Spotting—and treating—PTSD in primary care

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Applied Evidence

Spotting—and treating—PTSD in primary care

J Fam Pract. 2010 February;59(2):75-80

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References

1. US Department of Veterans Affairs. National Center for PTSD. How common is PTSD? Available at: www.ptsd.va.gov/public/pages/how-common-is-ptsd.asp. Accessed January 18, 2010.

2. Freedy JR. Post-traumatic stress disorder. In: Ebell M, ed. Evidence Based Medicine. New York: John Wiley and Sons; in press.

3. Kessler RC. Posttraumatic stress disorder: the burden to the individual and to society. J Clin Psychiatry. 2001;61:4-12.

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5. RAND. Invisible wounds of war. 2008. Available at: www.rand.org/pubs/monograph/MG720. Accessed January 13, 2010.

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7. Brock CD, Johnson AH, Koopman RJ, et al. Difficult doctor-patient relationships that cause diagnostic and management dilemmas. J Balint Soc. 2006;33:6-10.

8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR). Washington, DC: American Psychiatric Association; 2000.

9. SJ Morewitz, ed. Domestic Violence and Maternal and Child Health. New York: Kluwer Academic/Plenum Publishers; 2007:224.

10. Freedy JR, Magruder KM, Zoller JS, et al. Traumatic events and mental health in civilian primary care: Implications for training and practice. Fam Med. In press.

11. Breslau N, Chilcoat HD, Kessler RC, et al. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. Am J Psychiatry. 1999;156:902-907.

12. McQuaid JR, Pedrelli P, McCahill ME, et al. Reported trauma, post-traumatic stress disorder and major depression among primary care patients. Psychol Med. 2001;31:1249-1257.

13. Freedy JR, Hobfoll SE. Traumatic Stress: From Theory to Practice. New York: Plenum Publishing; 1995.

14. Freedy JR, Monnier J, Shaw DL. Putting a comprehensive violence curriculum on the fast track. Acad Med. 2001;76:348-350.

15. US Department of Veterans Affairs. National Center for PTSD. Trauma, PTSD, and the primary care provider. Available at: http://www.ptsd.va.gov/professional/pagestrauma-ptsd-provider.asp. Accessed January 15, 2010.

16. Freedy JR, Brock CD, Blue AB, et al. The art of professionalism: being in role as the fundamental skill. J Balint Soc. 2009;37:51-54.

17. Leskin GA, Ruzek JI, Friedman MJ, et al. Effective clinical management of PTSD in primary care settings: screening and treatment options. Prim Care Psychiatry. 1999;5:3-12.

18. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.

19. Breslau N, Peterson EL, Kessler RC, et al. Short screening scale of DSM-IV posttraumatic stress disorder. Am J Psychiatry. 1999;156:908-911.

20. Meltzer-Brody S, Churchill E, Davidson JRT. Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatry Res. 1999;88:63-70.

21. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.

22. PTSD CheckList–Civilian Version (PCL-C) Available at: www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf. Accessed January 18, 2010.

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The time that has elapsed since the traumatic event is also a factor in diagnosis (TABLE 2).⁸ While PTSD can be acute (lasting months prior to full resolution), symptoms more often follow a chronic, recurrent course,^2,3 as in Maureen’s case.

However, the 4 categories—acute, chronic, delayed, and subclinical PTSD—are not mutually exclusive; an acute case may become chronic if it is unrecognized and untreated; subclinical PTSD may be reactivated by recent reminders of a past traumatic event.² Several years after Dominic returned to baseline function, for example, a fire in a neighbor’s home triggered another acute episode.

