PTSD Treatment: Pharmacology, Therapy, and Nursing

Wellness Resources

• Content on PTSD and addictions can be difficult and may trigger personal experiences
• Available support resources include:
  • U of C Wellness Center at (403) 210-9355
  • Distress Centre at (403) 266-4357
  • Calgary Counselling Center at (403) 265-4980
• An IOR can also be contacted

Class Objectives

• Identify how pharmacological agents and psychotherapy are jointly used in PTSD treatment
• Describe how pharmacological and psychotherapeutic interventions maintain the safety and well-being of PTSD patients throughout their lives
• Critique how the SEDoHs influence pharmacological and psychotherapeutic interventions
• Describe how nurses utilize age-appropriate communication skills
  • Skills include normalizing, active and reflective listening, intervening, injecting doubt, and confrontation
  • These skills are used with individuals, families and groups
• Nurses summarize their role in Motivational Interviewing (MI)
• Explain how the nurse would integrate MI as an intervention to support wellness momentum for PTSD patients and their families
• Summarize the five components of empathy in relation to MI, how they're implemented in the elicit-provide-elicit cycle
• Define the principles of change talk using DARN and CAT

PTSD: Brain Structures and Neurotransmitters

• Key structures involved in PTSD:
  • Amygdala
  • Thalamus
  • Hippocampus
  • Prefrontal cortex
• Key neurotransmitters:
  • GABA (gamma-amino butyric)
  • Dopamine
  • Norepinephrine
  • Serotonin

Six Principles of Trauma-Informed Care

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment, voice and choice
• Cultural, historical, and gender issues

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 are usually prescribed to decrease symptoms:
  • Anxiety
  • Depression
  • Panic
  • Difficulty falling asleep
  • Nightmares
  • Increased arousal symptoms
• Early intervention promotes the best outcomes across the lifespan
  • Resolve trauma before another occurs
  • Identify maladaptive coping skills and to develop healthy, adaptable coping mechanisms
• SSRIs are considered first-line medications
  • The only approved medication for PTSD in Canada
  • Frequently used in all age groups
• Medications used for "off-label" indications:
  • Antipsychotics
  • Benzodiazepines
  • Clonidine (Catapres)
  • Guanfacine (Tenex)
  • Propranolol
• 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
• Individuals with PTSD:
  • 50% will have an alcohol addiction
  • 30% will have a drug addiction
• Considerations when medications are prescribed includes lab and diagnostic tests, and education.

Pharmacology: Across the Lifespan

• 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
• Older adults:
  • Caution needed as medications are metabolized in the liver
    • Increase risk for drug-to-drug interactions
    • Decreased liver functioning

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 concentration of Warfarin, digoxin, beta-blockers, benzodiazepines
• Diuretics and alcohol can increase the 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, brief psychotic reactions (off-label uses)
• Medications include:
  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)

Pharmacology: Benzodiazepines

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

Pharmacology: Other Medications

• Clonidine (Catapres)*:
  • Reduce anxiety and arousal
  • Improve concentration and mood
  • Decrease behavioral impulsivity
• Guanfacine (Tenex)*:
  • Reduces nightmares
• Propranolol*:
  • Reduce arousal symptoms

PTSD: Therapeutic Interventions

• Therapeutic interventions help the individual develop 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 coping strategies, such as:
  • Relaxation
  • Mindfulness
  • Naming feelings
  • Connecting feelings with thoughts and behaviors
• Mindfulness which involves:
  • Becoming aware of one’s thoughts and feelings and accepting them without judgment
  • Interrupt autonomic processing

PTSD: Trauma Narrative

• Role of the nurse is to facilitate the patient moving forward
  • Curiosity about the patients own resources; not solely about the experience
  • Acknowledge and validate as part of their unique experience
  • Inquiry; not advice giving
  • Focuses on parts of the experience 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
  • Hypervigilant
  • Risk of burnout

Homework in Mental Health

• Purpose is to summarize and consolidate learning
• It provides an 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 may be focused on physical needs, mental status needs, safety needs, functional needs, ADLs or medication (knowledge, administration, adherence)

Communication

• Consider how nurses’ roles and skills may be similar and different when working with individuals, families, and groups, as well as, across the lifespan.
• Nurse-Patient:
  • Focus on specific individual problems
  • Relationship between the patient and the therapist is integral
  • Solutions are tailored to the individual and his/her circumstances
• Nurse-Family:
  • Explore relationships as a way to approach change within a larger support system
  • Nurse is facilitator
  • Understand communication patterns.
• Nurse-Group is for people to:
  • Learn about “insight” in relation to “outsight”
  • Explore relationships
  • Gain new techniques or skills from learning that is acquired from others
  • Provide for healthy emotional experiences
  • Exploration of dependency
  • Develop social skills
  • Increase confidence.
• Types of Groups include:
  • Open vs. closed
  • Homogeneous vs heterogeneous
  • Educational
  • Process

Addictions: Pharmacological Interventions

• Two purposes of using medications:
  • Manage withdrawal, assessed by way of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A)
  • Treatment
• When to begin monitoring for withdrawal:
  • When there is a likelihood of alcohol withdrawal
• When to stop monitoring for withdrawal:
  • When the score is <10 for three consecutive assessments
    • Continue to monitor informally for re-emergence of symptoms
• Considerations: - Waking your patient - Eye contact - Use of Ativan or Valium will not necessarily prevent seizures
• Medications for treatment are always used in conjunction with behavioral therapies
  • Benzodiazepines include Ativan and Valium
  • Methadone:
    • Used for opioid addiction
    • Suppress withdrawal symptoms
    • Relieve cravings
  • Tobacco:
    • Nicotine replacements
    • Bubroprion (Wellbutrin)
    • Varenicline (Champix)

Addictions: Motivational Interviewing

• Motivational Interviewing (MI) goals:
  • Process Goal: for the patient to use his/her own voice to express concerns, and recognize the argument for change
  • Outcome Goal: to have the patient resolve ambivalence and increase his/her motivation and commitment to change
• Role of the Nurse:
  • Engage the patient to tell his/her story
  • Collaborate to create understanding -Direct attention to potential change
  • Provide expertise
• Empathy:
  • A way of listening and responding to foster understanding
  • Involves aspects of communication such as:
    • Validation
    • Clarification
    • Inquiry
    • Eye contact
    • Tone of voice
• OARS represents the four components to develop empathy:
  • O - Open ended questions
  • A - Affirmation
  • R - Reflective Listening
  • S - Summarizing
• Change Talk involves:
  • Listening for discrepancies and expressions of ambivalence
• Categories of change talk (DARN):
  • D - desire
  • A - ability
  • R - reasons
  • N - need
• Facilitates action (CAT):
  • C - commitment
  • A - (taking) Action
  • T - trying (effort)