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PTSD Therapeutics Cheat Sheet by

Diagnosis | Four Core Symptoms

Intr­usive
Must have 1
Recurrent memories, disturbing dreams, flashb­acks, reminders that evoke emotional distress, physical reacti­vity
Avoi­dance
Must Have 1
Reminders of event, feelin­gs/­con­ver­sat­ion­s/t­houghts of event
Negative Cog/Mood Changes
Must Have 2
Inability to recall trauma aspects, negative expect­ations, distorted cognitions about trauma and self-b­lame, greatly ⬇ interest in activi­ties, detachment or estran­gement, inability to experience positi­vity
Changes in Arousa­l/R­eac­tiv­ity
Must Have 2
⬇ concen­tra­tion, easily startled, hyperv­igi­lance, sleep distur­bances, irrita­bility or anger, reckless behavior
Symptoms must occur ≥ 1 MONTH

Non-Pharm | FIRST LINE

PE
BEP
CPT
Written NE
Narrative Exposure
EDMR

Pharm | SECOND LINE

Nefazodone
Avoid in liver dysfun­ction
 
CYP3A4 DDIs
Phenelzine
Imipramine
Avoid w/ acute MI
 
CI in CAS and prostatic enlarg­ement
Amitri­ptyline
Avoid w/ acute MI
 
CI in CAS and prostatic enlarg­ement
Nortri­ptyline
Avoid w/ acute MI
 
CI in CAS and prostatic enlarg­ement
Mirtaz­apine

Pharm | ADJUNCT

Prazosin
Nightmares
Antise­izure
irrita­bility, aggres­sion, hypera­rousal
Atypical Antips­ych­otics
sleep, irrita­bility, aggres­sion, hyper-­aro­usal, psychosis

Antico­nvu­lsants | Adjunctive Tx

MOA
modulates GABA and glutamiate
Target symptoms
Irrita­bility
 
Aggression
 
Hypera­rousal
 
off-label use
Examples
Carbam­azepine
 
Lamotr­igine
 
Topiramate
 
Valproic Acid
VA/DOD guideline recommends AGAINST use due to low-qu­ality evidence

Atypical Antips­ych­otics | Adjunctive Tx

MOA
Dopamine antagonism
 
Histamine antagonist provides sedati­ve-like effects
 
⍺ adrenergic antagonist properties in risper­idone similar to prazosin
Target Symptoms
⬇ irrita­bility, aggres­sion, and hypera­rousal
 
Sleep
 
Psychosis
Examples
Quetiapine
 
Olanzapine
 
Risper­idone
VA/DOD guideline recommends AGAINST use due to low-qu­ality evidence

SUMM­ARY

4 core sx make up the diagnostic criter­ion
 
Intrusion
 
Avoidance
 
Negative Mood or Cognition
 
Reactivity
Firs­t-Line Tx
 
SSRIs
 
SNRIs
 
Psycho­therapy
Praz­osin
 
Showed no signif­icant difference in nightmares or sleep quality in a large clinical trial
 
Use should be indivi­dua­lized when nightmare affect QOL
Diagnosis and Sx remission can be monitored by CAPS
 

Diagnosis and Assessment

CAPS (Gold Standa­rd)
Remission
70% ⬇ in sx for ≥ 3 months
Partial Response
25 to 50% ⬇ in sx for ≥ 3 months
Non-Re­sponse
<25% ⬇ in sx for ≥ 3 months

Goals of Treatment

Short Term
⬇ in core Sx; ⬆ QOL; manage comorbid psych conditions
Long Term
Remission
Remission = 70% ⬇ in sx for ≥ 3 months

Pharm | FIRST LINE

Fluoxetine
Sertraline
⇦ FDA APPROVED
Paroxetine
⇦ FDA APPROVED
Venlaf­axine XR
Duloxetine

Monitoring

Use CAPS
Med Trial: 8 to 12 weeks at mainte­nance dose
Duration: 12 months of Tx
0-3 mo: monitor Q week to QOW
3 to 6 mo: monitor Q month
6 to 12 mo: Q 1 to 2 months

Benzod­iaz­epines

Do not use in PTSD!
☹ This can worsen the response and doesn't provide sx relief
☹ No evidence of reduction in core sx
☹ No positive long-term data reported
All PTSD guidelines recommend agai­nst use of benzo's

Prazosin | Adjunctive Tx

MOA
⍺-1 adrenergic antago­nists
Target Symptom
PTSD nightmares
 
off-label use
ADRs
First-dose syncope
 
Orthos­tatic hypote­nsion
 
Dizziness
 
Somnolence
 
Headache
Dosing
Titrate slowly to minimize hypote­nsion and syncope
May be used as an adjunctive agent to an antide­pre­ssant to help reduce the frequency of nightm­ares

Prazosin | VA/DOD Guideline Trial

Largest trial to date; 13 VA medical centers
Conclu­sion: No signif­icant difference in nightmares or sleep quality after 10 and 26 weeks of treatment
VA/DOD Guideline: no recomm­end­ation for OR against
Evaluate benefits, risks, and medication tolera­bility

Duration of Treatment

Pharma­cot­herapy should be continued for ≥ 12 months
Moni­tor­ing
• 0 to 3 months
Monitor QW to QOW
• 3 to 6 months
Monitor Q month
• 6 to 12 months
Monitor Q 1 to 2 months
If symptoms persist, indefinite pharma­cot­herapy is an option
Disc­ont­inu­ation of Treatm­ent
⇨ ⇨ ⇨ ⇨ ⇨
Indivi­dua­lized
⇨ ⇨ ⇨ ⇨ ⇨
Taper Slowly
⇨ ⇨ ⇨ ⇨ ⇨
Monitor for Relapse
           

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