21st Century VA Independent Study Course: Post-Traumatic Stress Disorder (PTSD): Implications for Primary Care, Combat, Military Sexual Assault, Diagnosis, Treatment, Medicine, Compensation
Department of Veterans Affairs
Smashwords Edition
Copyright 2011 Progressive Management
Questions? Suggestions? Comments? Concerns? Please contact the publisher directly at
Remember, the book retailer can't answer your questions, but we can!
* * * * * * * * * * *
Smashwords Edition, License Notes
This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each person you share it with. If you're reading this book and did not purchase it, or it was not purchased for your use only, then you should return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.
* * * * * * * * * * *
This is a privately authored news service and educational publication of Progressive Management. Our publications synthesize official government information with original material - they are not produced by the federal government. They are designed to provide a convenient user-friendly reference work to uniformly present authoritative knowledge that can be rapidly read, reviewed, or searched. Vast archives of important data that might otherwise remain inaccessible are available for instant review no matter where you are. This e-book format makes a great reference work and educational tool. There is no other reference book that is as convenient, comprehensive, thoroughly researched, and portable - everything you need to know, from renowned experts you trust. For over a quarter of a century, our news, educational, technical, scientific, and medical publications have made unique and valuable references accessible to all people. Our e-books put knowledge at your fingertips, and an expert in your pocket!
Post-Traumatic Stress Disorder: Implications for Primary Care
Department of Veteran Affairs Independent Study Course
EXECUTIVE SUMMARY
Have you ever encountered patients who are…
1. irritable or hostile?
2. avoidant of medical appointments?
3. chronically poor in self-care health habits?
4. exhibiting confusion or poor memory when being interviewed about health?
5. stoic and reluctant to admit to health problems, or extremely needy and/or demanding?
6. extremely reluctant to follow up on any intrusive or gynecological examinations?
7. more likely to present in emergency than for regularly scheduled appointments?
8. presenting with a history of alcohol/substance abuse, depressive symptoms, chronic relationship difficulties and/or intermittent employment history?
9. presenting with hypertension and atherosclerotic heart disease, abnormalities in thyroid and other hormone functions, frequent infections and immunologic disorders, and/or problems with pain perception, pain tolerance and chronic pain syndrome?
Patients with Post-Traumatic Stress Disorder (PTSD) and/or histories of trauma are likely to present to primary care with some (or many) of these characteristics. Their behavior can interfere with patient-provider communication, impede compliance with treatment regimens, and generally, frustrate the practitioner. These patients are at high risk for deteriorating health.
Most trauma victims do not seek mental health services. Instead, they look for assistance and care in the primary care setting.
Medical providers in VA frequently encounter patients with PTSD (often undiagnosed) related to severe prior traumas (especially combat, sexual assault while in the military, prisoner-of-war experiences or childhood physical and sexual abuse). PTSD has profound effects on physical and emotional health and social functioning; it also influences health care utilization and a patient’s ability to interact effectively with the health care system. To increase the identification of PTSD, medical providers should routinely screen for PTSD, using simple available instruments. Medical providers also should routinely screen for exposure to traumas, including combat, sexual assault and domestic violence. Effective treatments for PTSD (both psychotherapy and pharmacotherapy) are available, so most patients should be referred to mental health to confirm the diagnosis and initiate treatment. Being able to help those with PTSD better understand their problems and find real help in addressing them can be very gratifying for the practitioner.
Most trauma victims do not seek mental health services. Rather, they look for assistance and care in the primary care setting. In fact, most mental health treatment is delivered by non-psychiatrist physicians or nurses. Research suggests that most previously traumatized patients do not object to being queried about their trauma history in a primary care setting. While treatment-seeking patients do not typically disclose personal trauma histories spontaneously, they usually will provide this information if queried directly.
WHAT PRIMARY CARE PRACTITIONERS NEED TO KNOW ABOUT PTSD
This manual describes why routine screening for traumatic stress symptoms is crucial in the primary care setting, how often the primary care provider should screen for PTSD and other trauma-related conditions, and how screening in the primary care setting can have an impact on both physical and emotional/behavioral/social health.
Because addressing the topic of trauma presents real challenges to both practitioners and their patients, there is also a discussion of provider and patient attitudes that impede detection of PTSD and ways to ameliorate these barriers. It describes the nature of trauma and the diagnoses associated with trauma exposure (including post-traumatic stress disorder and acute stress disorder) and other psychiatric conditions and features associated with trauma exposure.
