Category: anxiety

Navigating PTSD in Primary Care

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INTRODUCTION 

During the COVID-19 pandemic, rates of posttraumatic stress disorder (PTSD) surged in the US. The Centers for Disease Control (CDC) and National Center for PTSD estimate that 5% of adults struggle with PTSD. Over the past five years, rates of PTSD in college students more than doubled. Globally, the World Health Organization (WHO) has found that 1 in 3 people who encounter trauma will go on to develop PTSD. And of those impacted, more than a quarter will experience severe symptomatology. 1,2,3

First recognized as “shell shock” in veterans returning from the Great War, our understanding of the brain and body’s response to trauma has evolved with time. As has our definition of trauma. PTSD is characterized by the following constellation of symptoms: 

  1. Intrusive re-experiencing (nightmares, flashbacks) 
  2. Avoidance (of places or stimuli that recall the trauma) 
  3. Negative alterations in cognition and mood 
  4. Markedly increased arousal and reactivity (sleep disturbance, hypervigilance, irritability) 

These symptoms must come in the context of direct experience of trauma or extreme exposure to details of a trauma. Our definition of traumatic events and exposures include the classic exposures like war and violent crime but also now include motor vehicle accidents, extreme weather events, intimate partner violence and ACEs – adverse childhood events. We also recognize that sentinel events can precipitate PTSD as frequently as chronic exposure and serial events can. Our evolving understanding of trauma response has also broadened our diagnostic conceptualization. The WHO has recognized cPTSD or complex PTSD as being on a spectrum with PTSD and borderline personality disorder. That is to say, those who experience trauma may exhibit maladaptive coping strategies and interpersonal struggles alongside hypervigilance, re-experiencing and avoidance.  

CLINICAL PRESENTATION 

Patients with posttraumatic stress disorder frequently present to their primary care or family medicine providers before ever being seen by a psychiatrist or other mental health specialist. Those with PTSD frequently experience somatic complaints: 

  • Headache 
  • Constipation or Diarrhea 
  • Insomnia 
  • Changes in Functional Status 

Without clear evidence of physiologic changes on exam, many patients leave appointments with unresolved worry, often returning to urgent care or even emergency department settings with similar complaints. Unfortunately, this often leads to a pattern of high utilization of services by patients and compassion fatigue and demoralization for healthcare providers.

When patients report recent or past exposure to trauma, obtaining a subjective history of symptoms alongside objective data is indicated. Many who suffer from PTSD will have co-occurring struggles with: 

  • Substance Use 
  • Depression 
  • Anxiety and Agoraphobia 
  • Executive Dysfunction or Functional Impairment  

While it is often impossible to eliminate confounding variables, trauma and trauma response are often central to many other mental health struggles. And accurately diagnosing PTSD and steering patients towards effective and evidence-based treatments will lead to an overall improvement in functioning and a decrease in suffering.  

PATHOPHYSIOLOGY 

Traumatic events, whether sentinel or chronic and sequential, elicit a reflexive fear response in the body and brain. Better known as “Fight, Flight or Freeze”, our autonomic nervous system quickly responds to a perceived threat to maintain safety. For those who move on from a traumatic event to experience PTSD, their autonomic nervous system is primed to respond. That is, their brain’s fear circuitry is chronically active, always ready to fight, flee (or freeze) if cues in the environment signal danger. While a car backfiring may elicit a startle response in the average person, those who struggle with PTSD would experience significant autonomic reactivity that may result in elevated blood pressure, heart rate and even panic. Signs of elevated autonomic arousal may include: 

  • Elevated resting heartrate 
  • Decreased heart rate variability 
  • Elevated blood pressure 
  • Decreased appetite and/or carbohydrate cravings 
  • Impaired memory and attention 
  • Insomnia 
  • Fatigue 

COLLABORATION AND CARE 

Offering validation and acknowledgement of the severity of symptoms promotes trust with patients who have PTSD. A sturdy alliance with the promise of collaboration often leads to improved health outcomes and reduced utilization of services. Arriving at a formal diagnosis of PTSD is not always easy in primary care settings. The PCL website includes a link to the Primary Care PTSD Screen a 5-item screen designed to identify individuals with probable PTSD. Fortunately, formal diagnosis does not have to occur before symptom management can start.  

Psychotherapy is the gold standard for treating PTSD. At the UW, we train providers in Cognitive Processing Therapy though we recognize this is a limited resource and there are other types of short-term, targeted therapy that patients may find helpful. Therefore, a referral to an experienced mental health professional is the preferred treatment approach. If a patient is struggling with co-occurring depression, substance use or severe functional impairments, consideration of involving Social Work would be indicated, as well.

