PTSD Treatment: Pharmacology & Psychotherapy

Wellness Resources

• Content discussed may be triggering.
• Support resources:
  • U of C Wellness Center: (403) 210-9355
  • Distress Centre: (403) 266-4357
  • Calgary Counselling Center: (403) 265-4980
• You can also contact IOR.

Class Objectives

• Identify the combined role of pharmacological agents and psychotherapy in PTSD treatment.
• Describe how pharmacological and psychotherapeutic interventions promote safety and well-being across the lifespan and throughout the trajectory of PTSD.
• Critique how pharmacological and psychotherapeutic interventions are influenced by the SEDoHs.
• Describe the nurse's role of using age-appropriate communication skills with individuals, families, and groups through normalizing, active and reflective listening, intervening, injecting doubt, and confrontation.
• Summarize the nurse's role in Motivational Interviewing (MI).
• Explain how the nurse would include Motivational Interviewing (MI) as an intervention to create forward momentum towards wellness for PTSD patients and families.
• Summarize the five components of empathy, in relation to Motivational Interviewing (MI), and explain how these are implemented in the elicit-provide-elicit cycle.
• Define the principles of change talk using DARN and CAT.

Review Questions

• Role of the following structures in PTSD:
  • Amygdala
  • Thalamus
  • Hippocampus
  • Prefrontal cortex
• Six principles of trauma-informed care
  • Safety
  • Trustworthiness and transparency
  • Peer support
  • Collaboration and mutuality
  • Empowerment, voice, and choice
  • Cultural, historical, and gender issues
• Function of the following neurotransmitters
  • GABA (gamma-amino butyric)
  • Dopamine
  • Norepinephrine
  • Serotonin

PTSD & DID Interventions

• Outcomes are connected to the Determinants of Health:
  • Income & social status
  • Social Support Networks
  • Education
  • Employment/working conditions
  • Social Environments
  • Physical Environments
  • Health Services
  • Personal Health Practices/Coping Skills
  • Healthy Child Development
  • Biology and Genetic Endowment
  • Gender
  • Culture

PTSD: Pharmacology

• Medications do not decrease flashbacks or feelings associated with the original trauma.
• Medications prescribed to decrease symptoms:
  • Anxiety
  • Depression
  • Panic
  • Difficulty falling asleep
  • Nightmares
  • Increased arousal symptoms
• Early intervention promotes the best outcomes across the lifespan.
• Early intervention:
  • Resolves trauma prior to another trauma occurring
  • Identifies maladaptive coping skills and develops healthy, adaptable coping mechanisms
• SSRIs are considered 1st line medications:
  • Only approved medication for treatment of PTSD in Canada.
  • Frequently used in all age groups.
• Medications used for "off-label" indications include antipsychotics and benzodiazepines and Clonidine (Catapres), Guanfacine (Tenex), and Propranolol.
• It important to treat any other co-morbid or concurrent conditions:
  • Common mental co-morbid health conditions
  • Bi-polar and psychotic disorders
  • Common co-morbid physical health conditions
  • Arrhythmias and diabetes mellitus
• PTSD individuals statistics:
  • 50% will have an alcohol addiction.
  • 30% will have a drug addiction.

PTSD: Pharmacology Considerations

• Lab and diagnostic tests
• Education
• Children and Adolescents:
  • Use of medications has become more frequent
  • Early intervention is critical
  • Relieving even one symptom has a significant positive impact on overall functioning
  • Dependent on the parent's, child's, and adolescent's beliefs and values of pharmacological interventions
  • SSRIs are the most researched medications in children and adolescents
• Older adults:
  • Caution as medications are metabolized in the liver
  • Increase risk for drug-to-drug interactions
  • Decreased liver functioning
• Seven considerations when implementing pharmacological interventions across the lifespan:
  • Early intervention
  • SSRIs are 1st line medications
  • SSRIs are the most researched medications for use in PTSD and the only medications approved by Health Canada for PTSD
  • Important to treat other co-morbid disorders
  • Children/Adolescents in particular benefit from the relief of even one symptom
  • Children/Adolescents – inclusion of medication in the treatment plan is largely based on the values and beliefs about medication in child and adolescents
  • Caution when using medications in older adults related to liver function.

Pharmacology: SSRI

• Address symptoms associated with serotonergic dysregulation.
• Decreased risk of relapse if prescribed for at least a year.
• Side effects include suicidal ideation and behavior.
• SSRIs can increase blood a concentration of:
  • Warfarin
  • Digoxin
  • Beta-blockers
  • Benzodiazepines
• Diuretics and alcohol can increase blood concentration of SSRIs.
• Ibuprofen, naproxen, and aspirin can decrease the blood concentration of SSRIs.
• Medications approved by Health Canada:
  • Citalopram (Celexa)
  • Sertraline (Zoloft)
• Additional medications prescribed (off-label):
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)

Pharmacology: Antipsychotics

• Address symptoms such as agitation, dissociation, hypervigilance, paranoia, or brief psychotic reactions (off-label uses).
• Medications include:
  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)

Pharmacology: Benzodiazepines

• Intended for short-term management only.
• Used in crisis situations.
• Address symptoms of anxiety and hyper-vigilance.
• Medications include:
  • Lorazepam (Ativan)
  • Alprazolam (Xanax)
  • Diazepam (Valium)

Pharmacology: Other Medications

• Clonidine (Catapres)*
  • Reduces anxiety and arousal
  • Improves concentration and mood
  • Decreases behavioral impulsivity
• Guanfacine (Tenex)*
  • Reduces nightmares
• Propranolol*
  • Reduces arousal symptoms
• * Indicates off-label use.

