Prioriteringsriktlinjer BUP Västra Götaland - Stresssyndrom

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1 Prioriteringsriktlinjer BUP Västra Götaland - Stresssyndrom Tillstånd DSM-IV/ICD-10 Angelägenhetsgrad GAF Medicinskt acceptabel väntetid Åtgärd Effekt av åtgärd Grad av vetenskaplig dokumentatio n Risk med åtgärd Qualy Nytta av åtgärd Vårdnivå Vårdform PTSD /F Inom 1 vecka Traumafokuserad KBT med psykoedukativa inslag B God Liten 1 L ÖV Individ och familj (1,, 3) SSRI (4-6) C-D Viss L SV/ÖV Adrenerga substanser C-D Viss (7,8, 9) Antikonvulsiva substanser (10, 11) Atypiska antipsykotika (1) C-E C-E Ringa Ringa L Inom 3 mån Traumafokuserad KBT med psykoedukativa inslag B God Liten 1 L ÖV Individ och familj (1,, 3) EMDR B Viss Liten 1 L ÖV (1, ) Stödjande terapi D Ringa Liten 3 L ÖV (1,, 3) 1(1)

2 Psykodynamisk Individualterapi D Ringa Liten 3 L ÖV (1, ) Gruppterapi D Ringa Liten 3 L ÖV (1, ) SSRI (4-6) C-D Viss L SV/ÖV Adrenerga substanser C-D Viss (7,8,9) Antikonvulsiva substanser (10, 11) Atypiska antipsykotika (1) C-E C-E Ringa Ringa L (1)

3 Angelägenhetsgrad 1. Omedelbart livshot. Risk för mycket allvarlig skada, för tidig död, betydande invaliditet och outhärdlig situation 3. Risk för allvarlig skada, bestående men eller mycket låg livskvalitet 4. Risk för förväntad försämring/ej vidmakthållen funktion-adl-nivå 5. Risk för betydande olägenhet, ökad sjuklighet, förlängd sjukdomsperiod, sänkt livskvalitet 6. Risk för olägenhet, skada, bestående men eller låg livskvalitet 7. Sannolikt ökad risk för försämrad hälsoupplevelse eller icke optimal livskvalitet 8. Möjligen ökad risk för sjuklighet, försämring av funktionsnivå eller livskvalitet 9. Risk för sänkt livskvalitet enligt patientens uppfattning och vetenskap och beprövad kunskap inte motsäger detta 10. Ingen risk för ökad sjuklighet, försämrad funktionsnivå eller försämrad livskvalitet Global Assessment of Function (GAF) För uppskattning/bedömning av patientens vårdbehov (länk till pdf.fil). Medicinskt acceptabel väntetid Inom 1 vecka GAF 1-30 inom 3 månader GAF Åtgärd Allmänna behandlingsriktlinjer PTSD är ett uttryck för en störning i stressresponssystemet orsakat av ett eller flera trauman. Förstahandsvalet är traumafokuserade psykoterapeutiska interventioner. Huvudsyftet med dessa är integrering av det skrämmande och oacceptabla traumat. De massiva försvaren som primärt har en skyddande funktion måste bearbetas gradvis så att dissocierade delar av upplevelsen integreras för att inte riskera retraumatisering. Behandling av PTSD är vanligen multimodal och skall anpassas till barnets/ungdomens utvecklingsnivå. Traumafokuserad kognitiv beteendeterapi har visat sig vara effektivt vid behandling av PTSD hos barn och unga människor som har blivit sexuellt utnyttjade. Indikationer för läkemedelsbehandling är när PTSD symtomen hindrar patienten från att klara av psykoterapeutiska interventioner eller när symtomen kvarstår trots psykoterapeutisk behandling. Andra indikationer är svåra komorbida psykiatriska tillstånd. Målsättningen med läkemedelsbehandling är att normalisera ett överreaktivt stressresponssystem och därmed undanröja plågsamma symtom. Generellt är forskningsstödet för farmakologisk behandling av barn och ungdomar med PTSD mycket bristfälligt varför både försiktighet och restriktivitet anmodas. De läkemedel som kan komma ifråga är (S)SRI, adrenerga och antikonvulsiva substanser samt atypiska antipsykotika. Benzodiazepiner bör inte användas p.g.a. risken för beroendeutveckling och paradoxala reaktioner. En ingående kunskapsöversikt av farmakologisk behandling till barn och ungdomar med PTSD kommer att finnas på BUP, Drottning Silvias barn och ungomssjukhus hemsida. Kontakta Saga.isetorp@vgregion.se för mer information. 3(1)

