Chapter 11: PTSD

Question 1

Definition of PTSD

Answer 1

1. Expsoure to actual or threatened death, injury, sexual violence
2. Recurrent intrustive recollections or re-experienceing of a traumatic event
3. Avoidance of external or internal trauma reminders
4. Negative changes in cognitions & mood
5. changes in arousal and reactivity

Question 2

Exercise and PTSD

Answer 2

• Aerobic exercise and walking are beneficial
• Types of aerobic exercise needs to be studied (cycling was not beneficial)
• The exercise needs to be maintained for benefits to be ongoing

Question 3

Categories of Meditation Practices

Answer 3

1. Attentional (foster self-regulation)
2. Deconstructive (thoughts/ emotions are mental events rather than reflections of reality)
3. Constructive (strengthen positive psychological patterns)

Question 4

Transcendental / Mantram Repition & PTSD

Answer 4

• Mainly attentional type of meditation
• Both are beneficial for PTSD
• TM typically eyes closed 15-20 min, BID

Question 5

Mindfulness Meditation & PTSD

Answer 5

• Has both attentional and deconstructive elements
• MBSR and MBCT are two of the most widely available programs
• pay attention to your experience with curiosity
• can be a form of exposure therapy in PTSD
• RCTs comparing meditation practices showed no benefit of one vs the other (MBSR, yoga, mantram)
• The longer the intervention, the more reduction in PTSD

Question 6

Compassion & Loving Kindness Meditation

Answer 6

• Constructive category of meditation
• addresses emotional numbing, moral injury, trauma-related shame, social disconnectedness

Question 7

Yoga and PTSD

Answer 7

• Fosters upregulation of PANS, downregulation of SANS, decreased cortisol and catecholamine levels
• Trials demonstrate significant benefit

Tai Chi and Qigong have not been studied

Question 8

Visualization / Guided Imagery and PTSD

Answer 8

• focus on chronic nightmares
• Imaginal confrontation with nightmare contents (ICNC)
• Imagery rescripting and rehearsal (IRR)
• Imargery rehearsal therapy (IRT)
• Imagery rescripting and exposure therapy (IRET)

Evidence is too underdeveloped to determine it’s value! May be a supplement to other care

Question 9

Emotional Freedom Technique and Thought Filed Therapy

Answer 9

Combination of exposure through visualization plus acupoint tapping on energy meridians to release energy blockages that create the negative emotions.

Study shows that the tapping on acupoints is an active component!

Evidence is encouraging, but lack of active controls and other methodoligcal shortcomings preclude firm conclusions.

Question 10

Hypnotherapy and PTSD

Answer 10

• Guided, controlled access to traumatic memories that may be kept out of normal consciousness
• Hypnotherapetic Olfactory Conditioning - resistant olfactory induced flashbacks
• Abreactive Ego State Therapy - views personality as several ego states, and PTSD results from memory being tied to a particular ego state and being treated with emotional cathatrsis. Used more in other countries.
• Hypnosis has large effect size, but need more research

Question 11

Acupuncture and PTSD

Answer 11

• Large effect size in short term, medium effect size in follow up
• Low quality evidence. But studies are encouraging.
• May be appropraite for patients who prefer not to engage in more conventional therapies

Question 12

Trauma Focused Therapies

Answer 12

• CPT: cognitive processing therapy.
• PE Therapy: prolonged exposure
• EMDR: recount trauma memory while doing eye movements
• Narrative Exposure Therapy: create a story about their life and tell another person

Exposure treatments have stronger longer term outcomes than other forms

Trauma focused therapies do marginally better than non-trauma focused

Question 13

Non-trauma Focused THerapies

Answer 13

Emphasize strength-based activation of existing coping skills

• PCT: Present Centered Therapy. uses patient’s own coping skills. Inferior results to trauma-focused CBT but has better retention.
• SIT: stress inoculation training. Teaches new skills. Reasonable second line, effective in short term. Not as longer lasting effects as trauma-focused options.
• Psychodynamic therapies

Question 14

Psychotherapy after trauma to prevent PTSD

Answer 14

• debriefing sessions may increase risk of PTSD
• brief trauma-focused CBT may reduce acute traumatic stress (rather than post-traumatic stress, occuring within one month after trauma)
• modified trauma-focused interventions (very brief ones within a few wks of trauma) may help prevent PTSD

Question 15

SSRIs for PTSD

Answer 15

• Sertraline and Paroxetine are FDA approved for PTSD
• Paroxetine has better evidence than sertraline (which doesnt always do better than placebo)
• Fluoxetine and venlafaxine have some benefit too

Question 16

Antipsychotics for PTSD

Answer 16

Risperidone and Olanzapine have some evidence

Question 17

What pharmacologic agent is contraindicated for people with PTSD

Answer 17

Benzos!

Worse outcomes.

Question 18

Prazosin for PTSD

Answer 18

• alpha-1 agonist
• meta analysis showed solid support
• one VA trial showed little benefit over placebo for nightmares or sleep

Question 19

What is the first-line treatment for PTSD

Answer 19

• trauma focused psychotherapy

Endorsed as first line by the APA and VA.

Effects are more likely to endure once medications are discontinued.

Question 20

Pharmacology to prevent PTSD after trauma

Answer 20

• preliminary support for hydrocortisone

No support for propranolol, escitalopram, temazepam, gabapentin.

Question 21

Therapies to consider for PTSD

Answer 21

• Biofeedback. Especially HRV.
• ECT. Especially for those with comorbid depression.
• TMS (adverse = seizures, headache, pain, sleepiness, facial twitch, altered cognition during sessions)
• Inositol - no improvement in sx
• Ginkgo biloba - improved sx
• MDMA
• Cannabis - mixed evidence (not recommended)
• Ketamine - promising