what providers can do to identify signs and symptoms of ... ptsd.pdf · symptoms of ptsd, and link...

What Providers Can Do to Identify Signs and Symptoms of PTSD, and Link Individuals to the

Care They Need

PTSD is a disorder of reactivity to a traumatic event.

It is about the mind’s inability to properly integrate an experience into an individual’s own reality.

The traumatic event is so far outside the individual’s frame of reference that the brain cannot process the experience.

When this happens, the brain’s ability to form and recall memories can be altered.

About 60% of men and 51% of women are exposed to trauma in the US.

About 8% of men and 20% of women will develop PTSD.

About 40% of victims of combat related trauma will develop PTSD.

About 60% of victims of sexual assault will develop PTSD.

Am Fam Physician 2013 Dec 15;88(12):827-834

Trauma is a common occurrence

More Veterans and active duty military personnel are receiving health care from non-VA and non-military providers.

◦ Veterans have several insurance options such as Medicare, Medicaid, private insurance; others may lack health insurance.

◦ Active duty military personnel have TRICARE insurance which is now accepted by providers in the community.

Active Duty Military, Reservists and National Guard under your care may be exposed to trauma not just during deployment to war zones but during humanitarian deployments like hurricane preparation and relief

‣ First responders (such as police, fire, EMS) and healthcare professionals (including physicians, NPs, PAs, RNs, etc.) are frequently exposed to traumatic events and the impact of these events on the individual may accumulate over time.1

‣ Volunteer emergency service workers frequently have limited access to the necessary support services for mental health problems.2

1. Harvey SB. Aust N Z J Psychiatry. 2016 Jul;50(7):649-58.

2. Milligan-Saville J. Psychiatry Res. 2018 Jul 3.

Military occupations

Police Officers

Fire Fighters

Emergency Medical and Ambulance Personnel

First Responders to Disasters

Healthcare workers such as Physicians, NPs, PAs, Nurses

Journalists

*Relationship between these professions and PTSD should not be seen as causal;

Members of these professions are exposed to higher numbers of risk factors.

https://deserthopetreatment.com/ptsd-substance-abuse/high-risk-professions/

Living through dangerous events and traumas

◦ Experiences in combat

◦ Physical or sexual assault, either completed or attempted

◦ Being a victim of or witnessing acts other serious crimes or acts of terrorism

Being diagnosed with a serious and/or life-threatening illness, or having a relative diagnosed with one of these

Parents of children with severe medical conditions.

Getting hurt/Being involved in accidents, such as automobile accidents or accidents occurring in mass transportation

https://www.nimh.nih.gov/health/topics/post-traumatic- stress-disorder-ptsd/index.shtml

https://deserthopetreatment.com/ptsd-substance-abuse/ high-risk-professions/

Seeing another person hurt, or seeing a dead body

Childhood trauma

Feeling horror, helplessness, or extreme fear

Having little or no social support after the event

Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home

Having a history of mental illness or substance abuse

https://www.nimh.nih.gov/health/topics/post-traumatic- stress-disorder-ptsd/index.shtml

https://deserthopetreatment.com/ptsd-substance-abuse/ high-risk-professions/

According to the National Institute of Mental Health:

“Anyone can develop PTSD at any age.”

https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

Can you think of a patient(s) in your

practice who has these risk factors and

who you might want to assess for PTSD?

PTSD is a mental health disorder associated with significant psychosocial morbidity and other negative outcomes.

Those with PTSD are at increased risk for suicide.

◦ In 2014, an average of 20 Veterans died from suicide each day.1 A study that examining trends and correlates of reported PTSD among young male Veteran suicide decedents reported PTSD prevalence substantially increased among Veteran suicide decedents aged 25-34 years.2

◦ First responders (policemen and firefighters) are more likely to die by suicide than in the line of duty. PTSD and depression rates among firefighters and police officers have been found to be as much as 5x higher than the rates within the civilian population, which causes these first responders to commit suicide at a considerably higher rate.3

Those with PTSD are at increased risk for substance abuse.4

1. VA Suicide Prevention Program . 2016. https://tinyurl.com/yd9hejpu 2. O'Donnell J, et al. Suicide Life Threat Behav. 2018 Nov 29.