Traumatic experiences that happen to one member of a family can have an effect on everyone else in the family, and the primary care practitioner may see similar trauma-related behaviors in both trauma survivors and in family members or caretakers. A number of common reactions of family members are described.
Because traumatic stress is associated with increased health complaints, health services utilization, morbidity and mortality, the effects of trauma and PTSD on physical health are described, as well as the behavioral effects of trauma that might indirectly affect physical health. Some different traumatic experiences, current stressors and presentations of veterans of different wars also are briefly outlined.
Information on the consequences of sexual trauma and the rationale for screening for sexual trauma is included. This is in accordance with the recent VHA mandate that all veteran patients be screened for the presence of military sexual trauma. Although rates of sexual assault of both male and female veterans are quite high, most have never been asked by their primary care provider about a history of sexual trauma and few survivors are likely to spontaneously offer sexual trauma history. However, the overwhelming majority of women indicate that they would like to be asked about sexual trauma history.
GUIDELINES FOR SCREENING FOR TRAUMA-RELATED SYMPTOMS
Recommended PTSD screening and referral procedures are presented, and a screening tool that has been designed to identify trauma-related problems in the primary care setting is described.
The discussion of screening results with patients requires some skill. Specific guidelines assist the clinician in providing the appropriate context for discussing screening results, asking about trauma history, discerning whether traumatic events are ongoing in a patient’s life, responding if ongoing threats to safety are present, providing brief education about PTSD and psychological treatment and making recommendations for further evaluation and referral.
Special issues related to screening for sexual trauma also are addressed, including how to use the right language during the screen, to discern current ongoing danger, and access information on establishing a safety plan and providing assistance.
Finally, recommendations for understanding and responding to the patient who refuses referral to mental health are described.
EFFECTIVELY WORKING WITH TRAUMA SURVIVORS
The manual includes brief descriptions of the more common psychotherapeutic and pharmacological treatments for PTSD, with some commentary on the empirical evidence base for those treatments.
Information is given about interpersonal boundary problems sometimes encountered in working with trauma survivors, which may interfere with an effective patient-provider relationship. Such patients sometimes attempt to draw the clinician into being a friend, a rescuer or a romantic partner. Negative consequences of adopting these roles are described, as well as ways the primary care clinician can prevent harmful boundary crossings and promote better communication and patient care.
Several aspects of the medical setting that may trigger trauma-related symptoms are described, including invasive procedures, being touched, experiencing a power differential, being in pain or being in close proximity to a member of the opposite sex. Common avoidance and dissociative reactions of the trauma survivor that may interfere with medical compliance are identified. Ways the clinician can improve compliance and reduce distress to the patient, including understanding potential concerns, engaging in dialogue throughout an exam, planning ahead and respecting patient wishes are covered.
A substantial portion of veterans with PTSD have not applied for compensation for service-connected PTSD. Because many veterans with PTSD are more likely to report to primary care than mental health, the primary care provider can have significant impact on the veteran’s likelihood of receiving compensation for trauma-related symptoms. The compensation and pension process is therefore outlined, with suggestions for assisting the veteran through the process and specific description of compensation and pension issues for sexual assault survivors.
Finally, alternative models and benefits of behavioral healthcare integration within the primary care setting are outlined.
COMMONLY ASKED QUESTIONS ABOUT PTSD
We asked a number of primary care practitioners to identify questions about PTSD that they want answered. The questions they raised concerned diverse topics related to such issues as the differentiation of PTSD from other mental health problems, the relationship between PTSD and suicide risk, the distinction between traumatic and other stressors, the nature of traumatic stressors encountered in military life and rates of combat-related PTSD. Other topics included PTSD and aging, malingering, risk factors for PTSD, the nature of PTSD treatment and strategies for supporting the patient with PTSD. Brief answers to these and other questions are provided in the “Commonly Asked Questions about PTSD” section.
Many veterans with PTSD remain unrecognized and thus may not be receiving the treatment and support they need for this military-related condition. Primary care staff can play a key role in identifying these patients and getting them the help they need. Thus, it is the hope that this endeavor will increase the ability of staff to diagnose, refer to treatment, and provide support and education, as well as have a better understanding and more compassionate appreciation for the needs of veterans who are experiencing this life altering condition.