4 Beskrivning av specifika metoder Traumafokuserad kognitiv beteende terapi Behandlingen inleds med psykopedagogiska insatser i form av utbildning till barn/tonåringar, föräldrar, lärare och/eller andra betydelsefulla personer om symtom, kliniskt förlopp, behandlingsmöjligheter och prognos. Det är viktigt att barnet/ungdomen både får förklaringar till sina reaktioner och får veta vilka reaktioner som är normala efter upplevda trauman. Traumafokuserad individuell terapi a. Utforskande och öppen diskussion om den traumatiska händelsen så att barnet/ungdomen på olika sätt får uttrycka vad han/hon sett, hört, luktat och upplevt. Traditionella metoder för ångestreducering som t.ex. avslappning, desensibiliserings- och exponeringstekniker kan vara värdefulla hjälpmedel. b. Undersökning och förändring av kognitiva förvrängningar beträffande attributioner i samband med den traumatiska händelsen (t.ex. felaktig skuldbeläggning). c. Interventioner riktade mot icke-adekvata beteenden för att förhindra återupprepandet av traumat (t.ex. självskadande beteende). d. Kognitiva beteendeterapeutiska tekniker för att hjälpa barnet/tonåringen att få kontroll över påträngande återupprepningssymtom. Traumafokuserad föräldraterapi a. Utforskande och bearbetning av traumats känslomässiga påverkan hos föräldrarna b. Identifikation och förändring av icke adekvata attributioner angående traumat, t.ex. egna skuldkänslor och skuldbeläggande av barnet/tonåringen c. Identifiering och införande av stödjande och adekvata föräldrabeteenden d. Föräldraträning i att handskas med icke-adekvat beteende hos barnet. 1. Perrin S, Smith P & Yule W. (000). Practitioner review: the assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41, posttraumatic stress disorder (PTSD) is a syndrome defined by the intrusive reexperiencing of a trauma, avoidance of traumatic reminders, and persistent physiological arousal. PTSD is associated with high levels of comorbidity and may increase the risk for additional disorders over time. While controversies remain regarding the applicability of the PTSD criteria to very young children, it has proved to be a useful framework for guiding assessment and treatment research with older children and adolescents. This article presents an overview of the literature on the clinical characteristics, assessment, and treatment of PTSD in children and adolescents. There is a large body of literature showing that many children do suffer from PTSD or its symptoms following traumatic events. The PTSD symptomatology can be reliably assessed through semistructured interview and self-report measures, although the latter should not be used exclusively. A multidimensional and sensitive approach to the collection of information is strongly encouraged. The author concludes that there is general consensus among trauma experts that cognitive behavioral therapy in the form of prolonged therapeutic exposure and cognitive restructuring is the "first-line" treatment for PTSD.. Cohen, J. A. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry, 37, 4S-6S. 4(1)

5 These practice parameters review the current state of knowledge about posttraumatic stress disorder (PTSD) in children and adolescents. The parameters were written to aid clinicians in the assessment and treatment of children and adolescents with PTSD symptoms. A literature search and extensive review were conducted in order to evaluate the existing empirical and clinical information in this regard. Expert consultation was also solicited. The main findings of this process were the following: a wide variety of stressors can lead to the development of PTSD symptoms in this population; specific PTSD symptoms manifested may vary according to the developmental stage of the child and the nature of the stressor, and for this reason, the diagnostic criteria for PTSD in adults may not adequately describe this disorder in children and adolescents; several factors seem to mediate the development of childhood PTSD following a severe stressor; and most of the therapeutic interventions recommended for children with PTSD are trauma-focused and include some degree of direct discussion of the trauma. Controversies and unresolved issues regarding PTSD in children are also addressed. 