Medication management of symptoms may include: 

  • SSRIs to target anxiety and low mood 
  • Prazosin to target nightmares and autonomic reactivity 
  • AVOID benzodiazepines and hypnotics as these have been shown to worsen prognosis 
  • Similarly, avoiding alcohol and other CNS depressants is advised 

PTSD, like many chronic conditions, impacts entire family systems and the trajectory of many patients’ lives. Screening, diagnosis and intervention are essential so please never hesitate to seek out collaborative support from behavioral health providers including psychiatric consultation from the PCL team! 

1. https://www.ptsd.va.gov/

2. https://www.cdc.gov/mmwr/volumes/70/wr/mm7026e1.htm

3. https://www.who.int/news-room/fact-sheets/detail/post-traumatic-stress-disorder 

Additional References

https://hr.nih.gov/working-nih/civil/post-traumatic-stress-disorder-ptsd-2024

https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819206#:~:text=We%20observed%20upward%20trends%20in,%25%20(2021%2D2022).

Author

Tuesday Burns, MD

Dr. Burns is the medical director of UWMC-Roosevelt Outpatient Psychiatry Clinic. Her practice experience spans academic, research and clinical realms, with a focus on working with patients experiencing treatment-resistant depression, those with co-occurring medical complexities, and patients impacted by hormonal changes related to puberty, pregnancy, gender transitions and menopause. Dr. Burns’ background in the neurosciences and medical psychiatry gives her a comprehensive understanding of the biologic basis of psychiatric illness and the strength of the mind-body connection.

Related Resources

Dr. Burns presented on Navigating PTSD and Elizabeth Lehinger, PhD, presented on What is Complex PTSD? Understanding current evidence and treatment implications as part of the UW Psychiatry and Addictions Case Conference (PACC) series, a free, weekly teleconference that connects community providers from across Washington with UW Medicine psychiatrists, psychologists, and addictions experts. Sessions include both an educational presentation and (de-identified) clinical case presentations allowing providers an opportunity to receive feedback and recommendations from interdisciplinary attendees. CME is available for free or for a small fee. Visit the PACC website for more information.

The US Department of Veteran’s Affairs runs the National Center for PTSD, and their website includes a variety of free information and resources for patients, loved ones, and providers and has content in Spanish and English.

Addressing sleep-related difficulties

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“I’m having trouble sleeping” is a common concern of patients who report co-morbid mental health concerns like anxiety or depression and/or have a history of trauma, but sleep issues can be reported independently of other conditions as well. Though it can be tempting to suggest using melatonin or another medication to aid with sleep,  there are simple behavioral interventions that may be just as – if not more – effective in the long-term for addressing sleep-related concerns. 

One of the simplest ways to gain a better understanding of what sleep-related concerns our patients are facing is to ask. Is it that they aren’t sleeping as much as they would like to? Are they sleeping too much? Is their sleep interrupted? Asking about environmental factors is important, too. Do they have a new baby at home? Did they recently change jobs? Do the other people in their home sleep on different schedules than they do? Even clarifying what their sleep schedule looks like can help you to decide what to recommend.

Someone can have sleep-related problems that don’t rise to the diagnostic criteria for insomnia, or they may be experiencing primary or secondary insomnia. Once you’ve gathered information about what problems they are encountering, you’ll have a better sense of whether the difficulties are related to sleep onset, sleep maintenance, or early awakening (or some combination). It’s also a good idea to assess for other sleep disorders, not just insomnia. According to the Center for Disease Control, the most common sleep disorders, in addition to insomnia, are narcolepsy, Restless Leg Syndrome, and Sleep Apnea. An important note about sleep apnea – be sure to assess for it even in your patients who are not classified as obese, as apnea may occur in individual with normal or low BMI.

After clarifying what sleep-related difficulties your patient is reporting – and attending to any potential sleep disorders aside from insomnia – it’s a great time to begin talking about sleep hygiene. Consistency is key when it comes to sleep hygiene. Going to bed at the same time every night (when possible, of course) and getting up at the same time each morning can go a long way. Yes – even on non-workdays!

Another important sleep hygiene tip: the bed is for three things – sleep, sex, and sick. It can be tempting to read or watch TV in bed. And who among us hasn’t played on our phones instead of going to sleep? However, maintaining the sanctity of the bed for sleep, sex, and/or sick – and only these three things – encourages strong sleep-bed associations. Something else that encourages strong sleep-bed associations? Getting out of bed within 10-15 minutes of waking or if unable to fall asleep for approximately 15-20 minutes. The longer you are in bed and awake, the weaker your sleep-bed association will be.