Upon completion of this self-study program, participants should be able to:
1. integrate PTSD screening into veterans’ assessments;
2. identify the manifestations of PTSD in veterans;
3. describe the current treatment for PTSD;
4. refer veterans with PTSD to appropriate resources;
5. recognize the need to prepare veterans with PTSD for stressful medical procedures;
6. support and encourage identification of veterans with PTSD; and
7. appreciate veterans who have experienced situations that put them at risk for PTSD.
As a result of this program, clinicians will have a broader base of knowledge with which to provide effective care to patients with PTSD and a better understanding of patients who experience this condition.
This independent study is designed for VA Primary Care clinicians.
Program Content:
I. INTRODUCTION
Why Screen Veterans for Traumatic Stress
Obstacles to Detection of Traumatic Stress-Related Problems
A Rationale for Routine Traumatic Stress Screening in VA Health Care Settings
The Role of Health Care Providers
II. BACKGROUND INFORMATION ON TRAUMATIC STRESS
The Nature and Impact of Traumatic Stress
Women and Sexual Trauma
Men and Sexual Trauma
III. GUIDELINES FOR SCREENING FOR TRAUMA-RELATED SYMPTOMS
Screening and Referral Procedure Overview
Implementing Screening Procedures
IV. EFFECTIVELY WORKING WITH TRAUMA SURVIVORS
Treatments for PTSD
Pharmacotherapy for PTSD
Medical Compliance/Preparation for Medical Procedures
The Patient-Provider Relationship: Setting Boundaries
Special Considerations: The Compensation-Seeking Veteran with PTSD
Models of Care
V. COMMONLY ASKED QUESTIONS ABOUT PTSD
VI. REFERENCE MATERIALS
Quick Reference Guide
“Understanding Trauma and PTSD” Patient Information Sheet
Screening Tools
Patient Protection and Advocacy
References
Annotated Bibliography
VII. TESTING AND EVALUATION MATERIALS
Independent Study Test Questions
1 WHY SCREEN VETERANS FOR TRAUMATIC STRESS
Mary B. is a 57-year-old retired nurse. She is currently a patient in the women’s clinic. Her recent pap smear showed dysplastic cells. Today, she is seeing the GYN specialist from the university for further diagnostic procedures. Upon walking into the exam room, you notice she is sitting at attention in the chair as far away from the exam table as possible. She asks if you could re-schedule her appointment for another day. She says “I just don’t think I can do this today. It took all I could do to get the first exam done.”
You are concerned about delaying the test because of the medical urgency and difficulty in scheduling the visit in the near future.
What would you do?
Screening veterans for traumatic stress is important because:
1. trauma is common.
2. trauma often leads to PTSD and other impairment.
3. trauma often presents to primary care, but goes unrecognized.
4. failure to identify and treat PTSD has adverse effects on physical and mental health.
Trauma is Common
Approximately 85% of male veterans have been exposed to traumatic events (Hankin, Spiro, Miller, & Kazis, 1999). Fifty-two percent of World War II veterans and 35% of veterans of the Korean conflict have been exposed to combat. Women veterans also may have been exposed to combat, and 23% of women veterans using VA care report that they were sexually assaulted while in the military (Skinner, Kressin, Frayne, Tripp, Hankin, Miller, & Sullivan, 2000).
More than half of all male Vietnam veterans and almost half of all female Vietnam veterans–About 1,700,000 Vietnam veterans in all–have experienced “clinically serious stress reaction symptoms.”
Up to 90% of the general population in the United States is exposed to a traumatic stressor at some time (Breslau, Kessler, Chilcoat, Schultz, Davis, & Andreski, 1998). Common types of trauma include road traffic accidents, man-made or natural disasters, wartime combat, interpersonal violence (e.g., child abuse, sexual assault, domestic violence or other criminal violence), life-threatening medical conditions and sudden, unexpected death of a close relative or friend.
Patients with PTSD experience a significant degree of functional impairment, similar to that observed in patients suffering from major depression or chronic physical diseases, such as diabetes and congestive heart failure.