3. Cohen, J. A., Mannarino, A. P., Knudsen, K. (005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 9, Objective: To measure the durability of improvement in response to two alternative treatments for sexually abused children. Method: Eighty-two sexually abused children ages 8-15 years old and their primary caretakers were randomly assigned to trauma-focused cognitive-behavioral therapy (TF-CBT) or non-directive supportive therapy (NST) delivered over 1 sessions; this study examines symptomatology during 1 months posttreatment. Data analysis: Intent-to-treat and treatment completer repeated measures analyses were conducted. Results: Intent-to-treat indicated significant group x time effects in favor of TF- CBT on measures of depression, anxiety, and sexual problems. Among treatment completers, the TF-CBT group evidenced significantly greater improvement in anxiety, depression, sexual problems and dissociation at the 6-month follow-up and in PTSD and dissociation at the 1-month follow-up. Conclusion: This study provides additional support for the durability of TF-CBT effectiveness. Psykofarmakologisk behandling SSRI SSRI verkar sannolikt inhibitoriskt på flera nivåer i det överreaktibla stressresponssystemet och har dessutom troligen trofiska effekter på bl a centrala serotonin- och noradrenalinsystem. Kliniskt kan de påverka samtliga symtomkluster vid PTSD. Studier på vuxna visar att SSRI har god effekt på symtom som aggressivitet och impulskontrollproblem, men också positiv effekt på ångest, panikattacker, flash-backs, depressivitet och suicidalt beteende. Vuxenstudier indikerar en fortsatt symtomminskning vid långtidsbehandling och sannolikt förebygger man återfall. Huruvida SSRI har samma effekt på barn som på vuxna är osäkert då kontrollerade studier på barn och ungdomar med PTSD saknas. Konklusionen från de öppna studier som gjorts tillsammans med väsentligen positiva barnpsykiatriska kliniska erfarenheter är att SSRI kan vara användbara på barn och ungdomar med svårartad PTSD. Med utgångspunkt från i dagsläget befintliga studier är det svårt att rekommendera något preparat som förstahandsval. Möjligtvis är det citalopram på grund av sin mycket selektiva 5HT- profil och avsaknad av noradrenerg central tillägsaktivitet, förekomst av signifikant positiva bamstudier goda kliniska erfarenheter med relativt få ångestaktiveringssymtom samt låg droginteraktion. Även sertralin och fluoxetin kan användas speciellt för behandling av komorbida tillstånd; det förra på grund av relativt utbredd klinisk erfarenhet, låg droginteraktion, hög evidens för vissa komorbida tillstånd samt vuxenindikation; det senare på grund av god evidens för vissa komorbida tillstånd, vuxenindikation i USA, samt relativt ringa symtomaktivering vid utsättning. Alla SSRI kan i vissa fall utlösa agitation och våld liksom suicidrelaterade beteenden hos barn och ungdomar. Storleken på riskökningen varierar från olika studier och för olika preparat mellan 1.5 till 3.5 gånger jämfört med placebobehandling. Exakt hur stora riskerna är vid behandling av barn och ungdomar med just PTSD är inte klarlagt. Tillsvidare bör man följa EU:s och EMEA: s anmodan, d v s att visa stor restriktivitet och försiktighet vid SSRI-behandling. De bör endast förskrivas av specialist i barn- och ungdomspsykiatri. 5(1)

6 4. Seedat, S., Lockhat, R., Kaminer, D., Zungu-Dirwayi, N,, & Stein, D. J. (001). An open trial of citalopram in adolescents with post-traumatic stress disorder. Int Clin Psychopharmacol., 16, 1-5. In this preliminary, 1-week open-label study, eight adolescents with moderate to severe post-traumatic stress disorder (PTSD) were treated with citalopram (the most selective of the selective serotonin reuptake inhibitors) in a fixed daily dose of 0 mg, and rated at -week intervals. The Clinician-Administered PTSD Scale (Child and Adolescent Version) was the primary measure used to assess treatment outcome. Core PTSD symptoms (re-experiencing, avoidance, and hyperarousal symptoms) showed statistically significant improvement at week 1 on the Clinician-Administered PTSD Scale (Child and Adolescent Version) (CAPS-CA), with a 38% reduction in total CAPS scores between baseline and endpoint. Citalopram failed to effect improvement on self-reported depressive symptoms. All seven adolescent completers were rated as much improved or very much improved on Clinical Global Impression Improvement scores. Citalopram was well-tolerated overall with reported adverse experiences being relatively benign. However, larger, controlled trials are needed to consolidate these preliminary results. 5. Seedat S, Stein DJ, Ziervogel C, Middleton T, Kaminer D, Emsley RA, Rossouw W. (00). Comparison of response to a selective serotonin reuptake inhibitor in children, adolescents, and adults with posttraumatic stress disorder. J Child Adolesc Psychopharmacol. 