PTSD: Therapeutic Interventions

• Purpose of therapeutic interventions develops new coping skills and new ways of understanding his/her traumatic experience.
• Therapeutic interventions include:
  • Relaxation and mindfulness techniques
  • Cognitive restructuring
  • Emotional regulation.

PTSD: Trauma-Focused CBT

• Trauma-focused Cognitive Behavior Therapy (TF-CBT) includes three components:
  • Psychoeducation
  • Telling the trauma narrative
  • Restructuring.

PTSD: Psychoeducation

• Normalizing symptoms
• Learn the following coping strategies:
  • relaxation
  • mindfulness
  • naming feelings
  • connecting feelings with thoughts and behaviors
• Mindfulness:
  • Becoming aware of one's thoughts and feelings and accepting them without judgment
  • Interrupting autonomic processing

PTSD: Trauma Narrative

• Role of the nurse facilitates the patient moving forward:
  • Curiosity about the patients' own resources occurs, not solely about the experience.
  • Acknowledge and validate as part of their unique experience.
  • Inquiry, not advice, focusing on the experience parts that are missing in the narrative.

PTSD: Restructuring

• Move from automatic thinking to conscious thinking.
• Uses CBT to identify negative thought patterns and develop healthy coping strategies.
• Consequences of not restructuring:
  • Getting stuck in the past
  • Hypervigilance
  • Risk of burnout

PTSD: Cognitive Behavior Therapy (CBT) Examples

• Traps include: Catastrophizing, Theorizing, Mood Checking, Emotions working as a memory filter
• Cognitive traps include: Generalizations that are accepted for all situations, Disqualifying the positive, Mind Reading, Fortune Telling, Labelling

Homework in Mental Health

• Summarizes and consolidate learning.
• Provides opportunity for the patient to practice what he or she has learned.
• Allows the nurse to provide feedback and encourage problem solving.
• Related to the patient's goals.
• Homework focused on specific areas:
  • Physical needs
  • Mental status needs
  • Safety needs
  • Functional needs
  • ADLs
  • Medication (knowledge, administration, adherence).

Communication

• Nurse-Patient :
  • Focuses on specific individual problems
  • Relationship between the patient and the therapist is integral
  • Tailoring solutions to the individual and his/her circumstances
• Nurse-Family
  • Explores relationships as a way to approach change
  • Nurse acts as facilitator
  • Understands communication patterns

Communication: Nurse-Group

• Purpose:
  • To learn about "insight" in relation to "outsight."
  • Explore relationships.
  • Gain new techniques or skills from learning acquired from others.
  • Enhance healthy emotional experiences.
  • Explore dependency.
  • Develop social skills.
  • Improve confidence.

Review: Groups

• Types of Groups: Open vs. closed, Homogeneous vs. heterogeneous, Educational, Process

Addictions: Pharmacological Interventions

• Two purposes for using medications: manage withdrawal and treatment.
• CIWA-A to begin monitoring: likelihood of alcohol withdrawal.
• CIWA-A when to stop monitoring: score is <10 for three consecutive assessments.
• Continue to monitor informally for re-emergence of symptoms.
• Withdrawal: CIWA-A considerations:
  • Waking your patient
  • Eye contact
  • Use of Ativan or Valium will not necessarily prevent seizures
• Medications are always used in conjunction with behavioral therapies.
• Medication: treatment:
  • Benzodiazepines: Ativan and Valium
  • Methadone: used for opioid addiction, suppresses withdrawal symptoms, and relieve cravings.
  • Tobacco: uses Nicotine replacements, Bubroprion (Wellbutrin), and Varenicline (Champix)

Motivational Interviewing (MI)

• Process Goal: for the patient to use his/her own voice to express concerns, and recognize the argument for change.
• Outcome Goal: to have patient resolve ambivalence and increase motivation and commitment to change.
• Role of the Nurse:
  • Engage the patient
  • Collaborate to create understanding
  • Direct attention to potential change
  • Provide expertise
• Empathy is a way of listening and responding to foster understanding which involves aspects of communication such as validation, clarification, inquiry, eye contact and tone of voice
• OARS represents the first four:
  • O - Open ended questions,
  • A - Affirmation,
  • R - Reflective Listening
  • S - Summarizing Change Talk: Listening for discrepancies and expressions of ambivalence
• Eliciting Change Talk
  • Categories of change talk (DARN)
    • D - desire
    • A - ability
    • R - reasons
    • N - need Facilitates action (CAT)
  • C - commitment
  • A - (taking) Action
  • T - trying (effort)

Explore the synergy of pharmacological agents and psychotherapy in PTSD treatment. Understand interventions promoting safety across the lifespan. Learn the nurse's role in communication using MI techniques.