3. Rudderman Family Foundation. 2018. https://tinyurl.com/yak7tscp 4. McCauley JL, et al. Clinical Psychology: Science and Practice.

2012;19(3), 283-304.

PTSD may cause relationship, employment,

financial, and legal problems.

◦ In a study evaluating interpersonal behavior differences among male

military service members with and without PTSD and their female

partners, couples with PTSD displayed more interpersonal hostility and

control; more sulking, blaming, and controlling behavior; and less

affirming and connecting behavior than couples without PTSD.1

◦ Reservists with symptoms of PTSD have been found to earn

substantially less than average in both their military and civilian

employment prior to deployment. On average they earn up to 6% less

than they would have earned if they had not had such symptoms in the

first 4 years following deployment.2

1. Knobloch-Fedders LM, et al. Behav Ther. 2017;48(2):247-261. 2 Loughran DS, et al. RAND Corporation, 2013.

https://www.rand.org/pubs/technical_reports/TR1006.html.

PTSD is associated with both physical and psychological comorbidities.

Individuals with PTSD commonly have symptoms of:

J Clin Psychiatry 2000:61 (suppl 7)

• Depression • Anxiety • Panic disorder

• Substance abuse disorders • Sleep disorders • Eating disorders

Recovery from PTSD is highly dependent on early intervention.

Patients assessed within hours or days after an acute trauma may benefit from supportive psychotherapeutic and psychoeducational interventions.

Effective treatment of PTSD and comorbid conditions increases the likelihood of reintegration into society which is the ultimate treatment goal.

Am J Psychiatry 161;11 Nov. 2004 supplement.

Individuals with PTSD may experience physical symptoms that drive them to visit a primary care provider, including:

◦ Breathing issues (asthma)

◦ Chronic unexplained pain

◦ Muscle aches and pains (Fibromyalgia)

◦ Chronic fatigue

◦ Severe headaches

◦ Lack of focus and concentration

◦ Dizziness

◦ Heart problems (HTN)

◦ History of traumatic brain injury: Individuals with history of head trauma not associated with loss of consciousness (TBI) are at higher risk of developing PTSD.

PTSD Alliance

Many with PTSD avoid reporting symptoms and seeking treatment due to negative stereotypes1,2

◦ Being labeled by others as "dangerous/violent," or "crazy“

◦ Being labeled by others as having a “mental illness”

◦ Being labeled by others as “weak”

Individuals with PTSD may also see themselves as “weak” for not being able to “handle it”

Individuals may question the validity of their pain because they view the trauma they went through as “not as bad” as the trauma someone else went through

1. Mittal D. Psychiatr Rehabil J. 2013 Jun;36(2):86-92. 2. Clement S. Psychol Med. 2015 Jan;45(1):11-27.

Just because the traumatic event(s) is not recent, doesn’t mean PTSD should be excluded from the clinician’s index of suspicion.

Many people develop coping mechanisms that enable them to live with their undiagnosed PTSD—although doing so may have significant impact on the lives of the individual and their families.

Assessment of symptoms is the first step in an integrated treatment approach.

The key to an informative assessment is an effective health interview.

Identifying a patient as a veteran or first responder can be a critical first step to providing quality care.

◦ First, always ask patients, “Have you served in the military or as a first responder?”

◦ Then ask, “Do you have history of trauma exposure?”

◦ If the answer is “yes” use standard screening tools (created by staff at VA’s National Center for PTSD

https://www.ptsd.va.gov/professional/assessment/ screens/index.asp

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5):

‣ Asks respondents whether they have experienced prior trauma(s) in their life time, and provides examples of events that qualify as trauma:

Sometimes things happen to people that are unusually frightening, horrible, or traumatic. For example:

A serious accident or fire

A physical or sexual assault or abuse

An earthquake or flood

A war

Seeing someone be killed or seriously injured

Having a loved one die through homicide or suicide.

‣ Have you ever experienced this kind of event? YES / NO

‣ If no, screen total = 0. Please stop here.

https://www.ptsd.va.gov/professional/assessment/ screens/pc-ptsd.asp

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5):

If yes, please answer the questions below.