1, BACKGROUND: Although the pathophysiology of posttraumatic stress disorder (PTSD) is considered multifactorial, empirical evidence suggests that serotonergic dysregulation may characterize the disorder. The efficacy of the selective serotonin reuptake inhibitors (SSRIs) in treating essential symptoms (re-experiencing, avoidance, numbing, hyperarousal) in both adults and children is likely to involve potentiation of this neurotransmitter. OBJECTIVE: This study compared outcome in an 8-week open trial of citalopram (an SSRI) in children/adolescents and adults with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of PTSD. METHODS: Twenty-four children/adolescents and 14 adults assessed for PTSD severity at baseline were followed up on citalopram treatment (0-40 mg/day) at two-weekly intervals over 8 weeks. The Clinician- Adminstered PTSD Scale (CAPS) and the Clinical Global Improvement Scale (CGI) were used as outcome measures. RESULTS: Although there were no significant differences in outcome measures between children/adolescents (n = 4) and adults (n = 14), both groups had significant reductions in mean CAPS total scores, symptom cluster scores, and CGI ratings at endpoint. CONCLUSION: Although the SSRIs have established efficacy and safety in the treatment of adult PTSD, literature on their use in child and adolescent PTSD is sparse. Controlled data are needed to support the clinical perception that SSRIs are agents of choice in the treatment of pediatric PTSD. 6. Davidson JR, Rothbaum BO, van der Kolk BA, Sikes CR, Farfel GM. (001). Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry, 58, BACKGROUND: Posttraumatic stress disorder (PTSD) is a common illness associated with significant disability. Few large, placebo-controlled trials have been reported. METHODS: Outpatients with a DSM-III-R diagnosis of moderate-to-severe PTSD were randomized to 1 weeks of double-blind treatment with either sertraline (N = 100) in flexible daily doses in the range of 50 to 00 mg or placebo (N = 108). Primary outcome measures consisted of the Clinician-Administered PTSD Scale (CAPS-) total severity score, the patient-rated Impact of Event Scale (IES), and the Clinical Global Impression-Severity (CGI-S) and - Improvement (CGI-I) ratings. RESULTS: Mixed-effects analyses found significantly steeper improvement slopes for sertraline compared with placebo on the CAPS- (t =.96, P =.003), the IES (t =.6, P =.0), the CGI-I score (t = 3.6, P<.001), and the CGI-S score (t = 4.40, P<.001). An intent-to-treat end-point analysis found a 60% responder rate for sertraline and a 38% 6(1)

7 responder rate for placebo (chi()(1) = 8.48, P =.004). Sertraline treatment was well tolerated, with a 9% discontinuation rate because of adverse events, compared with 5% for placebo. Adverse events that were significantly more common in subjects given sertraline compared with placebo consisted of insomnia (35% vs %), diarrhea (8% vs 11%), nausea (3% vs 11%), fatigue (13% vs 5%), and decreased appetite (1% vs 1%). CONCLUSION: The results of the current study suggest that sertraline is a safe, well-tolerated, and significantly effective treatment for PTSD. Adrenerga substanser En av de centrala patofysiologiska störningarna vid PTSD är α--adrenerg dysfunktion. Vissa adrenerga substanser minskar sympatisk tonus och de kan vara mycket effektiva när det gäller att behandla hyperarousalrelaterade symtom som motorisk överaktivitet, ångest, panikreaktioner, impulsivitet, aggressivitet, mardrömmar och sömnsvårigheter. Baserat på öppna studier kan de adrenerga α--agonisterna klonidin och guanfacin liksom β-antagonisten propranolol övervägas vid sådana traumasymtom. Vuxenstudier antyder att propranolol eventuell kan förebygga PTSD-utveckling om det ges i anslutning till traumat. 