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Intrusive
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Must have 1
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Recurrent memories, disturbing dreams, flashbacks, reminders that evoke emotional distress, physical reactivity
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|
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Avoidance
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Must Have 1
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Reminders of event, feelings/conversations/thoughts of event
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Negative Cog/Mood Changes
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Must Have 2
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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
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Changes in Arousal/Reactivity
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Must Have 2
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⬇ concentration, easily startled, hypervigilance, sleep disturbances, irritability or anger, reckless behavior
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|
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PE
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BEP
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CPT
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Written NE
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Narrative Exposure
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EDMR
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Nefazodone
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Avoid in liver dysfunction
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CYP3A4 DDIs
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Phenelzine
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|
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Imipramine
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Avoid w/ acute MI
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CI in CAS and prostatic enlargement
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|
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Amitriptyline
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Avoid w/ acute MI
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CI in CAS and prostatic enlargement
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|
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Nortriptyline
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Avoid w/ acute MI
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CI in CAS and prostatic enlargement
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Mirtazapine
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|
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Prazosin
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Nightmares
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Antiseizure
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irritability, aggression, hyperarousal
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Atypical Antipsychotics
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sleep, irritability, aggression, hyper-arousal, psychosis
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MOA
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modulates GABA and glutamiate
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Target symptoms
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Irritability
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Aggression
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|
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Hyperarousal
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off-label use
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Examples
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Carbamazepine
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Lamotrigine
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|
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Topiramate
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Valproic Acid
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MOA
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Dopamine antagonism
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Histamine antagonist provides sedative-like effects
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⍺ adrenergic antagonist properties in risperidone similar to prazosin
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|
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Target Symptoms
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⬇ irritability, aggression, and hyperarousal
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|
Sleep
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|
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Psychosis
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Examples
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Quetiapine
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Olanzapine
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Risperidone
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4 core sx make up the diagnostic criterion
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Intrusion
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Avoidance
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Negative Mood or Cognition
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Reactivity
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First-Line Tx
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|
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SSRIs
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SNRIs
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Psychotherapy
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Prazosin
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|
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Showed no significant difference in nightmares or sleep quality in a large clinical trial
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|
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Use should be individualized when nightmare affect QOL
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|
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CAPS (Gold Standard)
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|
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Remission
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70% ⬇ in sx for ≥ 3 months
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Partial Response
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25 to 50% ⬇ in sx for ≥ 3 months
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Non-Response
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<25% ⬇ in sx for ≥ 3 months
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Short Term
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⬇ in core Sx; ⬆ QOL; manage comorbid psych conditions
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Long Term
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Remission
|
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Fluoxetine
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|
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Sertraline
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⇦ FDA APPROVED
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Paroxetine
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⇦ FDA APPROVED
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Venlafaxine XR
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Duloxetine
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|
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Use CAPS
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Med Trial: 8 to 12 weeks at maintenance dose
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Duration: 12 months of Tx
|
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0-3 mo: monitor Q week to QOW
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3 to 6 mo: monitor Q month
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6 to 12 mo: Q 1 to 2 months
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Do not use in PTSD!
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☹ This can worsen the response and doesn't provide sx relief
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☹ No evidence of reduction in core sx
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☹ No positive long-term data reported
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MOA
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⍺-1 adrenergic antagonists
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Target Symptom
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PTSD nightmares
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off-label use
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|
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ADRs
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First-dose syncope
|
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Orthostatic hypotension
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|
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Dizziness
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|
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Somnolence
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Headache
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Dosing
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Titrate slowly to minimize hypotension and syncope
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Largest trial to date; 13 VA medical centers
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|
Conclusion: No significant difference in nightmares or sleep quality after 10 and 26 weeks of treatment
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VA/DOD Guideline: no recommendation for OR against
|
|
Pharmacotherapy should be continued for ≥ 12 months
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|
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Monitoring
|
|
|
• 0 to 3 months
|
Monitor QW to QOW
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• 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
|
|
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Discontinuation of Treatment
|
|
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⇨ ⇨ ⇨ ⇨ ⇨
|
Individualized
|
|
⇨ ⇨ ⇨ ⇨ ⇨
|
Taper Slowly
|
|
⇨ ⇨ ⇨ ⇨ ⇨
|
Monitor for Relapse
|
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