PTSD - Kansas Association of Sleep Professionals

Report
Combat Posttraumatic Stress Disorder
(PTSD), Sleep, Prazosin and Nightmares
October 24, 2014
Thomas Demark, MD
Kansas City VA Medical Center
Honor Annex – PTSD Treatment Program
Objectives
 To have a better understanding of military/combat related PTSD.
 Improved ability when treating a patient who has PTSD,
Nightmares and Insomnia.
 Summarizing CSP #563: “Prazosin and Combat Trauma PTSD”
DSM 5 definition of PTSD
 1. exposure to traumatic event (combat)
 2. persistent re-experiencing (intrusive thoughts/images, nightmares,
flashbacks)
 3. persistent avoidance (avoidance of triggers, social isolation)
 4. persistent hyper-arousal (anxiety, panic attacks, irritability, anger,
hypervigalence, paranoia)
 5. symptoms > 1 month
 6. significant impairment in social or occupational
functioning (work, school, relationships, etc)
Combat related PTSD – Post Traumatic Stress Disorder
(shell shock, battle fatigue, psychoneurosis, traumatic war neurosis)
Severe Anxiety Disorder: hyperarousal of amygdala and (emotional
memories and fear), hippocampus and prefrontal region
 Civilian: abuse, rape, MVA, injury, divorce, etc (anything traumatic)
 Military
 Combat: since the times of the Greeks and Romans
 Non-combat
 Military Sexual Trauma (MST)
Combat-related PTSD
Physical injury and disfigurement (loss of limb/s, loss of eye/s,
burns to body/face, loss of genitals)
Surrounded by death, watching friends die traumatic deaths:
Sole survivor or few survivors after a battle.
Observing or participating in atrocities of war
Rape, torture, mutilation of bodies, harming of civilians, women, children
and/or elderly
Taking of life, many lives – killing (“On Killing” D. Grossman)
Treatment for combat PTSD
 Medication
 Individual Talk Therapy
 Group Therapy
 Couple/ Marital / Family Therapy
PTSD and Insomnia
Pts with combat PTSD most often meet criteria for insomnia.
Pts generally sleep for 2-4 hours of broken sleep
Trouble falling and staying asleep
Frequent nightmares and night sweats, 5 or more times per week.
Occasional transition from a nightmare into a flashback.
Hypervigilence with each waking, will get weapon, check all
doors and locks, will secure perimeter. May or may not patrol
outside of the home.
 Many veterans do not get peace of mind until sunrise, thinking I
have survived one more night and daytime is safe time.
 Frequent night missions, this is a time for danger/hyperarousal.
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Evaluation of Insomnia 2/2 PTSD
 Trouble with sleep initiation (falling asleep)
 Trouble with sleep maintenance (staying asleep)
 Trouble with both (falling and staying asleep)
 Presence of nightmares and / or night sweats
 Any acting out / violence when sleeping
 Any reports of snoring or stopping of breathing
 Nightmares are reported by 52% of combat veterans
with PTSD diagnosis.
Treatment of Insomnia 2/2 PTSD
 Trouble with sleep initiation (falling asleep) - zolpidem
 Trouble with sleep maintenance (staying asleep) - temazepam
 Trouble with both (falling and staying asleep) – combination
therapy
 Presence of nightmares and / or night sweats – alpha or beta
blocker
 Any acting out / violence when sleeping - atypicals
 Any reports of snoring or stopping of breathing – sleep study
consult
Treatment of Insomnia 2/2 PTSD
 Good sleep hygeine (get a nightlight for bedroon, do not watch the news, history
or military channel before bedtime)
 MEDICATIONS:
 Sleep:
• Diphenhydramine / Benedryl 25-50mg.
• Hydroxyzine / Vistaril 10-100mg.
• Trazodone / Deseryl 25-200mg.
• Zolpidem / Ambien 2.5-10mg at bedtime, up to 20mg
• Benzodiazepines (alprazolam 0.25-2mg, lorazepam 0.5 to 2mg, diazepam 520mg, temazepam 7.5-30mg, clonazepam 0.5-2mg)
• SSRI (mirtazipine / remeron 7.5-15mg)
• Atypicals (seroquel 50-300mg, risperdone 0.25-4mg)
• Haldol / haloperidol 1-10mg.
Combination Treatment/Polypharmacy
 Often times combinations of sleep medications, whether used
label or off label, in combination with alpha or beta blocker, plus
an atypical is what is needed for the patient to get more than 5
hours of sleep.
 Fluctuations of dosing may be necessary as the condition and
insomnia waxes and wanes over time. Vacilating in nature.
 Increase in severity of insomnia near military holidays: Veterans
Day, Labor Day and especially Independence Day (4th of July) –
symptoms are triggered by fireworks. Noise made by fireworks
resemble small arms fire, rockets, grenades, RPGs, mortars, and
IEDs.
Nightmare and Night Sweat
suppression
 Alpha blockers (prazosin)
 Doses from 1-15mg at bedtime, start with 2-5mg, then titrate upward
based on response and tolerability
 Recent research with prazosin doses up to 20mg total (15mg at bedtime
and 5mg in morning)
 Beta blockers (metoprolol, labetalol, etc)
 PM dose, titrate up based on tolerability and response
 Atypicals (quetiapine/seroquel, risperidone, zyprexa)
 Used for sedation and nightmare suppression, do not help suppress
nightsweats.