Other sleep hygiene tips:

  • Avoid napping (unless it’s a safety concern). It can be tempting, especially when someone is very tired, but it ultimately decreases one’s “sleep appetite” and makes it harder to sleep at night.
  • Implement a wind-down routine, preferably without screens (TV, phones, computers, etc.). Try to avoid screens for an hour or more before bed.
  • Keep your bedroom cool and dark.
  • Avoid exercise, eating, or drinking close to bedtime. If someone wakes due to hunger, trying a small snack before bed could help – but it’s best to avoid a large meal.
  • Avoid alcohol, cigarettes, and other substances close to bedtime. For those individuals who smoke cigarettes – a gentle reminder that nicotine is a stimulant and therefore counterproductive to sleep can be helpful.
  • If waking in the middle of the night, avoid eating, drinking, or smoking. Our bodies become habituated to patterns and if you eat a snack every night at 2:00am, 2:00am may officially become snack time!
  • Don’t go to bed unless you’re tired. This might run counter to “consistent bedtime” however, getting into bed just because the clock (but not your body) says it is time can make it harder to sleep.

Individuals who are not able to correct their sleep difficulties with sleep hygiene alone may benefit from completing a course of Cognitive Behavioral Therapy for Insomnia. This treatment typically occurs across 4-8 sessions, though individuals may begin to see positive results in as few as 3 weeks. This treatment can be completed with a trained therapist or via a self-paced online course. CBT-I can be tried before sleep medications and, in many cases, may end up making medication unnecessary.

CBT-I provides education about sleep, sleep hygiene, and helps to identify specific strategies to improve an individual’s sleep. It may involve sleep restriction – the practice of restricting when a person gets into bed and gets up – which helps consolidate sleep into a more solid block. As sleep becomes consolidated (and sleep efficiency improves), more time in bed is added based on individual need and bedtimes/wakeups are adjusted.

One last caveat – if you are seeing a patient who has been diagnosed with ADHD and is reporting sleep-related concerns, you may want to explore the possibility of Delayed Sleep Phase Syndrome (DSPS), in which the sleep/wake phase occurs later than “normal.”

Sleep is extremely important to health – and when we’re not getting enough of it, it shows. Hopefully this information will prove helpful in working with patients with that ever-present concern of, “I’m having trouble sleeping!” You can always call the Psychiatry Consultation Line (877-927-7924) for clinical advice when sleep issues co-present with mental health concerns like anxiety, depression or ADHD as well as assessment, treatment decisions and monitoring of mental health conditions in general. Call us anytime – we are a part of your team!

Author
Koriann Cox, PhD
Acting Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences

Learn More:
UW Psychiatry and Addictions Case Conference series (UW PACC)*

When should I use sleep aids in my patients with sleep disorders… (and when should I not?)
Presenter: Catherine McCall, MD
The objectives of this presentation are to 1) learn about different ways in which insomnia can manifest; 2) understand the pathophysiology of insomnia; and 3) explore different ways to address and treat
insomnia effectively.

Psychological and behavioral treatments for insomnia
Presenter: Katherine Palm-Cruz, MD
The objectives of this presentation are to 1) develop an understanding of psychological and behavioral treatments for insomnia disorder; 2) understand recommendations for first line treatments for chronic insomnia; and 3) appreciate the evidence of how CBT-I compares to pharmacologic treatments for insomnia.

My patient has good sleep hygiene. What should I counsel them to do next to improve their poor sleep?
Presenter: Barbara McCann, MD
The objectives of this presentation are to 1) conduct a 24-hour interview to identify problem areas in need of remediation to address insomnia; 2) identify two broad areas of sleep-interfering cognitions and suggest strategies for dealing with each type; and 3) make use of stimulus control principles to address sleep-interfering behaviors.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Learn More: other resources

Non-stimulants for adult ADHD

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While the data on the efficacy of stimulants in adult ADHD is robust, we have had numerous calls to the PCL program from providers seeking information on medications that have a lower misuse and abuse potential.

Atomoxetine has an FDA indication for adult ADHD. Atomoxetine is often thought of as the first-line medication for adult ADHD in patients with a history of substance use disorder. There are several studies that demonstrate an improvement in quality of life ratings, for example, with longer term use in patients with ADHD. Atomoxetine selectively inhibits norepinephrine reuptake and medications with this mechanism of action convey a risk of psychosis and mania, especially in patients with a personal or family history of bipolar disorder or psychosis. Like many medications with an antidepressant-like mechanism of action, atomoxetine has a black box warning for increased suicidality in children, adolescents and young adults.

