Uncertainty: Was difficulty falling asleep and hypervigilance related to fear of ventricular tachycardia returning, or fear of being shocked again?

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1 Manuel Tancer, MD Chart Review: PTSD PATIENT INFO 55 Age: Background: Overweight nurse with 6-month history of nightmares, hyperarousal, and flashbacks; symptoms began after implanted defibrillator was triggered by run of ventricular tachycardia while patient was at work. Uncertainty: Was difficulty falling asleep and hypervigilance related to fear of ventricular tachycardia returning, or fear of being shocked again? Also had depression, increased alcohol use, and hopelessness about future. Work performance deteriorated often late and appeared distracted; flinched and startled when IV alarms rang. Best Practices List three best practices agreed to by the group in your chart review session: 1. Understand what the trauma means to the person. 2. Use medication aggressively. 3. May need to use combination therapy important to use both psychotherapy and pharmacotherapy.

2

3 PTSD Chart Review Manuel Tancer, MD Wayne State University School of Medicine

4 Manuel Tancer, MD Disclosures Research/Grants: None Speakers Bureau: None Consultant: None Stockholder: None Other Financial Interest: None Advisory Board: None

5 Learning Objective Diagnose and identify appropriate treatment strategies for posttraumatic stress disorder (PTSD)

6 Case Vignette 55 yo overweight nurse with 6-month history of nightmares, hyperarousal, and flashbacks Symptoms began after implanted defibrillator was triggered by run of ventricular tachycardia while patient was at work

7 Case Vignette (cont.) Uncertainty: Was difficulty falling asleep and hypervigilance related to fear of ventricular tachycardia returning, or fear of being shocked again? Also had depression, increased alcohol use, and hopelessness about future Work performance deteriorated Often late and appeared distracted Flinched and startled when IV alarms rang

8 Three Domains of PTSD 1. Re-experiencing the event (1 must be present) Distressing recollections Nightmares Physiological reactions to triggers Psychological reactions to triggers 2. Avoidance/numbing (3 must be present) Avoid conversations, activities, places, or people Selective amnesia Withdrawal, detachment, loss of interest, or hopelessness 3. Increased arousal (2 must be present) Decreased sleep Irritability/anger Loss of ability to concentrate Hypervigilance Startle Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1995.

9 Diagnosis of PTSD Must specifically ask about trauma Assess presence of core symptoms Assess comorbidity Depression, substance use disorders, anxiety disorders Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. American Psychiatric Association, Washington, DC, 2004.

10 Prevalence of PTSD Males Females Incidence (%) Age (Years) Kessler RC, et al. Arch Gen Psychiatry 1995;52:

11 Non-Combat-Related Trauma Associated with PTSD Males Females Incidence (%) Kessler RC, et al. Arch Gen Psychiatry 1995;52:

12 PTSD Treatment Psychotherapy Both CBT and psychodynamic shown to be helpful Pharmacotherapy FDA-approved therapies: paroxetine and sertraline Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. American Psychiatric Association, Washington, DC, 2004.

13 PTSD Treatment (cont.) Other medications that may be of use for specific symptoms: Prazosin ( -adrenergic blocker) used to decrease nightmares TCAs may also reduce nightmares by suppressing REM sleep Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. American Psychiatric Association, Washington, DC, 2004.

14 an educational series offered by CME Outfitters, LLC This CME/CE activity is co-sponsored by

15 PTSD Manuel Tancer, MD Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Washington, D.C.: American Psychiatric Association, 2000:589. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52: Practice Guideline for the Treatment of Patients with Panic Disorder. American Psychiatric Association, Washington, DC, 2009.

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