Trauma Often Leads to PTSD and Other Impairment
The percentage of those exposed to traumatic stressors who then develop post-traumatic stress disorder (PTSD) can vary depending on the nature of the trauma. In one major U.S. epidemiological study (Kessler et al., 1995), lifetime prevalence rates of PTSD following specific types of trauma were:
Combat: Men 38%
Rape: Men 65% / Women 46%
Life-threatening accident: Men 6% / Women 9%
Physical Attack: Men 2% / Women 21%
About one in 12 adults experiences PTSD at some time during their lifetime (women =10.4%; men = 5%; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Women are twice as likely as men to develop PTSD following exposure to traumatic events.
Among American Vietnam theater veterans, 31% of men and 27% of women are estimated to meet criteria for PTSD at some point in their lives. An additional 22.5% of male and 21.2% of female veterans have had partial PTSD at some point. This means that more than half of all male and almost half of all female Vietnam veterans–about 1,700,000 Vietnam veterans in all-have experienced “clinically serious stress reaction symptoms” (Kulka, Schlenger, Fairbank, Hough, Jordan, Marmar, & Weiss, 1990).
Life-threatening medical conditions such as myocardial infarction, severe burns, severe injuries and cancer can cause or exacerbate PTSD.
20% of VA ambulatory care outpatients screen positive for PTSD (Hankin et al., 1999); this is higher than the rate seen in private sector patients.
A VA ambulatory care outpatient who has been exposed to trauma is three times more likely to be diagnosed with depression and two times more likely to be diagnosed with an alcohol disorder.
Patients with PTSD experience a significant degree of functional impairment (Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000) similar to that observed in patients suffering from major depression.
Primary care patients with untreated anxiety report levels of functioning within those ranges expected for patients with chronic physical diseases, such as diabetes and congestive heart failure (Fifer, Mathias, Patrick, Mazonson, Lubeck, & Buesching, 1999).
PTSD is associated with significant problems in living, including alcohol abuse, marital problems, unemployment and suicide, with high levels of use of medical services.
Traumatic experiences and traumatic stress bring about hormonal, neurochemical, immune functioning and autonomic nervous system changes which can affect physical health.
PTSD Often Presents in Primary Care, but Goes Unrecognized
In the private sector, nearly half of all patient visits for a mental health disorder are to a medical clinic or provider. Of those visits, 90% are to primary care providers.
Despite its prevalence, PTSD is likely to remain unrecognized and untreated in primary care patients. Few medical clinics systematically identify trauma survivors with related mental health problems.
Failure to Identify and Treat PTSD has Adverse Effects on Physical and Mental Health
Traumatic stress is associated with increased health complaints, health services utilization, morbidity and mortality (Schnurr & Jankowski, 1999; Schnurr, Friedman, Sengupta, Jankowski, & Holmes, 2000).
Untreated PTSD can impair recovery from medical conditions.
In failing to address the impact of traumatic stress on health, patient and doctor become less likely to achieve desired outcomes.
2. OBSTACLES TO DETECTION OF TRAUMATIC STRESS-RELATED PROBLEMS
“Although screening for PTSD does take a little time, it is time well spent. I will never forget my first experience screening a patient specifically for PTSD. The patient seemed depressed and upon discussion with the patient, it became clear that the patient had suffered from PTSD for nearly 30 years. I referred him to the Trauma Recovery Program where he was treated with care and compassion. What a difference this made in the lives of the patient and his family. The patient and his family still sing my praises for this. Of course, this opened my eyes to the real need to screen my patients for PTSD and since that time, I have seen many positive results of PTSD screening and treatment.”
What are the obstacles to routine and active identification of veteran patients with a history of trauma exposure and symptoms of PTSD?
Lack of Awareness
Awareness of the impact of trauma exposure and PTSD on health is very new. It is not a familiar issue to many health care providers. In fact, the diagnosis of PTSD is itself relatively new to the psychiatric nomenclature.
Lack of Time
In all primary care settings, time is of the essence. In a world with cost constraints on health care, there is less and less time to chat with the patient and little time to consider issues that do not appear to be directly related to presenting health complaints.
Lack of Assessment Tools
Until recently, the lack of a time-efficient and cost-efficient screening method to identify patients with post-traumatic stress symptoms was an obstacle to screening.
Provider Attitudes that Impede Detection
It is hard to bring up the subject of trauma, and most health care providers have little experience in doing so. Moreover, providers may have a variety of concerns about asking about traumatic experiences and symptoms.
Concern / Consider
“It’s upsetting to the patient.”
