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Assistant Professor, Department of Psychiatry, University of Nebraska Medical Center and Omaha Veterans Affairs, Medical Center, 4101 Woolworth Avenue, Omaha, Nebraska 68105, fax 402/943-5543, ppadala{at}unmc.edu
Recovery Center Coordinator, Omaha Veterans Affairs Medical Center
Professor and Vice Chair for Research Department of Psychiatry, Creighton University and Omaha Veterans Affairs Medical Center
Chief Mental Health and Behavioral Sciences Department, Omaha Veterans Affairs Medical Center
Published Online, September 11, 2007. www.theannals.com, DOI 10.1345/aph.1H534
Case Report. A 57-year-old white veteran had chronic PTSD related to combat experience in Vietnam. He related that his most traumatic experience was to pick up bodies and mutilated parts of his friends. He was also exposed to concussion injury. The veteran suffered from PTSD symptoms soon after this experience but did not seek treatment for more than 20 years. Multiple medication trials including paroxetine, citalopram, and quetiapine were unsuccessful. He was also included in the PTSD clinic and participated in group therapy, although his participation was limited due to his anxiety. He said that the medications were not working and reported being more "jumpy" and irritable and having more nightmares and flashbacks. He reported nightmares on a nightly basis; his wife reported sleep disturbance due to his nightmares. The patient identified triggers for flashbacks, which included watching coverage of the Iraq war, hearing a helicopter in the air, and watching war-related movies.
He had become more avoidant lately, and his wife asked him to be evaluated. The 17 item Clinician-Administered PTSD Scale (CAPS-C) yielded a score of 110, suggesting extreme PTSD symptomatology. He scored 6 on the 17 item Hamilton Depression Rating Scale and did not have any psychotic symptoms based on the clinical interview. His past medical history was positive for hypertension, hypercholesterolemia, and chronic backache. Medications included paroxetine 40 mg daily, lovastatin 80 mg daily, hydrochlorthiazide/triamterene 37.5 mg daily, atenolol 25 mg daily, and aspirin 81 mg daily.
The patient was started on aripiprazole 10 mg concomitantly with paroxetine. At 3 weeks, he reported improvement in symptoms of PTSD but experienced restlessness consistent with akathisia. This improved after the dose of aripiprazole was adjusted to 5 mg twice daily. He reported a marked decline in irritability, calmer mood, better sleep, less frustration, and less stress. He handled the anniversary date of his trauma well compared with previous years. His score on CAPS-C dropped to 58. The dose of aripiprazole was increased to 10 mg twice daily. At the 10 week follow-up, the veteran reported doing well. He experienced improvements in mood, appetite, and energy, with well-controlled symptomatology of PTSD. His last CAPS-C scale yielded a score of 44, suggesting good control of PTSD symptoms.
Discussion. CAPS-C is one of the most widely used tools for the assessment of PTSD.5 A score of 40-59 on the CAPS-C scale is generally considered moderate, a score of 60-79 is severe, and a score over 80 is considered extreme PTSD symptomatology. A 15 point change in PTSD symptomatology is generally considered clinically significant.5 In the current case, the CAPS-C score changed by 66 points (60% improvement). The dose of aripiprazole used in the case was lower than that used by Lambert.4
Although SSRIs are considered the first-line treatment of PTSD, non-response and incomplete response to these agents are common. Atypical antipsychotics may serve as important augmentation agents for patients with prominent psychotic symptoms and those not responding to SSRIs. They are generally well tolerated and are associated with fewer extrapyramidal side effects when compared with typical antipsychotics. However, the benefits of atypical antipsychotics must be weighed against the potential risk of metabolic syndrome associated with these agents.
References
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