VA Research Historical Accomplishments
 1925 - conducted the first hospital-based medical studies to be formally
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considered part of VA’s newly established research program.
1928 - Completed studies regarding the mortality of veterans with mental
illness.
1941 - Established a research lab at the Northport (NY) VA medical center to
conduct clinical and biomedical research in neuropsychiatric disorders.
1958 - Invented the implantable cardiac pacemaker.
1960 - Pioneered the concepts that led to the development of computerized
axial tomography (CAT) scans.
1984 - Developed the nicotine patch.
1997 - Identified a gene associated with a major risk for schizophrenia
2003 – Launched the largest-ever clinical trial of psychotherapy to treat
posttraumatic stress disorder (PTSD)
2007 – Found that prazosin, an inexpensive generic drug already used by millions of
Americans for high blood pressure and prostate problems (BPH), could help improve sleep
and lessen trauma nightmares inVeterans with PTSD.
CSP #563: “Prazosin and Combat Trauma PTDS”
CSP#563 (PACT)
 What is CSP? Cooperative Site Program = multi-centered
clinical trial.
 15 VA sites: Albuquerque, Atlanta, Columbia, Durham,
Kansas City, Loma Linda, Long Beach, Madison, Miami, New
York Harbor, Palo Alto, Providence, Salisbury, Salt Lake City,
Seattle.
Prazosin
 Prazosin, trade names Minipress, Vasoflex, Pressin and
Hypovase, is a sympatholytic drug used to treat high blood
pressure, anxiety, PTSD and panic disorder. It is an alphaadrenergic blocker that is specific for the alpha-1-receptors. These
receptors are found on the vascular smooth muscle, where they
are responsible for the vasoconstrictive action of noerepinephrine.
They are also found throughout the central nervous system. As of
2013, prazosin is off-patent in the USA, and the FDA has approved
at least one generic manufacturer.
CSP # 563 (PACT)
 The dosing strategies of the study were determined by the Chairs
during years of research and clinical experience using prazosin to
treat nightmares and PTSD.
 There had appeared to be a considerable range in the optimally
effective dose of prazosin: Some patients had marked
improvement in nightmares after the first week (low dose of 2mg
of prazosin per night), and others required several weeks of
titration to a higher dose (15mg at bedtime and 5mg in the
morning) to achieve the same effect.
 The doses were well within the dose ranges of prazosin prescribed
for other clinical conditions such as hypertension.
 It was a multicentered double blinded placebo controlled
study.
 Patients were combat veterans with combat PTSD ranging
from Vietnam, Iraq and Afganistan.
 This was to determine the efficacy of prazosin vs. placebo
in combat Veterans with PTSD.
 The CAPS (Clinician Administered PTSD scale) was used to
rate the severity of nightmares.
 Dosing was started at 1mg at bedtime and titrated over a
period of 7 to 35 days based on level of nightmares &
nightsweats and tolerability.
 Doses were titrated up to 15mg at bedtime.
 Doses were titrated up to 5mg in the morning, if nightmare
symptoms were still present once a maximum dose of 15mg
was reached at bedtime.
 Once a patient had achieved his/her optimal dose of
medication, he/she will continue on this dose for a total of
26 weeks of treatment.
 After the week 10 visit (effectiveness phase) safety visits
occurred monthly.
 After the week 10 visit, the study drug could not be further
increased, only decreased if there was the development of
unacceptable side effects.
 What was determined from this study?
Results
 Prazosin was effective for trauma nightmares, sleep
quality, global function, CAPS score, and the CAPS
hyperarousal symptom cluster.
 Prazosin was well tolerated, and blood presure changes
did not differ between the groups.
Conslusion
 Prazosin is effective for combat-related PTSD with
trauma nightmares and the benefits are clinically
meaningful and significant.
 Substantial residual symptoms suggest that studies
combining prazosin with effective pharmacotherapy and
effective psychotherapy might demonstrate further
benefit.
What if the patient has a re-occurring nightmare
that is not responding to medication or if
medication for nightmares is contraindicated?
 Technique called “Dream Restructuring” for a re-occuring nightmare.
1.Write out the nightmare on a single piece of paper, a general description of
the nightmare, leave out details
2. Rewrite the nightmare and turn it into a pleasant dream, change the setting
and outcome of the nightmare, use vivid details
3. Symbolically and literally destroy the nightmare (burn it, tear it up, bury it,
throw darts at it, flush it down the toilet, etc.)
4. Read pleasant dream every night just before bed
5.Over time, the nightmare will change into the rewritten pleasant dream (2
weeks to 2 months, may take longer)
 Technique may be used with or without medication.
Approach
• Are you a veteran or in the military?
– are you a combat veteran?
PTSD screen
1.
2.
3.
4.
mood disturbance?
sleep disturbance?
bad dreams or nightmares?
problems with anger?
* Encourage further evaluation and/or treatment at a local
VA Medical Center.
Prevention of combat PTSD, Insomnia
and Combat Trauma Nightmares
References
 Clinicians Manual on PTSD. Yahuda and Davidson
 CSP# 563: “Prazosin Combat Trauma PTSD”
 Down Range, to Iraq and Back. Cantrell and Dean
 DSM 4 and 5
 New Yorker Magazine. Dream Restructuring
 On Combat. Dave Grossman

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