It may be upsetting to the patient not to talk.
“It’ll re-traumatize the patient.”
Talking about trauma is not the same thing as experiencing a traumatic event.
“It won’t do any good.”
It may be perceived as caring or helpful by the patient and may lead to definitive treatment.
“I don’t know what to do about it.”
It may be helpful just to raise the subject and offer a referral.
“It’ll embarrass us both.”
Physicians and nurses routinely take on subjects that are potentially embarrassing, such as screening for substance abuse, sexual dysfunction or suicidality.
“It will offend him or her.”
Most trauma survivors will not be offended, and may instead feel relieved that they can talk about it.
“It’s not my role to ask about trauma history.”
It is the role of the health care provider to work to improve health, and trauma/PTSD affects physical and mental health.
“I don’t have the time.”
Raising this issue takes little time and may save valuable clinical time in the long run.
“It has little to do with health concerns.”
Trauma has documented associations with a host of physical health problems and health services utilization.
Patient Attitudes that Impede Detection
Like the professional helper, the veteran also may have a host of reasons for avoiding discussion of past (or recent) trauma. One very important reason is that patients fear that reminders of the trauma will cause distress, fear, anger or shame; they are, therefore, motivated to avoid reminders, including talking about the trauma. It is not unusual to hear from a veteran that he or she has never disclosed what happened to anyone. In addition, it is often the case that the person does not know about post-traumatic stress disorder, its causes and symptoms. It also is probable that the link between health concerns and emotional problems is not clear to the patient. Skepticism regarding benefits of sharing a trauma story are particularly widespread. The following kinds of fears of disclosure and its effects are common:
“This person can’t help me anyway.”
“It doesn’t have anything to do with my health.”
“If I talk about it, I’ll become upset/angry/hysterical.”
“This person doesn’t want to hear about it; it will upset the doctor.”
“It’s too private/shameful to tell.”
Despite these patient concerns, it is important to note that most previously traumatized patients do not object to being queried about their trauma history. In one study, a majority of female patients agreed that physicians should routinely ask about histories of trauma.
As primary care practitioners become more familiar with the ways in which they can help patients with education and referral regarding trauma, many of the patient concerns listed above can be acknowledged and addressed.
3. A RATIONALE FOR ROUTINE TRAUMATIC STRESS SCREENING IN VA HEALTH CARE SETTINGS
“I have had an 83-year-old patient in whom I suspected depression and PTSD. When I screened him, he began to cry and tell me that since WWII he had these think he was crazy. Since screening, problems but was scared to ask anyone about it because he thought they would he was referred for treatment and is much better. He suffered for 40 years! We must not continue to let our patients suffer in silence. We have an obligation to screen for this treatable illness. Who better to screen the patient than the primary care provider with whom they have a long term, therapeutic and hopefully trusting relationship?”
While treatment-seeking patients do not typically disclose personal trauma histories spontaneously, they usually will provide this information if queried directly.
Currently, most VA and non-VA medical professionals do not routinely screen for trauma history or PTSD (war-related or otherwise), so the majority of trauma survivors with problems go undetected. In a study conducted in the civilian sector, only 6% of adult female patients at a Family Medicine Clinic reported being asked by physicians about their trauma histories (Walker, Torkelson, Katon, & Koss, 1993). In another study, 83% of women whose emergency room visits were prompted by partner abuse were not asked about domestic violence and did not spontaneously disclose the abuse to emergency room personnel (Abbott, Johnson, Koziol-Mclain, & Lowenstein, 1995). Even in trauma medicine, where injuries and illnesses are recognized as life-threatening and traumatic, the emotional consequences of such medical events are not routinely identified or addressed.
Brief, direct questions about trauma exposure and post-trauma symptoms included as a routine part of contact can quickly identify many veterans whose traumatic experiences are continuing to have a significant impact on their functioning. An efficient way to accomplish this is to include questions about post-trauma symptoms and/or trauma exposure in the pencil-and-paper self-report forms that patients complete as a review of their health habits or medical symptoms prior to seeing their health care practitioner. Use of screening questionnaires is important because face-to-face interview screening places demands on staff resources that may not be acceptable.