7. Perry BD. (1994). Neurobiological sequelae of childhood trauma: Post-traumatic Stress Disorders in children. In: Catecholamine function in post-traumatic stress disorder: Emerging concepts (M Murburg, Ed.) American Psychiatric Press, Washington DC, Seventeen children with PTSD (13 male, 4 female; mean age range ) were drug free for at least four weeks during which time baseline symptoms were assessed by using the Psychiatric Symptom Assessment Scale, a 3-item modification of the Brief Psychiatric Rating Scale. As part of the clinical program, a weekly PSAS was performed, independently, by each child s teacher, individual therapist and primary childcare worker. For the four week, drug-free period prior to starting clonidine these PSAS scores were meaned. Clonidine was started after appropriate physical exam, lab work and consents had been obtained. Initial dosage was 0.05 mg bid and rapidly titrated up to 0.1 mg bid as tolerated. The only side effect of any significance was sedation, which was typically transient. Altering schedule to 0.05 qid significantly decreased sedation. The effects of clonidine on psychiatric symptoms were profound. This group of children had a wide range of presentations ( see descriptions above). Largest degree of improvement was in the areas of behavioural impulsivity, anxiety, arousal, concentration and mood. Interestingly, in the few children that had pre-psychotic or psychotic symptoms, improvement was seen in these symptoms as well as the more traditional PTSD symptoms. In addition to improvement in psychiatric symptoms there appeared to be a decrease in physiological lability, likely underlying the improvement in the other symptoms. Basal heart rate of this group prior to clonidine treatment was (as compared to in an age comparable non-ptsd psychiatric population). Following four weeks ot clonidine, the group mean dropped to In addition, the D-scale (autonomic arousal) score of the SI-PTSD (Davidson et al 1990) prior to medication, , dropped to 6+3. Overall, clonidine treatment, in this population, significantly improved the signs and symptoms of childhood PTSD. 8. Roger K. Pitman, Kathy M. Sanders, Randall M. Zusman, Anna R. Healy, Farah Cheema, Natasha B. Lasko, Larry Cahill, and Scott P. Orr. 00. Pilot Study of Secondary Prevention of Posttraumatic Stress Disorder with Propranolol. Biol Psychiatry;51: Background: Preclinical considerations suggest that treatment with a β--adrenergic blocker following an acute psychologically traumatic event may reduce subsequent posttraumatic stress disorder (PTSD) symptoms. This pilot study addressed this 7(1)

8 hypothesis. Methods: Patients were randomized to begin, within 6 hours of the event, a 10-day course of double-blind propranolol (n=18) versus placebo (n = 3,) 40 mg four times daily. Results: The mean (SD) 1-month Clinician-Administered PTSD Scale (CAPS) score of 11 propranolol completers was 7.6 (15.7), with one outlier 5. SDs above the others mean, and of 0 placebo completers, 35.5 (1.5), t = 1.1, df= 9, p =.15. Two propranolol patients scores fell above, and nine below, the placebo group s median, p -.03 (sign test). Zero of eight propranolol, but six of 14 placebo patients were physiologic responders during script-driven imagery of the traumatic event when tested 3 months afterward, p =.04 (all p vallues one-tailed). Conclusions: These pilot results suggest that acute, post trauma propranolol may have a preventive effect on subsequent PTSD. 9. Guillaume Vaiva, Frangois Ducrocq, Karine Jezequel, Benoit Averlan Philippe Lestavel, Alain Brunet, and Charles R. Marmar Immediate Treatment with Propranolol Decreases Posttraumatic Stress Disorder Two months after Trauma. Biol Psychiatry, 54: Background: This study investigated the efficacy of propranolol prescribed shortly after trauma exposure in the prevention of posttraumatic stress disorder PTSD symptoms and diagnosis. Methods: Eleven patients received 40 mg propranolol 3 times daily for 7 days, followed by a taper period of 8-1 days. They were compared with eight patients who refused propranolol but agreed to participate in the study. Though nonrandomized, the two groups did not differ in demographics, exposure characteristics, physical injury severity, or peritraumatic emotional responses. Results: Posttraumatic stress disorder rates were higher in the group who refused propranolol (3/8) compared with those who received the medication (1/11), as were the levels of PTSD symptoms (U = 85, p =.037). Conclusions: Our results are consistent with earlier findings and suggest that propranolol may be useful for mitigating PTSD symptoms or perhaps even preventing the development of PTSD. Antikonvulsiva