How do you know when a patient has recovered from PTSD (and you can consider de-prescribing medications)?

Nina is a 65 year old woman with PTSD and hypertension. She takes sertraline 100 mg daily, prazosin 10 mg every night, and losartan 25 mg in the morning. She taken these medications, at these doses, for 10+ years. She recently moved to San Francisco to be closer to her grandchildren and is establishing care with you. In reviewing her medications, you ask about the prazosin and how it has helped her. She says that the prazosin was prescribed for a recurring nightmare she was having many years ago about a sexual assault that occurred during the Vietnam War. She emigrated from Vietnam to the US as a refugee after the Vietnam War. Nina saw a psychiatrist for cognitive processing therapy and medications for a year, which she found helpful. The psychiatrist then retired, and her previous PCP has been refilling the sertraline and prazosin for 10+ years.

How do you know when a patient has recovered from PTSD (and you can consider de-prescribing medications)?

In PTSD, a traumatic event is defined as one in which an individual is directly exposed to actual or threatened serious injury, death or sexual violence, is indirectly exposed by learning about the traumatic experience of a loved one or witnessing severe trauma, or is repeatedly exposed within the context of employment (e.g. medics) (Spoont 2015). PTSD is characterized by:

  1. persistent re-experiencing of the traumatic event through nightmares, flashbacks, or intrusive thoughts
  2. avoidance of trauma-associations 
  3. increased negativity or numbed emotional responsiveness
  4. alterations in arousal or reactivity, such as an increased startle response (Spoont 2015).

The lifetime prevalence of PTSD ranges from 1.3 to 12.2% (Shalev 2017). After exposure to a traumatic event in the US, 13% of women and 6% of men develop PTSD (Spoont 2015). Between 30% and 50% of people with acute PTSD will have a chronic course (Spoont 2015). Adolescents and young adults with acute PTSD who went on to develop a more chronic course of PTSD had more severe PTSD symptoms at baseline and were more likely to have experienced a new traumatic event between baseline and follow up (Perkonigg 2005). In the same study, 43% of those with PTSD at baseline no longer had PTSD symptoms at follow-up assessments 20 and 42 months later (Perkonigg 2005). In other words, PTSD can go into remission, and many people heal.

Unfortunately, PTSD is still associated with long-term functional impairment even after remission (Sonis 2013). Primary care patients with a history of past PTSD without current PTSD had more impairment on quality of life indicators related to mental health (SF-12 MCS score) than their trauma-exposed counterparts who never developed PTSD (Westphal 2011). PTSD also co-occurs with mood, anxiety, or substance use disorders in more than 50% of cases (Shalev 2017).

How do you assess a patient for PTSD?

PTSD is a clinical diagnosis made based on a clinical interview. Structured screening tools may also be helpful in assessing a patient for PTSD. 

Screening Tools

In primary care, the PC-PTSD-5 can be used to screen for PTSD. The PC-PTSD-5 asks the patient to identify a traumatic event and then answer 5 questions about re-experiencing, avoidance, arousal, and negativity symptoms. Each yes adds a point, and the scores range from 0-5. Men who score 4 or higher or women who score 3 or higher on the PC-PTSD-5 should be further evaluated for PTSD, based on research from a large sample of primary care patients in the VA (Bovin 2021). 

For a more complete assessment of PTSD symptoms, primary care clinicians can ask patients to fill out the PTSD checklist (PCL-5). A provisional PTSD diagnosis can be made by treating each item rated as 2 (moderately) or higher as a symptom endorsed, then following the DSM-5 diagnostic rule which requires at least:

  • 1 re-experiencing symptom (Criteria B – Questions 1-5)
  • 1 avoidance symptom (Criteria C – Questions 6-7)
  • 2 symptoms related to negative alterations in cognition or mood (Criteria D – Questions 8-14)
  • 2 symptoms related to alterations in arousal or reactivity (Criteria E – Questions 15-20) (Bovin 2016).