While treatment-seeking patients do not typically disclose personal trauma histories spontaneously, they usually will provide this information if queried directly. In a study of 50 emergency room charts selected at random, references to sexual abuse were found in only 6% of the charts. Subsequently, physicians were instructed to routinely ask patients about histories of childhood sexual abuse. Among 50 women directly queried, 70% reported having been sexually molested (Briere & Zaidi, 1989). Screening leads to increased detection.
Research suggests that most previously traumatized patients do not object to being queried about their trauma history in a primary care setting.
In summary, PTSD symptom screening is an important addition to routine preventive health screening in VA primary health care settings because:
patients are unlikely to report trauma history or symptoms unless directly asked.
trauma exposure and PTSD are associated with many problems – emotional and physical–that affect health.
in veteran patients with long lasting PTSD, significant improvements in symptoms are unlikely to occur without treatment.
Screening for PTSD should be a regular occurrence in the primary care setting, as symptoms are cyclical for some individuals and may be “triggered” by events such as personal trauma anniversaries (e.g., anniversary of Khe Sanh) or news in the media (e.g., peacekeeping mission coverage; “Saving Private Ryan”). For this reason, all new patients should be routinely screened, with screening on an annual or semi-annual basis thereafter.
4. THE ROLE OF HEALTH CARE PROVIDERS
Health care providers in primary care settings can play an important role in identifying traumatized veterans and helping them get treatment. Some of the things health care providers can do include:
conducting (or having mental health specialists conduct) brief screening for PTSD symptoms.
providing on-site, trauma-related patient and family education.
providing referral for specialized PTSD evaluation and treatment for patients with trauma-related problems.
educating staff about identification and referral of veterans with trauma-related problems.
using understanding of trauma and its effects to inform treatment planning for patients whose severe psychological complications interfere with medical care.
contributing to the development of genuinely multidisciplinary teams that ensure integration and continuity of patient care.
Often the “difficult” or “impossible” patient is persistently confused, angry, depressed, caught up in abuse of alcohol or drugs or otherwise emotionally dependent and demanding because she or he has not fully recovered from trauma.
Note: In this guide, we do not emphasize the diagnosis of PTSD. That is beyond the scope of the typical primary care provider. Rather, we encourage providers to take steps to detect post-traumatic stress symptoms and to refer patients for further evaluation by mental health personnel.
We recommend that, whenever possible, primary care providers develop ongoing collaborative relationships with mental health professionals and establish screening and intervention procedures for their patients with problems related to traumatic experiences.
Primary care providers may elect to treat some symptoms of PTSD with medications. However, many patients with PTSD will benefit from mental health referral for evaluation and treatment, in addition to any pharmacotherapy that is indicated. There is wide availability of mental health services within the VA Health Care System, and referral for mental health assistance can:
enable the survivor to prevent trauma from continuing (e.g., by interrupting ongoing domestic violence),
reduce trauma-related distress and hasten the survivor’s emotional recovery, and
reduce stress-related medical problems and increase the survivor’s adherence to and benefit from medical care.
A very useful resource for primary care practitioners is Module P of the Major Depressive Disorder Clinical Practice Guidelines, which addresses assessment and treatment of PTSD co-occurring with Major Depressive Disorder. The guidelines are available on the web at http://www.va.gov/HEALTH/mdd.hlp.
When veterans and their family members begin to understand that much of their distress and many of their problems are connected with their war (or other traumatic) experiences and post-traumatic stress, they often are willing to reach out for many kinds of help that are available. Often the “difficult” or “impossible” patient is persistently confused, angry, depressed, caught up in abuse of alcohol or drugs or otherwise emotionally dependent and demanding because she or he has not recovered from trauma. These medical management problems can lead to physical deterioration despite excellent care and a thorough mental health examination is essential to find the best approaches to intervention.
5. THE NATURE AND IMPACT OF TRAUMATIC STRESS
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV; 1994, p. 424) specifies criteria for the diagnosis of post-traumatic stress disorder. These include:
• exposure to a traumatic event that involved actual or threatened death or injury (to self or others) or a threat to physical integrity,
• the person’s response to the traumatic life event must have involved intense fear, helplessness, or horror,
• persistent re-experiencing of the event (criteria specify that the person must have one or more of the re-experiencing symptoms; see below),
• persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (three or more avoidance symptoms; see below),
• two or more persistent symptoms of arousal (see below),
• duration of symptoms must last more than one month, and
• symptoms must cause clinically significant distress or impaired functioning.