In the past month, have you…

1. Had nightmares about the event(s) or thought about the event(s) when you did not want to? YES / NO

2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the events(s)? YES / NO

3. Been constantly on guard, watchful, or easily startled? YES / NO

4. Felt numb or detached from people, activities, or your surroundings? YES / NO

5. Felt guilty or unable to stop blaming yourself or others for the event(s) may have caused? YES / NO

Scoring: a cut-point of 3 (answer “yes” to any 3 questions) is optimally sensitive to probable PTSD.

Those screening positive require further assessment, preferably with a structured interview (DSM-5 criteria; PTSD Checklist [PCL] questionnaire).

https://www.ptsd.va.gov/professional/assessment/ screens/pc-ptsd.asp

PTSD criteria based on the DSM-5 include:

Exposure to a traumatic event

Intrusion symptoms

Avoidance symptoms

Changes in Cognition and Mood

Alterations in Arousal and Reactivity

Duration: More than a month

Specifiers:

With dissociative symptoms (depersonalization; derealization)

With delayed expression (>6 months)

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

DSM-5 defines “Trauma” as the exposure to: ◦ Actual or threatened death

◦ Actual or threatened serious injury

◦ Actual or threatened sexual violence

Types of exposure:

◦ Direct exposure

◦ Witnessing in person

◦ Indirectly by learning about a loved one or close friend that has experienced a traumatic event

◦ Repeated or extreme exposure to aversive details of the traumatic events usually in the course of professional duties (First responders; military; emergency room professionals).

American Psychiatric Association: Diagnostic and Statistical Manual of

Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Intrusive Symptoms (At least one): Recurrent involuntary and intrusive distressing memories.

Recurrent distressing dreams (nightmares).

Dissociative reactions (flashbacks).

Intense psychological distress after exposure to internal or external cues that resemble traumatic event.

Marked physiological reactivity after exposure to internal or external trauma-related stimuli.



Avoidance Symptoms (At least one):

Avoidance of trauma-related memories, thoughts or feelings.

Avoidance of trauma-related external reminders:

◦ People

◦ Places

◦ Things



Negative Changes in Cognition and Mood (At least two):

Inability to recall key elements of the traumatic event.

Persistent negative beliefs and expectations about oneself or the world.

Persistent distorted blame of self or others for event or resulting consequences.

Persistent negative trauma-related emotions: fear, anger, shame, guilt.

Diminished interest in activities.

Feeling alienated from others.

Constricted affect: persistent inability to experience positive emotions.



Alterations in Arousal and Reactivity (At least two):

Irritability and angry outbursts (verbal or physical aggression)

Self-destructive or reckless behaviors

Hypervigilance

Exaggerated startle response

Problems in concentration

Sleep disturbances



If an individual demonstrates PTSD symptoms during the interview (dissociation, flashbacks, hypervigilance), the following strategies may be helpful:

o Display calmness

o Provide reassurance

o Orient to place

o Make periodic “check-ins”

o Take a break

PTSD Toolkit for Nurses. American Nurses Foundation Resource.

Use the interview to identify what stage of change the patient is in (Stages of Change Model) and to guide next steps

Pre-contemplation — not ready; shows lack of awareness

◦ Next Step: give them literature on PTSD, and leave door open for future consultation.

Contemplation — getting ready; considering pros and cons

◦ Next Step: review all options and give them a phone number for mental health.

Preparation — ready; intention and planning for change

or

Action — doing; overt changes

◦ Next step: make appointments with mental health professionals immediately.


The goal of intervention is to strengthen the person’s motivation for seeking help.

Successful interventions depend on the use of motivational interviewing techniques that encourage patients to discuss symptoms related to traumatic events and engage in treatment.

Motivational interviewing is a counseling technique developed by a psychologist William Miller that focuses on producing reflection and personal change:

◦ Ask questions that encourage elaboration and thought

◦ Encourage and reaffirm the patient’s self-examination

◦ Reflective listening confirms that patient is understood


Health providers should educate the individual with PTSD and his or her family about PTSD symptoms, and any comorbid condition(s).

It is important to emphasize that PTSD has no boundaries; it can affect anyone; it is not a sign of weakness.

Individuals should be encouraged to participate actively in decisions about their care.

Assessment and Management of PTSD. Am Fam Physician 2013

An online tool is available from the National Center for PTSD to educate people with PTSD about effective treatment options and encourage them to participate actively in decisions about their care.