Clinical Interview

Alternatively, PCPs can use the JAMA Rational Clinical exam interview guide to direct a conversation (Spoont 2015). The text for the JAMA Rational Clinical exam has been reformatted in the table below with minor modifications.

DSM-5 Diagnostic Criteria and Questions to Assess PTSD Once Trauma Exposure Has Been Established

Intrusion symptoms (≥1 meets PTSD criteria)Questions
Recurrent, involuntary, intrusive distressing memories of the traumatic event(s)Do you find yourself thinking about the trauma even when you don’t want to? Can you push those thoughts out of your mind?
Recurrent distressing dreams related to the traumatic event(s)Are you having bad dreams or nightmares about the trauma? If so, how often are you having them?

Dissociative reactions
Sometimes people who have had traumatic experiences can have brief periods when they feel that they are back in that previous traumatic experience, as though they are reliving it, even though the actual event happened in the past. Has that happened to you?
Intense or prolonged distress at exposure to triggers that resemble or symbolize the traumatic event(s)Have you been getting emotionally upset when something reminds you of the trauma? How long does it last? How bad does it get?
Marked physiological reactions at exposure to triggers that resemble or symbolize the traumatic event(s)When something reminds you of the trauma, do you have physical reactions (eg, heart pounding, trouble breathing, or sweating)?
Avoidance symptoms (≥1 meets PTSD criteria)Questions
Avoidance of distressing memories, thoughts, or feelings associated with the traumatic event(s)Have you been trying to avoid thinking about the trauma?
Avoidance of external reminders of the traumatic event(s)Have you tried to avoid people or things that remind you of the trauma?
Alterations in cognition and mood (≥2 meets PTSD criteria)Questions
Inability to recall an important aspect of the traumatic event(s)Do you have trouble remembering some important part of the trauma?
Persistent negative beliefs or expectations about oneself, others, or the worldAre you having more negative thoughts about yourself, other people, or the world since the trauma?
Persistent, distorted cognitions about the causes or consequences of the traumatic event(s)Do you feel like the trauma is all your fault? Why? Do you think that it is all someone else’s fault?
Persistent negative emotional stateHave you been feeling bad since the trauma—having lots of anger, fear, anxiety, or guilt much of the time?
Diminished interestHave you been less interested in things that you used to enjoy before the trauma?
Feelings of detachment or estrangement from othersHave you been feeling distant from people or like you can’t connect with them? Does this include family?
Persistent inability to experience positive emotionsHave you had trouble having good feelings (eg, happiness or love) since the trauma? Do you feel emotionally numb?
Marked alteration in arousal and reactivity (≥2 meets PTSD criteria)Questions
Irritable behavior and angry outburstsHave you been feeling more irritable or angry and acting on it? Do other people notice?
Reckless or self-destructive behaviorHave you been more reckless, taking too many risks or bigger risks even though you could have been really hurt? Have you injured yourself?
HypervigilanceDo you feel hyper alert, constantly looking over your shoulder even when you don’t really need to?
Exaggerated startle responseDo you feel like you are more jumpy and easily startled? More so than other people?
Problems with concentrationHave you been having a harder time focusing?
Sleep disturbancesHave you been having trouble sleeping? What kinds of problems are you having?

To meet diagnostic criteria for PTSD, these symptoms must not be due to a substance use disorder or a medical condition. Symptoms must persist for at least 1 month and cause significant distress or impairment. For each symptom, ask about duration: “How long have you been having this symptom?” 

Returning to Nina

You ask Nina if she continues to have this nightmare. She thankfully has not had it in years. In fact, she shares that she has not had nightmares, flashbacks, or intrusive thoughts about the Vietnam War for many years. She used to feel a lot of guilt related to the assault and was convinced that she was responsible for attracting the rapist to her. She had struggled to be physically intimate with her husband and often distanced herself from him. She had been hypervigilant about her daughter’s whereabouts, unable to sleep soundly or focus. Through therapy, however, she grappled with the trauma she experienced. Therapy was incredibly difficult, but she believes it helped her to finally move on. The recent births of her grandchildren were immensely joyous for her, and she is thrilled that she and her husband live close to them. You complete a PCL-5 with Nina, and her total score is 2, “a little bit,” for Questions 6 and 7 that focus on avoidance. Nina no longer has acute or active PTSD. 