As noted above, we do not emphasize the diagnosis of PTSD. That is beyond the scope of the typical primary care provider. Rather, we encourage providers to take steps to detect post-traumatic stress symptoms and to refer patients for further evaluation by mental health personnel.
Rates of PTSD will be higher if trauma exposure has been more severe. For example, between 30 and 70% of POWs will have chronic PTSD.
Traumatic Events and PTSD
Many experiences in combat may be potentially traumatic. Veterans involved in firefights and their aftermath will have been exposed to injury, personal life threat, death and dying, mass death, sights of mutilated bodies and/or atrocities. Those who provided medical care in the field (e.g., nurses) may have experienced many of these same traumas. Prisoners of war (POWs) also will have experienced many such events (e.g., torture, starvation) during their captivity. Some veterans have been sexually assaulted in the war zone or during other military service.
At the time of a traumatic event, many people feel overwhelmed with fear, while other people feel numb or disconnected. Most trauma survivors will be upset for several weeks following an event, but recover to a variable degree without treatment. The percentage of trauma victims that will continue to have problems and develop post-traumatic stress disorder (PTSD) will depend upon many factors, including the severity of trauma exposure. As noted above, one major epidemiological study of American civilians aged 15-54 (National Comorbidity Survey, Kessler et al., 1995) indicated lifetime prevalence rates of PTSD following specific types of trauma:
Combat: Men 38%
Rape: Men 65% / Women 46%
Life-threatening accident: Men 6% / Women 9%
Physical attack: Men 2% / Women 21%
Witnessing death or injury: Men 6% / Women 8%
Natural disaster: Men 4% / Women 5%
Diagnostic Criteria for PTSD
Post-traumatic stress disorder (PTSD) is a mental disorder resulting from exposure to an extreme traumatic stressor. PTSD has a number of unique defining features and diagnostic criteria, as published in DSM-IV. These Criteria include:
Criterion A– Exposure to a traumatic stressor
Criterion B – Re-experiencing symptoms
Criterion C – Avoidance and numbing symptoms
Criterion D– Symptoms of increased arousal
Criterion E – Duration of at least one month
Criterion F – Significant distress or impairment of functioning
Criterion A: Exposure to a traumatic stressor
A traumatic event involves actual or threatened death or injury to oneself or to others.
Response to the trauma involves intense fear, helplessness or horror.
For Criterion A to be met, the person must have been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and (2) the person’s response to the trauma involved intense fear, helplessness or horror. (In children, this may be expressed instead by disorganized or agitated behavior.)
Stressful events of daily life that do not meet these criteria include divorce and financial crisis, which may lead to adjustment problems, but are not sufficient to meet Criterion A for PTSD.
According to the DSM-IV, the witnessing of and learning about stressors experienced by others can be sufficient to induce PTSD. Common examples include witnessing or learning about the sudden death of a loved one, or observing serious injury or unnatural death of another person. The more distant the individual is to the traumatic event, such as learning about the death/injury of another person, the less likely one usually is to develop PTSD symptoms or have protracted or severe emotional disturbance.
Qualifying stressors must induce an intense emotional response. According to DSM-IV, a qualifying stressor must not only be threatening, but it also must induce a response involving intense fear, helplessness or horror. Some severely traumatized individuals may dissociate during a stressor or have a blunted response due to defensive avoidance and numbing. Often, the intense emotional response to the stressor may not occur until considerable time has elapsed after the incident has terminated.
Criterion B: Re-experiencing symptoms
Criterion B symptoms of PTSD involve persistent and distressing re-experiencing of the traumatic event in one or more of the following ways:
recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.
recurrent distressing dreams of the event.
acting or feeling as if the traumatic event were recurring, such as a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those which occur on awakening or when intoxicated.
intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect to the traumatic event.
physiological reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
In these symptoms, the trauma comes back to the PTSD sufferer in some way, through memories, dreams or distress in response to reminders of the trauma. PTSD is distinguished from “normal” remembering of past events by the fact that re-experiencing memories of the trauma(s) are unwanted, occur involuntarily, elicit distressing emotions and disrupt the functioning and quality of life of the individual.
Criterion C: Avoidance and numbing symptoms
Criterion C symptoms of PTSD involve persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as evident by three or more of the following symptoms that were not present before the trauma:
efforts to avoid thoughts, feelings or conversations associated with the trauma.