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 |
|
Created By
Metadata
Favourited By
Comments
No comments yet. Add yours below!
Add a Comment
Related Cheat Sheets
More Cheat Sheets by kfisher17