TABLE 1
Diagnostic criteria for PTSD

Diagnostic criteria	Distinguishing features
Traumatic event	Experienced, witnessed, or was confronted with an event involving actual or threatened death or serious injury, or threat to physical integrity; responded with intense fear, helplessness, or horror
Reexperiencing trauma (≥1 feature)	Intrusive thoughts, nightmares, flashbacks, intense psychological distress to internal/external cues; physiologic reactivity to cues
Avoidance/numbing (≥3 features)	Avoidance of internal/external cues; trauma-related amnesia; diminished interest or participation, social detachment/estrangement; restricted affect; sense of foreshortened future
Arousal (≥2 features)	Sleep disturbance, irritability/anger, concentration difficulty, hypervigilance, exaggerated startle response
Duration	Symptoms persist ≥1 month
Functional impairment	Academic, occupational, social
PTSD, posttraumatic stress disorder.
Adapted from: American Psychiatric Association. DSM IV-TR. 2000.⁸

TABLE 2
PTSD diagnosis: How time affects it

Diagnosis	Distinguishing features
Acute PTSD	Symptoms 1-3 months posttrauma; better prognosis than chronic PTSD
Chronic PTSD	≥3 months of symptoms; worse prognosis than acute PTSD
Delayed PTSD	< 5% of cases; symptom onset ≥6 months after trauma exposure
Subclinical PTSD	Symptoms may wax and wane; physical or psychological stress may reactivate symptoms
PTSD, posttraumatic stress disorder.
Adapted from: American Psychiatric Association. DSM IV-TR. 2000.⁸

When to suspect PTSD: A review of risk factors

FAST TRACK

Risk factors for PTSD include a history of trauma; current or past mental health problems; vague, persistent medically unexplained physical symptoms; physical injuries; and pregnancy.

A history of trauma (particularly rape or other forms of sexual assault, physical assault involving weapons, severe injury or perceived life threat, or combat exposure); personal or family mental health problems; substance abuse; vague, persistent medically unexplained physical symptoms; physical injuries; and pregnancy (4%-8% of US women are physically abused during pregnancy⁹) are key risk factors for PTSD.^2,3,10-12

Straightforward as that may seem, physicians frequently fail to consider PTSD in the differential diagnosis—and patients often fail to discuss symptoms. Some patients avoid talking about their problems because of the stigma of mental illness. Others, like Maureen, know little about PTSD and are unaware that events that occurred many years ago can have a profound effect on them now.¹³

Barriers to detection
There are no specific recommendations for screening for PTSD in primary care, at least in civilian settings. The US Preventive Services Task Force (USPSTF) recommends that physicians address health behaviors that are potential outcomes of violence—tobacco and alcohol use, depression, illicit drug use, and suicidal ideation among them—but does not address PTSD itself.¹⁰

A number of other factors work against routine screening for trauma and PTSD, some on the provider side and others on the part of patients.

Provider barriers^7,10,14-16 include:

Education deficit. (The medical aspects of, and sequelae to, violence are not sufficiently addressed; violence is not seen as a medical issue.)
Time constraints
Physician discomfort addressing violence. (Repeatedly victimized patients typically display a sense of vulnerability that can induce negative feelings in physicians, potentially causing them to act counterproductively.)
Misunderstanding of patient needs. (The physician may not realize the importance of providing a psychologically safe environment in which the patient is neither shamed for his or her behavior nor excused from responsibility for self-care.)
Lack of awareness/limited knowledge of PTSD resources and treatment.

Physicians who have little experience with serious mental health issues may need to take steps to develop the knowledge and skills to work with patients with PTSD—continuing medical education and professional reading, participation in Balint groups (small groups of physicians who meet, typically for 1-2 years, for the purpose of learning to better manage doctor-patient relationships), psychotherapy, and/or professional consultation. You can learn more about Balint groups from the American Balint Society (http://www.americanbalintsociety.org). Information about PTSD and lists of clinicians who specialize in treating it are available at the National Center for PTSD (http://www.ptsd.va.gov), National Crime Victims Research and Treatment Center (http://colleges.musc.edu/ncvc), and Eye Movement Desensitization and Reprocessing Institute, Inc. (www.emdr.com).

Patient barriers^13,17 include:

Fear of retribution. (Victims of violence are often threatened with further harm if they tell anyone about the abuse.)
Embarrassment, guilt, and shame. (Ironically, refraining from talking about traumatic events can reinforce patients’ sense of shame.)
Low self-esteem
Learned helplessness
Limited insight.

Many of these barriers were affecting Maureen: She had been threatened by the man who sexually abused her. And, because of repeated trauma, she suffered from learned helplessness; she did not consider herself competent enough to take steps to improve her health or otherwise help herself. Nor did she realize that her past continued to profoundly affect her—until she underwent screening for PTSD.