PTSD: National Center for PTSD

Assessment and Treatment for PTSD with Co-occurring Neurocognitive Disorder (NCD)

Matthew Yoder, PhD, Sonya Norman, PhD, and Matthew J. Friedman, MD, PhD

Posttraumatic stress disorder (PTSD) commonly co-occurs with neurocognitive disorders (NCD), yet specific assessment techniques and treatments for patients with both diagnoses have not been established. Early evidence suggests existing assessment measures and evidence-based treatments for PTSD are appropriate for patients with mild NCD, however the impact of moderate to severe NCD on assessment and treatment of PTSD is less clear. See Co-occurring PTSD and Neurocognitive Disorder (NCD) for a review of the research on the association between these conditions.

PTSD Assessment Considerations

The presence of PTSD symptoms such as nightmares, trauma history, or agitation in response to certain cues can be signs that evaluation of PTSD is warranted in patients with NCD. Assessment measures for PTSD have not yet been adequately validated for use among individuals with NCD. However, there is preliminary support for use of the PTSD Checklist (PCL for DSM-IV) with older adults, a population with higher incidence of NCD (1). In addition, the following self-report scales may be considered as they have been validated with older adults, although not specifically for NCD or for individuals with cognitive decline (2). Most of these measures take about five minutes to complete and can be read to a patient if necessary.

• PTSD Checklist for DSM-5 (PCL-5)
• Mississippi Scale for Combat Related PTSD (M-PTSD)
• MMPI-2 PK subscale (3)
• Impact of Event Scale - Revised (IES-R)
• Symptom Checklist-90 PTSD Scale (SCL-90 PTSD; 4)
• Self-Rating Inventory for PTSD (SRIP; 5)

While these scales may be useful PTSD screening instruments for patients with NCD, their format may not be easily understood by this population. Cook et al. (2005) recommend developing rating scales that are shorter, with simpler response options (e.g. 1-3 instead of 0-5) and with response options that do not shift directions between items (1).

Treatment for PTSD with Co-occurring NCD

More research is needed to understand how any particular NCD impacts treatment for PTSD. The primary treatments for PTSD are psychotherapy and pharmacotherapy.

Psychotherapy

The extensive literature on evidence-based psychotherapy for PTSD is reviewed in the Overview of Psychotherapy for PTSD. A small body of research suggests that some individuals with NCD and PTSD can benefit from psychotherapy for PTSD. Most research to date has been with mild NCD. A recent meta-analysis of cognitive behavioral therapy (CBT) broadly, found positive results on patients with an acquired brain injury and co-occurring PTSD (6). For PTSD therapy to be effective, patients must be able to attend psychotherapy sessions and remember what was discussed. Because the diagnoses categorized as NCD vary widely in their presentation and level of impairment, the care of each patient should be considered on a case by case basis.

One of the most effective treatments for PTSD is a type of CBT called Prolonged Exposure (PE) and a recent case study reported on an older adult with PTSD and early onset dementia who showed improvements in PTSD and depression symptoms after completing PE (7). Similarly, a preliminary study of 10 Veterans with mild to moderate TBI and PTSD who were experiencing cognitive deficits found that PE resulted in significant improvements in PTSD and depression symptoms from pre- to post-treatment (8). Emerging evidence suggests that patients across the spectrum of TBI severity may benefit from PE. A recent study using archival clinical data found that Veterans and active duty service personnel diagnosed with PTSD and a history of TBI responded well to PE. Across both the mild and moderate/severe TBI categories, patients who completed treatment showed significant improvement in PTSD symptoms (9).

Cognitive Processing Therapy (CPT), another front-line CBT treatment for PTSD, has also shown early promise in treating PTSD with co-occurring mild NCD. A study of 42 Veterans in residential TBI-PTSD treatment, all of whom reported cognitive deficits, showed that a modified version of CPT (see below) resulted in significant improvements in PTSD symptoms and depression from pre- to post-treatment. Those with mild TBI had comparable outcomes to those with moderate/severe TBI group, suggesting both groups responded similarly to treatment (10).

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Modifications to PTSD Psychotherapy Protocols for Clients with NCD

Researchers and clinicians have taken varied approaches to how much they have varied PTSD treatment protocols for delivery to patients with co-occurring mild NCD. Wolf and colleagues (2012) reported very few procedural modifications in delivering PE to patients with mild to moderate NCD and PTSD, with the exceptions of using memory aids, adding more structure, and conducting longer sessions when appropriate (8). Similarly, few changes were made to the PE protocol in a case study that reported on the treatment of a patient with early-stage dementia and PTSD (7).

As discussed above, Chard and colleagues (2011) reported significant modifications to the CPT protocol for use with patients in a TBI-PTSD residential treatment facility, including increasing the number of sessions per week, combining group and individual therapy, and augmenting the treatment with cognitive rehabilitation (9). There is a study underway in the San Diego Veterans Health Care System that is exploring whether augmenting CPT with compensatory cognitive rehabilitation principles is effective in treating PTSD and post-concussive symptoms in Veterans with comorbid PTSD and mild to moderate TBI. The results from this study may further inform the field regarding treatment of these co-occurring conditions (11).