You offer Nina the opportunity to stop prazosin while continuing the sertraline. Prazosin is a centrally-acting, alpha-1 adrenergic receptor antagonist that is used off-label to treat PTSD-nightmares and sleep disturbances. It may also reduce hyperarousal and hypervigilance.  There is little literature to guide us on how to stop prazosin 10mg daily in people with a history of PTSD. You recommend that Nina reduce the prazosin dose to 5mg for 2 weeks, then 2mg for 2 weeks, and then stop it. Because stopping prazosin carries a theoretical risk of rebound hypertension, you recommend that Nina check her blood pressure regularly. She should also let you know if her sleep changes.   

Sertraline is an effective PTSD treatment (Davidson 2004) and also a mainstay of treatment for mood and anxiety disorders. You schedule a follow up appointment to specifically focus on Nina’s history with anxiety and mood disorders, both of which commonly co-occur with PTSD. If Nina doesn’t have another indication for continued treatment with an SSRI, you plan to taper the sertraline after she has stopped the prazosin.  

Look out for a follow up PsychSnap on the nuances of medications for PTSD treatment.

Key Points:

1) PTSD is characterized by persistent re-experiencing of the traumatic event, avoidance of trauma-associations, increased negativity or numbing, and altered arousal.
2) People can recover from acute PTSD; PTSD can also be a chronic life-long illness. PTSD is often associated with other psychiatric comorbidities.
3) Primary care clinicians can screen for PTSD symptoms with the PC-PTSD-5. A positive screen should prompt a clinical interview and/or a structured questionnaire (PCL-5).

References:
Bovin, M. J., Kimerling, R., Weathers, F. W., Prins, A., Marx, B. P., Post, E. P., & Schnurr, P. P. (2021). Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Among US Veterans. JAMA Network Open4(2), e2036733. https://doi.org/10.1001/jamanetworkopen.2020.36733

Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment28(11), 1379–1391. https://doi.org/10.1037/pas0000254

Davidson, J. R. T. (2004). Long-Term Treatment and Prevention of Posttraumatic Stress Disorder. J Clin Psychiatry 2004;65[suppl 1]:44–48. 

Perkonigg, A., Pfister, H., Stein, M. B., Höfler, M., Lieb, R., Maercker, A., & Wittchen, H.-U. (2005). Longitudinal Course of Posttraumatic Stress Disorder and Posttraumatic Stress Disorder Symptoms in a Community Sample of Adolescents and Young Adults. American Journal of Psychiatry162(7), 1320–1327. https://doi.org/10.1176/appi.ajp.162.7.1320

Shalev, A., Liberzon, I., & Marmar, C. (2017). Post-Traumatic Stress Disorder. New England Journal of Medicine376(25), 2459–2469. https://doi.org/10.1056/NEJMra1612499

Sonis, J. (2013). PTSD in Primary Care—An Update on Evidence-based Management. Current Psychiatry Reports15(7), 373. https://doi.org/10.1007/s11920-013-0373-4

Spoont, M. R., Williams, J. W., Kehle-Forbes, S., Nieuwsma, J. A., Mann-Wrobel, M. C., & Gross, R. (2015). Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review. JAMA314(5), 501. https://doi.org/10.1001/jama.2015.7877

Westphal, M., Olfson, M., Gameroff, M. J., Wickramaratne, P., Pilowsky, D. J., Neugebauer, R., Lantigua, R., Shea, S., & Neria, Y. (2011). Functional impairment in adults with past posttraumatic stress disorder: Findings from primary care. Depression and Anxiety28(8), 686–695. https://doi.org/10.1002/da.20842