_guidelines forposttraumatic stress disorder临床指南后创伤后应激障碍课件

Clinical Guidelines for Post-traumatic Stress Disorder Mylea Charvat PTSD Specialist War Related Illness and Injury Study Center VA Palo Alto Health Care System Outline Epidemiology and Criteria Risk Pathways to PTSD Gender Schlenger et al., 1992) Estimates of TE Exposure & PTSD prevalence among OEF/OIF Veterans Risk Pathways to PTSD TEs that involve injury to self or others TEs that are more “malicious” and “grotesque” Dissociation at the time of the TE Lower education levels Lower SES Minority racial/ethnic status Family psychiatric history (esp. childhood abuse) Lack of social support Feelings of guilt or shame re the TE Previous trauma history Also small literature indicating prior trauma may inoculate against future trauma/PTSD Gender Issues in PTSD Women are at greater risk for PTSD than men When trauma characteristics are more “equal” (political situations or violent community) gender differences in PTSD rates disappear Gender Issues in PTSD Differences seem to be defined by trauma characteristics Women are more likely to experience sexual assault and chronic abuse (intimate partner or childhood sexual abuse) VA-DOD Clinical Guidelines Recommendations for the performance or exclusion of specific procedures or services for specific disease entities Derived through a rigorous methodological approach Includes a systematic review of the evidence to outline recommended practice Displayed in the form of a flowchart algorithm Treatment Guidelines A potential solution to inefficiency and variation in care A user-friendly format for training and education on PTSD treatment Designed to inform and support clinicians Must always be applied in the context of an individual providers clinical judgment for the care of a particular patient Development of DoD/VA Treatment Guidelines DoD represented by members of Army, Navy, and Air Force DVA represented by staff of VAMCs, Readjustment Counseling Service, and the National Center for PTSD Disciplines represented include psychiatrists, primary care physicians, psychologists, nurses, pharmacists, occupational therapists, social workers, counselors, chaplains, and administrators Scope of DoD Treatment Guidelines Developed to address the full spectrum of traumatic- stress response Acute Stress Response/Combat Stress Response Acute Stress Disorder PTSD Acute PTSD Chronic PTSD PTSD with co-morbid Major Depression and/or substance abuse Complex PTSD Negative health behaviors known to adversely affect clinical outcomes in those with PTSD Limitations and Challenges Inadequate clinical trials in combined treatments (such as psychotherapy and pharmacotherapy) versus single treatment approaches. Not clear whether a treatment effective for combat Veterans with PTSD will be equally useful for survivors of another trauma, such as recent sexual assault. Inadequate research on treatment of PTSD in patients with dual diagnosis (i.e. substance abuse/MDD) Diagnosis & Assessment of PTSD All new patients should be screened for symptoms of PTSD Thereafter, annually or more frequently if suspicion, recent exposure, history of PTSD Paper-and-pencil or computer-based screening tools should be used Notes importance of Balancing efficacy with practical concerns (staffing, time constraints, current clinical practices) Avoiding stigmatization and adverse occupational effects of positive screens Individuals with positive screens should receive more detailed assessment of their symptoms (i.e. CAPS, MMPI) PTSD Checklist (PCL-M or PCL-C) 17 item self report questionnaire In the public domain Available in CPRS or pen and paper Short and easy to score/interpret Total Severity Score correlation with the CAPS = .94 For women Veterans utilize the PCL-C Pharmacology Guidelines Monotherapy Strongly recommend SSRIs 2nd line: TCAs and MAOIs Consider trial of at least 12 weeks before changing medications Consider 2nd generation (e.g., trazodone, buproprion) Augmented therapy for targeted symptoms Consider prazosin for nightmares and other PTSD symptoms Recommend medication compliance assessment at each visit Recommend against Benzodiazepines to manage core symptoms of PTSD Typical antipsychotics in management of PTSD Psychotherapies Significant benefit Strongly recommended Cognitive Therapy Exposure Therapy Stress Inoculation Training Eye Movement Desensitization Reprocessing (EMDR) Some benefit Imagery rehearsal therapy Psychodynamic therapy Patient education (recommended for all patients) Cognitive Therapy Systematic approach to challenging negative trauma-related beliefs (e.g., “I should have prevented it”) Educate about role of beliefs in causing distress Identify distressing beliefs Discuss, review evidence, and generate alternative beliefs Rehearse revised beliefs Exposure Therapy Imaginal exposure = repeated retelling of trauma story with emotional activation In vivo exposure = assignments to confront feared stimuli in environment Prolonged Exposure Multiple repetitions via homework Listening to cassette Writing Intended to help survivors habituate to stimuli Stress Inoculation Focus on management of symptoms Coping skills training Education Muscular relaxation training Breathing retraining (slow abdominal breathing) Assertiveness Covert modeling Role playing Thought stopping Positive thinking and self-talk EMDR Identify Disturbing image (worst part of event) Associated body sensation Negative self-referring cognition (what learned from event) Positive self-referring cognition Hold image/sensation/negative cognition in mind while tracking clinicians moving finger for 20 seconds Describe changes, new associations Repeat tracking episodes and reinforce positive cognition Imagery Rehearsal Therapy Select a memory or nightmare “Change the memory any way you wish” Patient writes down the “new version” Rehearse daily Includes education, tools for controlling imagery Psychodynamic Therapy Re-engage normal adaptation by addressing unconscious to make it conscious. Deals with fears, fantasies, wishes, and defenses. Managing transference and counter- transference issues with an emphasis on the importance of the therapeutic relationship. Strength of evidence: few clinical trials exist overall. Most evidence is in clinical case studies Patient Education Recommended for all Veterans diagnosed with PTSD Usually conducted as a once a week group with a different topic each week Topics include (but are not limited to): What is PTSD? Types of symptoms Sleep and PTSD Anger and PTSD Evaluation of Treatment Efficacy Regular use of self-administered checklists Follow up status should be routinely monitored at least every 3 months, using interview and questionnaire methods Trauma Assessment in Primary Care If presumed PTSD or positive PTSD screen, then conduct or refer for in-depth PTSD Assessment Recommend use of self-report measures (PCL-M, PCL- C, Mississippi-M, Mississippi-C) PTSD Evaluation in Primary Care If H/O Trauma - Recommend assessment of: PTSD Symptoms Dangerousness to self or others Family and social environment Ongoing health risks Medical/psychiatric co-morbidities Thorough history and physical Appropriate lab evaluation Radiological assessment Level of functioning Risk factors for development of ASD/PTSD Substance use Primary Care Treatment Recommendations Formulate presumptive diagnosis Consider initiating treatment or referral Treat complicating problems Pain, insomnia, anxiety, depression If complicated, refer to mental health Consult with MH Stay involved in treatment Take leadership in convening collaborative team Primary Care Encouraged to: Routinely provide: Early recognition of PTSD Supportive counseling PTSD-related education PTSD symptoms Other traumatic stress problems/consequences Practical w