Pharmacotherapy for PTSD

The extensive literature on evidence-based pharmacotherapy for PTSD is reviewed in the Clinician's Guide to Medications for PTSD. In short:

• First-line medications are selective serotonin reuptake inhibitors (SSRIs) and the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine.
• Second-line treatments are mirtazapine, nefazadone and older antidepressants (e.g., tricyclics (TCAs) and MAO inhibitors (MAOIs)) with promising findings for topiramate.
• Prazosin is recommended for traumatic nightmares.
• Specific medications contraindicated for PTSD include benzodiazepines, risperidone and most mood stabilizers / anticonvulsants.

Pharmacotherapy for NCD

These medications are often utilized for NCD (without comorbid PTSD):

• SSRIs are safe and usually well-tolerated. They are indicated because mood dysfunction is not infrequent among individuals with NCD. For example, mTBI patients with co-occurring depression have greater functional impairment, higher psychological distress, and perceive their injuries as more severe than those without depression (12).
• Anticonvulsants are useful for seizure prevention and mood stabilization.
• Atypical antipsychotics are useful for aggression, agitation and irritability.
• Andrenergic beta blockers are useful in the most severe cases of aggression, agitation and irritability.
• Dopamine agonists (e.g., bromocriptine, amantadine) and CNS stimulants (e.g., methylphenidate, modafinil) improve cognition, concentration and focus.
• Cholinesterase inhibitors (e.g., donepezil) improve memory.

Pharmacotherapy for co-occurring PTSD and NCD

The challenge in selecting a medication for an individual with co-occurring PTSD and NCD is that the evidence base is very weak. There have not been any published randomized controlled trials (RCTs) testing a specific medication for combined PTSD and NCD. Therefore, any suggested treatments are primarily inferences from the separate PTSD and NCD evidence bases. This can be very problematic since a medication with known efficacy for PTSD may have questionable utility for NCD - and vice versa. The following table summarizes this information and compares evidence-based pharmacotherapy for PTSD and traumatic brain injury (TBI), an NCD that commonly co-occurs with PTSD.

Note: There are also medications that should be avoided in patients with co-occurring PTSD and NCD. Benzodiazepines can increase the risk of cognitive impairment, confusion and sedation and thus should be avoided in adults with NCD and PTSD (13,14). They may also interfere with cognitive behavioral treatments for PTSD.

Table 1. Pharmacotherapy for co-occurring PTSD and TBI may conflict

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Implications for NCD Care Settings

PTSD may be the source of distress and behavioral problems among patients with moderate or severe NCD in residential care setting such as nursing homes. In such settings, when a client's NCD is too advanced for the person to benefit from PTSD psychotherapy, it can be helpful to remember PTSD symptoms may be "triggered" by a variety of situations, depending on the nature of the traumatic event(s). Generally, PTSD triggers can be idiosyncratic, so a good strategy is to get to know the patient to identify his or her triggering events. Examples of possible triggers include:

• TV shows, movies, or news coverage related to someone's traumatic event.
• Being bathed (for someone who had sexual trauma).
• Male or female caregivers for someone who has been physically or sexually assaulted, depending on the sex of the person who perpetrated the trauma.
• Smells (e.g., bodily smells, wounds, fires, certain foods).
• Sounds (e.g. songs, foreign languages, loud noises such as alarms).
• Perceived threats or physical touch.

Once triggers are identified, the staff can try to problem-solve ways to ameliorate the triggers. This might mean removing, avoiding, or minimizing the patient's contact with specific triggers (21). Interventions such as providing social support or engaging in positive activities may also be effective in reducing stress or problem behaviors.

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Patient and Family Support

Being a family member of someone with PTSD and co-occurring NCD can be difficult. Family members may feel worried or overwhelmed when they witness the emergence of PTSD symptoms, especially if those symptoms were less apparent prior to the onset of NCD. Sharing information with caregivers about the relationship between PTSD and NCD may be helpful. The following information is intended for a general audience (and is available in Spanish): Helping a Family Member Who Has PTSD and Help for Family and Friends.