Bupropion does not have an FDA indication for ADHD, though there are meta-analyses that suggest it has some utility. Bupropion is FDA-approved for major depressive disorder. The symptom of poor concentration can be magnified when patients with ADHD experience a major depressive episode. For some of these patients, bupropion might help both disorders. Providers should keep in mind, however, that bupropion is not effective for anxiety disorders. Moreover, some patients with anxiety disorders find that bupropion worsens their anxiety symptoms. Like atomoxetine, bupropion has a black box warning for suicidality in patients under the age of 25. Bupropion can also cause mania and psychosis, particularly in patients with a personal or family history of bipolar disorder or psychosis. Bupropion can increase the risk of seizure and is contraindicated in patients with eating disorders.

While guanfacine has an FDA indication for pediatric ADHD, it does not have an FDA indication for adult ADHD. Some authors are pessimistic about its utility in adult ADHD. Overall, the data is mixed and there have only been a few controlled studies, though research is actively being done and the efficacy (or lack thereof) of guanfacine in adult ADHD may be more clearly articulated in the next few years. Guanfacine is an alpha-2 agonist that is used to treat hypertension and thus it has a unique side effect profile compared to atomoxetine or bupropion.

If you are considering using any of the medications discussed above, please first review your own reference material for full details on side effects, dosing, adjustment in the setting of renal or hepatic impairment, cautions/contraindications, monitoring requirements, and safety in pregnancy and lactation. We most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/. You can also call the Psychiatry Consultation Line (877-927-7924) for clinical advice on using these medications in the treatment of adult ADHD as well as assessment, treatment decisions and monitoring of mental health conditions in general. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line

Learn More
Cognitive Behavioral Therapy (CBT) for adult ADHD: does ADHD need therapy (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Kristen Lindgren, PhD, ABPP
The objectives of this presentation are to 1) review diagnostic criteria for ADHD, 2) understand the Role of CBT in the Treatment of adult ADHD, and 3) describe how combined medication and CBT can benefit adults with ADHD

Treating ADHD in SUD patients: how do I treat patients with ADHD and SUDs without making them addicted to stimulants? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Robert Sise, MD, MBA, MPH
The objectives of this presentation are to 1) review general considerations in diagnosis of adult ADHD, 2) explore multimodal treatment for adult ADHD with co-occurring SUDs, 3) discuss risks and benefits of pharmacotherapy, and 4) explore how ADHD treatment should be coordinated with SUDs treatment.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Treating Generalized Anxiety Disorder with buspirone

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A common question to the Psychiatry Consultation Line is around treatment of Generalized Anxiety Disorder (GAD) in patients with a history of substance use disorders and for whom a Selective Serotonin Reuptake Inhibitor has not been effective. First-line treatments for Generalized Anxiety Disorder include Cognitive Behavioral Therapy (CBT), Serotonin Reuptake Inhibitors (SRI), or a combination of both. In cases where adjunctive CBT and multiple trials of SRIs have failed, buspirone can be given some consideration.

In 1980s-era, double-blind studies of GAD, buspirone’s efficacy was shown to be similar to benzodiazepines. An important difference between benzodiazepines and buspirone is that it takes buspirone longer to start working. Buspirone requires a multi-week or multi-month trial to assess efficacy. Compared to benzodiazepines, buspirone is less likely to cause sedation and, importantly, is not associated with the development of tolerance or dependence. Common side effects of buspirone include dizziness, nausea, and headache.

The FDA max dosing is 60mg/day and while some patients require a high dose, average therapeutic doses are in the range of 20 to 45 mg/day. Buspirone has a short half-life and some patients benefit from TID dosing.

Please refer to your own reference material for full prescribing information regarding medication dosing, risks, benefits, side effects, monitoring requirements, and drug interactions. We most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatric Consultation Line

Learn more
How do I address emerging anxiety during substance use recovery?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) discuss characteristics between a substance induced anxiety disorder and a primary anxiety disorder, and 2) to talk through different treatment options for anxiety symptoms.

CBT for Anxiety (CBT-A): What can I do with my patient instead of giving them a PRN benzodiazepine?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Patrick Raue, PhD
The objectives of this presentation are to 1) understand the CBT model of anxiety symptoms, 2) describe how to give the “treatment pitch” to patients, and discuss the difference between treatment with exposure vs. anxiety management strategies, 3) understand how to develop and work on an exposure hierarchy with patients and 4) describe anxiety management strategies that use physical and cognitive approaches.

Anxiety: fast facts and skills for the primary care physician  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Ryan Kimmel, MD
A brief overview of diagnosing and treating anxiety in primary care.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.