Diagnosis | Four Core SymptomsIntrusive | 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 LINEPE | BEP | CPT | Written NE | Narrative Exposure | EDMR |
Pharm | SECOND LINENefazodone | 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 | ADJUNCTPrazosin | Nightmares | Antiseizure | irritability, aggression, hyperarousal | Atypical Antipsychotics | sleep, irritability, aggression, hyper-arousal, psychosis |
Anticonvulsants | Adjunctive TxMOA | 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 TxMOA | 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 SUMMARY4 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 AssessmentCAPS (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 TreatmentShort Term | ⬇ in core Sx; ⬆ QOL; manage comorbid psych conditions | Long Term | Remission |
Remission = 70% ⬇ in sx for ≥ 3 months Pharm | FIRST LINEFluoxetine | Sertraline | ⇦ FDA APPROVED | Paroxetine | ⇦ FDA APPROVED | Venlafaxine XR | Duloxetine |
MonitoringUse 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 |
BenzodiazepinesDo 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 TxMOA | ⍺-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 TrialLargest 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 TreatmentPharmacotherapy 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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