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References

1. Cook, J. M., Elhai, J. D., Cassidy, E. L., Ruzek, J. I., Ram, G. D., & Sheikh, J. I. (2005). Assessment of trauma exposure and post-traumatic stress in long-term care Veterans: Preliminary data on psychometrics and post-traumatic stress disorder prevalence. Military Medicine, 170, 862-866. doi: 10.7207/MILMED.170.10.862
2. Thorp, S. R., Sones, H. M., & Cook, J. M. (2011). Posttraumatic stress disorder among older adults. In K. H. Sorocco & S. Lauderdale (Eds.), Cognitive behavior therapy with older adults: Innovations across care settings. (pp. 189-217): Springer Publishing Company, New York, NY.
3. Keane, T. M., Malloy, P. F., & Fairbank, J. A. (1984). Empirical development of an MMPI subscale for the assessment of combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 52, 888-891. doi: 10.1037/0022-006X.52.5.888
4. Derogatis, L. R., & Cleary, P. A. (1977). Confirmation of the dimensional structure of the scl-90: A study in construct validation. Journal of Clinical Psychology, 33, 981-989. doi: 10.1002/1097-4679(197710)33:4<981::AID-JCLP2270330412>3.0.CO;2-0
5. Van Zelst, W., De Beurs, E., Beekman, A., Deeg, D., Bramsen, I., & Van Dyck, R. (2003). Criterion validity of the self-rating inventory for posttraumatic stress disorder (SRIP) in the community of older adults. Journal of Affective Disorders, 76, 229-235. doi: 10.1016/S0165-0327(02)00095-2
6. Waldron, B., Casserly, L. M., & O'Sullivan, C. (2013). Cognitive behavioural therapy for depression and anxiety in adults with acquired brain injury. What works for whom? Neuropsychological Rehabilitation, 23(1), 64-101. doi: 10.1080/09602011.2012.724196
7. Duax, J. M., Waldron-Perrine, B., Rauch, S. A., & Adams, K. M. (2013). Prolonged exposure therapy for a Vietnam Veteran with PTSD and early-stage dementia. Cognitive and Behavioral Practice, 20, 64-73. doi: 10.1016/j.cbpra.2012.02.001
8. Wolf, G. K., Strom, T. Q., Kehle, S. M., Eftekhari, A. (2012). A preliminary investigation of prolonged exposure therapy with Iraq and Afghanistan Veterans with a diagnosis of posttraumatic stress disorder and mild to moderate traumatic brain injury. Journal of Head Trauma Rehabilitation, 27(1), 26-32. doi: 10.1097/HTR.0b013e31823cd01f
9. Wolf, G. K., Kretzmer, T., Crawford, E., Thors, C., Wagner, H. R., Strom, T. Q., Eftekhari, A., Klenk, M., Hayward, L., & Vanderploeg, R. D. (2015). Prolonged exposure therapy with Veterans and active duty personnel diagnosed with PTSD and traumatic brain injury. Journal of Traumatic Stress, 28, 339-347. doi: 10.1002/jts.22029
10. Chard, K. M., Schumm, J. A., McIlvain, S. M., Bailey, G. W., & Parkinson, R. B. (2011). Exploring the efficacy of a residential treatment program incorporating cognitive processing therapy-cognitive for Veterans with PTSD and traumatic brain injury. Journal of Traumatic Stress, 24, 347-351. doi: 10.1002/jts.20644
11. Jak, A. Enhanced cognitive rehabilitation to treat comorbid TBI and PTSD. In ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2015 July 20]. Available from: https://clinicaltrials.gov/ct2/show/NCT01943162?term=NCT01943162&rank=1 NLM Identifier: NCT01943162.
12. Fann, J. R., Uomoto, J. M., & Katon, W. J. (2001), Cognitive improvement with treatment of depression following mild traumatic brain injury. Psychosomatics, 42, 48-54. doi: 10.1176/appi.psy.42.1.48
13. Billioti, D. G. S., Bégaud, B., Bazin, F., Verdoux, H., Dartigues, J., Pérès, K, & Pariente, A. (2012). Benzodiazepine use and risk of dementia: Prospective population based study. British Medical Journal, 345, e6231. doi: 10.1136/bmj.e6231
14. Lader, M. (2011). Benzodiazepines revisited--will we ever learn? Addiction, 106, 2086-2109. doi: 10.1111/j.1360-0443.2011.03563.x
15. Tucker, P., Zaninelli, R., Yehuda, R., Ruggiero, L., Dillingham, K., & Pitts, C. D. (2001). Paroxetine in the treatment of chronic posttraumatic stress disorder: Results of a placebo-controlled, flexible-dosage trial. Journal of Clinical Psychiatry, 62, 860-868. doi: 10.4088/JCP.v62n1105
16. Weintraub, D., & Ruskin, P. E. (1999). Posttraumatic stress disorder in the elderly: A review. Harvard Review of Psychiatry, 7, 144-152. doi: 10.1093/hrp/7.3.144
17. Friedman, M. J., & Davidson, J. R. T. (2014). Pharmacotherapy for PTSD. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.) Handbook of PTSD, 2nd Edition (pp. 482-501). New York, NY: The Guilford Press.
18. Peskind, E. R., Bonner, L. T., Hoff, D. J., & Raskind, M. A. (2003). Prazosin reduces trauma-related nightmares in older men with chronic posttraumatic stress disorder. Journal of Geriatric Psychiatry and Neurology, 16, 165-171. doi: 10.1177/0891988703256050
19. U.S. Food and Drug Administration. (2005). Public health advisory: Deaths with antipsychotics in elderly patients with behavioral disturbances. Retrieved from http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm053171.htm
20. Krystal, J. H., Rosenheck, R. A., Cramer, J. A., Vessicchio, J. C., Jones, K. M., Vertrees, J. E., et al. (2011). Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: A randomized trial. Journal of the American Medical Association, 306, 493-502. doi: 10.1001/jama.2011.1080
21. Cook, J. M., Cassidy, E. L., & Ruzek, J. I. (2001). Aging combat Veterans in long-term care. NC-PTSD Clinical Quarterly, 10; 25-29.

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