This tool offers comprehensive information on first-line, evidence-based PTSD treatments identified in the 2017 VA/DoD Clinical Practice Guideline

Available at: https://www.ptsd.va.gov/professional/ treat/txessentials/use_decisionaid.asp

Treatment Plan Might include:

Trauma-focused Cognitive Behavior Therapy (TF-CBT) and pharmacotherapy are first-line treatment options for PTSD.

SSRI and SNRI antidepressants are first-line pharmacological treatment options for PTSD.

Trauma-focused therapies, which may include: prolonged exposure; in vivo exposure; cognitive restructuring; eye movement desensitization and reprocessing (EMDR).

Detoxification programs for individuals with substance use disorders (alcohol; sedatives; opioids).

2017 VA/DoD Clinical Practice Guidelines

Collaborative care models offer an evidence-based approach for integrating physical and behavioral health services that can be implemented within a primary care-based medical setting.

Members of the care team may include:

Primary care Provider

Psychiatrists (MD; DO)

Clinical Psychologists (PhD; PsyD)

Social Workers (LCSW; MSW)

Advanced Psychiatric Nurse Practitioners (APN)

Archer J, et al. Cochrane Database of Systematic Reviews. 2012. https://tinyurl.com/ydbngpq9

VA PTSD programs

VA Community Based Outpatient Clinics (CBOC)

Community Hospital Inpatient Mental Health and

Substance Use Treatment Programs

First Responder Treatment Services

Community Outpatient Trauma Programs for Men

and Women

◦ Partial Day Hospital

◦ Intensive Outpatient

National Center for PTSD (VA): offers guidance on finding a PTSD therapist: https://www.ptsd.va.gov/gethelp/find_therapist.asp

National Alliance on Mental Illness (NAMI): is a national advocacy mental health organization with local chapters and meetings https://www.nami.org

Sidran Institute /Help Desk: provides referrals to trauma-related support groups; therapists; treatment centers https://www.sidran.org

American Psychological Association: psychologist locator http://locator.apa.org

Military OneSource: free 24/7 support and counseling https://www.militaryonesource.mil/

Do I need to learn more about what

specific resources (e.g. clinicians,

organizations) are available in my area

to help someone with PTSD?

National Institute of Mental Health (NIMH)

◦ basic information on PTSD; patient handouts; concise summary of recent research. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

National Center for PTSD (VA):

◦ listing of treatments, training videos, patient information; www.ptsd.va.gov

◦ PTSD Consultation Program for providers who treat Veterans: www.ptsd.va.gov/consult

◦ Mobile applications: [email protected] (Google Play; App Store)

Uniformed Services University (USU) / Center for Deployment Psychology (CDP)

◦ military culture training courses; online education in military behavioral health; https://deploymentpsych.org.

International Society for Traumatic Stress Studies (ISTSS)

◦ an international, interdisciplinary professional organization that promotes advancement and exchange of knowledge about traumatic stress; http://www.istss.org.

National Center for Telehealth and Technology (T2) ◦ One of the Defense Centers of Excellence (DCoE) for Psychological Health and

Traumatic Brain Injury, offers online health tools.

Helping Patients Cope with a Traumatic Event. Centers for Disease Control and Prevention. ◦ https://www.cdc.gov/masstrauma/factsheets/professionals/coping_

professional.pdf

Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror

◦ Author: Judith L. Herman, MD. 2015. ISBN-13: 978-0465061716

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

◦ Author: Bessel van der Kolk, MD. 2015. ISBN-13: 978-0143127741.

PTSD is not limited to those who have experience trauma; witnessing a traumatic event can cause the disorder, as can the awareness of trauma to a close friend or relative.

PTSD is frequently comorbid with other mental disorders such as depression, anxiety, substance abuse, suicide.

PTSD is frequently comorbid with medical conditions such as GI disorders, chronic pain, respiratory problems, sexual dysfunctions.

Patients with PTSD and comorbid conditions can benefit from psychosocial treatments, as well as from pharmacotherapy.

Non-mental health professionals have a key role to play in identifying those who may be living with PTSD and facilitating their referral to services which can help them

what providers can do to identify signs and symptoms of ... ptsd.pdf · symptoms of ptsd, and link...

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