.
 Other Antidepressants:
 There have been smaller RCTs with mirtazapine as well as open trials.
(Mirtazapine may be particularly helpful for treatment of insomnia in PTSD).
 Trazodone is also commonly used for insomnia in PTSD even though there is little
empirical evidence available for its use.
 Nefazodone (serazone) Is still available in a generic form but carries a black box
warning regarding liver failure.
 Depression is one of the major comorbidities (above medications are effective in
comorbid depression). Bupropion is useful in treating comorbid MDD (not PTSD)

22. Psychopharmacological Treatment of PTSD
 Mood stabilizers These medications, also known as
anticonvulsants or anti-epileptic drugs, either block
glutamate or potentiate GABA or do both.
 Topiramate has demonstrated promising results in
randomized controlled trials with civilians and
Veterans with PTSD.
 Despite some promising open label studies, other
RCTs have been negative for this group of
medications in treating PTSD

23. Psychopharmacological Treatment of PTSD
 Small single-site studies suggested that atypical antipsychotic agents
were effective adjunctive treatment for PTSD patients who had poor
responses to first-line SSRIs or SNRIs
 A recent large-scale multi-site trial of risperidone as an adjunctive agent
for SSRI poor/partial responders showed that there was no benefit (in
comparison with a placebo group).
 VA/DoD PTSD Clinical Practice Guideline has been revised as follows:
 Atypical antipsychotics are not recommended as mono-therapy for PTSD.
 Risperidone (Risperdal) is contraindicated for use as an adjunctive agent -
potential harm (side effects) exceeds benefits.
 There is insufficient evidence to recommend any other atypical antipsychotic
as an adjunctive agent for PTSD.

24. Psychopharmacological Treatment of PTSD
 Prazosin has been found to be effective in RCTs in decreasing
nightmares in PTSD. It blocks the noradrenergic stimulation of the
alpha 1 receptor. Its effectiveness for PTSD symptoms other than
nightmares has not been determined at this time.
 The tricyclic antidepressants and MAOIs act on a number of
neurotransmitters. While there are RCTs supporting their use, these
medications are not used as first line agents due to their safety and
side effect profiles
 The tricyclics have quinidine like effects on the heart and can cause
ventricular arrhythmias especially in overdose.
 The MAOI phenezine has been shown to be effective in PTSD. Careful
management of the MAOIs and strict dietary controls are important
because they can cause potentially fatal reaction.

25. Psychopharmacological Treatment of PTSD
 Buspirone is sometimes used adjunctively in treatment of hyperarousal
symptoms.
 Beta blockers also have been used to treat hyperarousal. Beta blockers
block the effects of adrenalin (epinephrine) on organs such as the
heart, sweat glands, and muscles. The evidence is not definitive at this
time. It is thought to re-wire the memories with out fight/flight response.
This is a neuroplastic based treatment.
 Benzodiazepines act directly on the GABA system which produces a
calming effect on the nervous system. This is the only potentially
addictive group of medications discussed. Studies have not shown them
to be useful in PTSD treatment as they do not work on the core PTSD
symptoms. Also these medications are addictive.

26. Questions???
Thank You!