Clinical Guidelines for Post-traumatic Stress Disorder,Mylea Charvat PTSD Specialist War Related Illness and Injury Study Center VA Palo Alto Health Care System mylea.charvatva.gov,Outline,Epidemiology and Criteria Risk Pathways to PTSD Gender & Cultural Issues in PTSD DoD Guidelines: Diagnosis & Assessment Pharmacology Psychotherapies Resources,DSM-IV Criteria,Person Experiences Traumatic Event Person Experiences Fear, Helplessness or Horror The person experiences a combination of the following Sx which are still present 4 weeks following the TE, last more than one month and cause significant distress,Epidemiology of Trauma Exposure,Only National Sample (Kessler et al., 1995) of trauma exposure 61% of men reported DSM-III TE 51% of women reported DSM-III TE Veteran Data (US DVA, 2003) surveyed 20,000 Veterans in US Combat exposure (41% men/ 12% women) 36% exposure to dead/dying/wounded No MST data were collected WWII Veterans reported a 54% exposure rate to combat compared to 19% for Korea,Epidemiology of PTSD,Rates Consistent since DSM-III-R Estimates range between 6% and 12% in general population Kessler et al., 1995 - National survey found PTSD rates of: 20% for women 8% for men,Epidemiology of PTSD in Veterans,Study of 2,300 Vietnam Era Veterans 31% of men met PTSD criteria 27% of women met PTSD criteria Prevalence higher with Army service (compared to other branches) 12 months service Entering service between age of 17 and 19 (Kulka et al., 1990; 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,