substanser Ett av huvudproblemen vid PTSD är den progredierande sensitivisering och kindling av stressresponssystemet som uppstår med tilltagande limbisk irritabilitet och intensifiering av såväl neurohormonella som beteendemässiga basala överlevnadsresponser. Med sina avsensibiliserande och antikindlande egenskaper bör antikonvulsiva substanser därför kunna ha positiva effekter vid PTSD. För karbamazepin, valproat och lamotrigin finns ett flertal positiva vuxenstudier och ett fåtal på barn med PTSD. De bedöms som användbara vid framförallt svårartade undvikandesymtom, hyperarousal och besvärliga sömnrubbningar, liksom vid tillstånd med kraftiga vredesutbrott. På liknande sätt som SSRI, har phenytoin till vuxna, gett antydningar om att kunna öka hjärnvolym och förbättra kognition och minne. 10. Looff, D., Grimley, P., Kuller, F., Martin, A., Shonfield, L.. Carbamazepine for PTSD. (1995). J Am Acad Child and Adolesc Psychiatry, 34(6): Beginning in mid-1993, encouraged by several reports in the psychiatric literature pointing up the relative efficacy of carbamazepine in treating the symptoms of posttraumatic stress disorder (PTSD) in adults (Brodsky et al., 1990; Keck et al., 199; Lipper et al., 1986; Silver et al., 1990; Wolf et al., 1988) the five attending child and adolescent psychiatrists at Millcreek Psychiatric Center for Children, a state psychiatric hospital for child and adolescent patients operated by the Ohio Department of Mental Health in Cincinnati, decided to test the effectiveness of this medication in our population. Accordingly, during the past 18 months (June 1, 1993, to December 1, 1994), we gave carbamazepine to a total of 1 girls and 16 boys whose primary diagnosis was PTSD and whose ages ranged between 8 and 17 years. Without exception, the 8 children and adolescents had been sexually abused frequently-usually by male family members-from early childhood on (verified). All 8 patients gave histories of frequent, recurrent, and intrusive distressing recollections (intrusive thoughts) of the abuse/abuser(s); feeling the 8(1)

9 abusive event(s) recurring (flashbacks); frequent auditory and visual hallucinations (frequently hypnagogic); and frequent nightmares related to the abuse. Most of them were hypervigilant, emotionally labile, and exhibited exaggerated startle responses. More than half of the group were comorbid for ADHD, depressive disorder, oppositional defiant disorder, or polysubstance abuse. The result of using carbamazepine with these children and adolescents was very encouraging: if we kept the total daily dosage (which varied from 300 to 1,00 mg per day, depending on the weight of the individual and his or her symptom severity) to that which produced a serum level around 10.0 to 11.5 micro gram/ml, of the 8 patients became asymptomatic; the remaining 6 patients were significantly improved, reporting only rare abuse-related nightmares (the daytime symptoms of PTSD were reported by them as no longer present). The carbamazepine protocol we followed and continue to use: baseline laboratory evaluations obtained before initiation of carbamazepine treatment included complete blood cell count with differential, chemistry profile (includes liver function tests, blood urea nitrogen, and serum creatinine), reticulocyte count, serum iron or serum ferritin, and urinalysis; carbamazepine was started at 100 mg b.i.d. in children 6 to 1 years of age and at 00 mg b.i.d. in children older than 1 (an average of 1 mg/kg per day); medication was taken after meals or with milk; increases were made every 4 to 7 days to avoid side effects, up to that total daily dosage which brought remission or near-remission of PTSD-related symptoms; serum carbamazepine levels were measured one time per week until symptoms remitted and every months thereafter; complete blood cell counts with differentials and reticulocyte counts were done every weeks for months and every 3 months thereafter. Four of our patients who were comorbid with ADHD were treated successfully with carbamazepine plus either methylphenidate (three cases) or clonidine (one case); four patients with significant depression plus PTSD-related symptoms required the addition of either sertraline (two cases), fluoxetine (one case), or imipramine (one case) to the carbamazepine regimen for overall improvement. No adverse drug reactions were experienced by any of the 8 patients during their hospital stays (which ranged from 17 to 9 days, with an average of 35 days). All 8 patients were discharged to community-based follow-up care on that dosage of carbamazepine, which had brought their PTSD-related symptoms into remission. 11. J. Douglas Bremner, Tanja Mletzko, Silke Welter, Sinead Quin, Chanda Williams, Marijn Brummer, Sajid Siddiq, Lai Reed, Charles B. Nemerof. Effects ot phenytoin on memory, cognition and brain structure in post-traumatic stress disorder: a pilot study. (005). Journal of Psychopharmacology 19(): Phenytoin (Dilantin ) is an anticonvulsant used in the treatmen of epilepsy. It is believed to act by modulation of glutamatergic transmission. Because the neurobiology of post-traumatic stress disorder (PTSD) has been hypothesized to involve alterations in gtutamatergic transmission with subsequention neurotoxicity, we assessed tthe effects of phenytoin on cognition and brain structure in PTSD patients. Phenytoin was administered in an open label fashion for 3 months to nine adult patients with PTSD related to a variety of traumas, including early abuse, combat and car acciddents. Subjects underwent magnetic resonance imaging for measurement of whole brain and hippocampal volume, and neuropsychotogical testing of memory and cognition, before and after treatment. Phenytoin treatment resulted in a significant 6% increase in right brain volume (p < 0.05). Increased hippocampal volume was correlated with reductions in symptom severity as measured by the Clinician Administered PTSD Scale and improvements in executive function as measured by the Trails test. Is test. However, treatment associated improvements in memory and cognition did not achieve statistical significance. These findings suggest that phenytoin treatment may be associated with changes in brain structure in patients with PTSD. Atypiska antipsykotika Kliniska erfarenheter liksom ett antal studier pekar på att atypiska neuroleptika i lågdos har måttlig till god effekt på PTSD med komorbida pykotiska symtom som paranoida beteendemönster, parahallucinatoriska fenomen m fl men också på intensiva flashbacks, svårartat självdestruktivt beteende, explosiv överväldigande vrede eller annat gravt disorganiserat beteende. Det finns för närvarande bara en enda Studie på barn med PTSD. (Horrigan JP, Barnhill LJ. Risperidone and PTSD in boys. J Neuropsychiatry Clin Neuroscience 1999; 11:16-7). I denna öppna studie med risperidon behandlades 18 pojkar med PTSD 9(1)

10 och hög grad av komorbida psykiatriska störningar, 83 % hade komorbid ADHD och 35 % bipolärt syndrom. 13 av de 18 barnen upplevde remission av sina PTSD-symtom. Vissa menar att atypiska neuroleptika som monoterapi kan ha lika god effekt på PTSD som SSRI. 1. Hamner, M. B, Faldowski, R. A, Ulmer, H G., Fruehm B. C., Huber, M. G., Arana, G. W. (003). Adjunctive risperidone treatment in post-traumatic stress disorder: a preliminary controlled trial of effects on comorbid psychotic symptoms. Int Clin Psychopharmacol., 18, 1-8. Positive and negative symptoms of psychosis may be common in patients with chronic post-traumatic stress disorder (PTSD), but few studies have investigated the use of antipsychotic agents in these patients. This preliminary study examined the potential efficacy of risperidone in treating psychotic symptoms associated with chronic PTSD. In a 5-week, prospective, randomized, double-blind, placebo-controlled trial, adjunctive risperidone treatment was assessed in 40 combat veterans with chronic PTSD and comorbid psychotic features. Most patients were receiving antidepressants and some other psychotics with doses of concurrent medications held constant for at least 1 month prior to and during the study. Thirty-seven patients completed at least 1 week of treatment with risperidone or placebo. The Positive and Negative Syndrome Scale (PANSS) and the Clinician Administered PTSD Scale (CAPS) were used to assess symptoms. The PANSS was the primary outcome measure. At treatment endpoint, risperidone-treated patients showed a significantly greater decrease from baseline, albeit modest, in psychotic symptoms (PANSS total scores) than placebo-treated patients (P < 0.05). CAPS ratings declined significantly in both groups but did not differ significantly between groups. However, CAPS re-experiencing subscale scores had greater improvement in the risperidone-treated patients at week 5 (P < 0.05, completer analysis) with a trend towards greater improvement versus placebo a endpoint (P < 0.1, LOCF). Risperidone was well tolerated with minimal extrapyramidal symptoms. These preliminary results support studying the potential efficacy of risperidone for treating global psychotic symptoms associated with chronic PTSD with a suggestion that core re-experiencing symptoms may also be responsive. Further research using randomized, controlled trial designs in larger patient groups are needed to define more adequately the role of risperidone and other atypical agents in PTSD. EMDR EMDR (Eye Movement Desensitization and Reprocessing) är en specifik metod för traumabehandling. Den innefattar utforskande och öppen diskussion om den traumatiska händelsen så att barnet/ungdomen på olika sätt får uttrycka vad han/hon sett, hört, luktat och upplevt liksom undersökning och förändring av kognitiva förvrängningar beträffande attributioner i samband med den traumatiska händelsen (t.ex. felaktig skuldbeläggning). Aktiverandet av traumat kombineras med bilateral stimulering av hjärnhalvorna genom ögonrörelser, beröring eller hörselintryck. 1. Perrin, S., Smith, P. & Yule, W. (000) Practitioner review: the assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41, Cohen, J.A. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry, 37, 4S-6S. 10(1)

11 Stödjande terapi Här avses icke-direktiv stödterapi, d.v.s. samtal av stödjande och lyssnande karaktär. 1. Perrin, S., Smith, P. & Yule, W. (000) Practitioner review: the assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines; 41, Cohen, J. A., Mannarino, A. P., Knudsen, K. (005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 9, Psykodynamisk individualterapi Insiktsorienterade, interpersonella och psykodynamiska terapeutiska interventioner kan vara adekvata för behandling av PTSD (ex barnpsykoterapi). Syftet är att bearbeta beteende- och känslomässiga svårigheter, som inte är relaterade till PTSD. Detta bör kombineras med traumafokuserade interventioner. 1. Perrin, S., Smith, P. & Yule, W. (000) Practitioner review: the assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines; 41, Cohen, J. A. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry, 37, 4S-6S. Gruppterapi Traumafokuserade grupper för barn på ungefär samma utvecklingsmässiga nivå, som har liknande traumatiska upplevelser, kan uppmuntra till öppna diskussioner och adekvata attributioner rörande traumat. 1. Perrin, S., Smith, P. & Yule, W. (000) Practitioner review: the assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines; 41, Cohen, J. A. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry, 37, 4S-6S. 11(1)

12 Effekt av åtgärd A. Sjuklighet - död kan förhindras B. Tillståndet kan botas C. Sjuklighet påverkas mycket, överlevnaden förlängs D. Sjukligheten påverkas i viss utsträckning E. Ingen effekt, F. Risk för försämring Grad av vetenskaplig dokumentation God = Två eller flera oberoende relevanta RCT med statistisk signifikanta och entydiga resultat eller meta analyser med entydiga resultat, Viss = Flera kontrollerade studier eller enstaka mindre RCT med entydiga resultat eller större RCT med divergerande resultat. Ringa = Fallserier vid olika centra och/eller enstaka kontrollerade studier eller enstaka RCT med motsägelsefulla resultat. Ingen = Enstaka fallbeskrivningar. Risk med åtgärd Stor Risk risk Liten risk Qaly Kostnad per kvalitetsjusterade levnadsår alternativt vunnet levnadsår. Låg < kr/qaly alternativt vunnet levnadsår kr/qaly alternativt vunnet levnadsår Hög miljon kr/ QALY alternativt vunnet levnadsår Mycket hög > 1 miljon kr/qaly alternativt vunnet levnadsår Ej bedömningsbar Nytta av åtgärd Sammanvägning av beprövad erfarenhet, effekt av åtgärd, grad av vetenskaplig dokumentation, risk med åtgärd och kostnadseffektivitet Bedöm graden av nytta från 1-4 där 1 är stor och 4 är liten. Vårdnivå R = Regional vård L = Länssjukvård H = Högspecialiserad vård Vårdform SV = Slutenvård ÖV = Öppenvård 1(1)