The Journal for Nurse Practitioners
Volume 5, Issue 7 , Pages 516-522, July 2009

An Overview of PTSD for the Adult Primary Care Provider

  • Molly Feliciano

      Affiliations

    • Molly Feliciano, MSN, APRN-BC, is an adult nurse practitioner in the Deployment Health Clinical Center of the Walter Reed Army Medical Center in Washington, DC.

Article Outline

Abstract 

Posttraumatic stress disorder (PTSD) is an anxiety disorder characterized by re-experiencing, avoidance, and hyperarousal symptoms that can develop after exposure to a traumatic event. It is estimated that approximately 60% of people in the United States experience at least one severe trauma in their lifetime, of which approximately 9% meet full diagnostic criteria for PTSD. Prevalence varies by a population's traumatic exposure but is estimated to be 12% to 14% among troops returning from Afghanistan and Iraq, 12% of patients in primary care, 38.6% of patients screened in primary care for depression and anxiety and, internationally, PTSD occurs in up to 30% of the population in areas of chronic civil unrest, violence, and terrorism. Despite growing awareness and its emergence as a significant public health concern, PTSD often goes undiagnosed and consequently untreated, particularly in adult primary care, where patients frequently present with other chief complaints and PTSD is not considered in the differential diagnosis. The debilitating sequelae of PTSD, coupled with the significant physical, psychological, and social comorbidities and related health care costs, demonstrate the need for improved identification and appropriate intervention by primary care providers. The goal of this article is to provide an introductory overview of PTSD in adult primary care that helps adult primary care providers understand the history and epidemiology of the disorder, become familiar with its diagnostic criteria and clinical presentation, understand the associated health care costs and comorbidities, develop a regimen to more thoroughly screen for PTSD, and become familiar with effective treatments for this disabling condition.

Keywords:  re-experiencing , emotional numbing , hyperarousal , hypervigilence , posttraumatic stress disorder , psychotherapeutic modalities

 

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Historical Background and Prevalence 

The term posttraumatic stress disorder (PTSD) was first applied in 1978 to describe a myriad of psychosocial behaviors and specific symptoms observed in Vietnam veterans.1 Recognized over 100 years ago and referred to by such terms as shell shock and “war neurosis,”2 PTSD was initially recognized as a consequence of military combat experience; however, it has become increasingly common in civilian populations3 as a consequence of terrorism, crime, sexual assault, serious accidents, and severe natural disasters.4

The development of PTSD appears to be related to the intensity of the trauma and severity of initial physical injuries5 as well as to the existence of risk factors, including gender, prior exposure to trauma (particularly in childhood), and family history of depression, anxiety, or antisocial behavior.6, 7 It is estimated that approximately 9% of the general population exposed to a traumatic event will experience PTSD sometime in their lives, with approximately 60% of men and 50% of women experiencing at least one traumatic event during their lifetime. Men most frequently identify acts of violence and serious accidents as major traumas while women identify physical and sexual assault most frequently.8 Although men typically report greater trauma exposure, women are twice as likely to develop PTSD.8, 9

Approximately 20 million Americans have had a least one lifetime episode of PTSD, but despite its prevalence, PTSD is frequently undiagnosed and untreated.10, 11 The majority of PTSD patients turn to primary care settings for their health care, presenting with vague physical complaints or psychological issues. Unaware of the relationship between these presenting symptoms and PTSD, primary care providers are often ill-equipped to screen for the disorder and make a diagnosis. The National Comorbidity Study revealed that patients with PTSD presented symptoms of PTSD for a mean duration of 5 years prior to accurate diagnosis.8 Retrospective studies of medical records have also revealed that as few as 2% of primary care providers accurately diagnosed PTSD12 and even if correctly identified, PTSD is documented in as few as 11% of patient records.13 This suggests that many of those affected may not be receiving appropriate treatment.

The World Health Organization (WHO) predicts that motor vehicle accidents, war, and violence will be the 3rd, 8th, and 12th leading causes of disability worldwide by the year 2020, a significant escalation from the respective rankings of 9th, 16th, and 19th in 1990.14 With this increased volume of traumatic events, it is evident that PTSD will remain a major public health concern in the future and primary care providers will increasingly become responsible for recognizing the symptoms, establishing the diagnosis, and providing appropriate treatment and rehabilitation.

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Diagnostic Criteria and Clinical Presentation 

The PTSD diagnosis was officially introduced in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) in 1980 and categorized as an anxiety disorder.15 Today, specific diagnostic criteria are presented in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)16 as well as WHO's International Code of Diagnostics – Version 10 (ICD-10).17 According to DMS-IV, a diagnosis of PTSD is given based on symptom criteria A-F. Initially, the individual must “experience, witness or be confronted with a traumatic event that involves actual or threatened death or serious injury.”16 This includes such stressors as violent physical assault, sexual assault, combat, serious accidents, child abuse, natural disasters, rescue work involving exposure to death, and diagnosis of a life-threatening illness. This exposure to a traumatic event qualifies as Criterion A1 and it must invoke an intense emotional response of fear, helplessness, or horror, which comprises Criterion A2. In response to this qualifying trauma, the patient subsequently develops a triad of symptoms, Criterion B, C, and D, which include:

•Re-experiencing the trauma (Criterion B) – flashbacks, nightmares, intrusive thoughts, and/or memories;

•Avoidance behaviors (Criterion C) – efforts to avoid talking or thinking about the trauma; avoiding people, places, or activities that invoke memories of the trauma; forgetting pertinent details about the trauma; feeling detached, emotionally numb, and unable to express loving feelings toward others; and/or sensing a shortened future;

•Hyper-arousal behaviors (Criterion D) – difficulty sleeping, racing thoughts, and concentration problems, excessive startle reflex, irritability, and hypervigilence demonstrated through such behaviors as continually locking doors, constantly scanning a room, sitting with one's back to the wall, mentally planning an escape route from a room, and other such behaviors.

These symptoms must be present for at least one month (criterion E) and cause significant disruption to the individual's life, including personal, social, or occupational functioning (Criterion F). To meet full diagnostic criteria, the individual must experience 1 re-experiencing symptom, 3 avoidance symptoms, and 2 hyperarousal symptoms. Duration of these symptoms for less than 3 months is considered acute PTSD, with chronic PTSD lasting greater than 3 months. If symptoms do not develop until 6 or more months after the traumatic event, it is referred to as delayed-onset PTSD; however, some researchers believe it is more likely a delay in diagnosis rather than a delay in onset of symptoms.18

The WHO's ICD-10 criteria are more commonly used as the international diagnostic standard for PTSD and for epidemiologic reference. Though similar to DSM-IV, there are noteworthy differences, including the absence of subjective emotional response (Criterion A2), the requirement of only one avoidance symptom, the onset of symptoms within 6 months of the traumatic event, and the absence of Criterion F, impairment of an individual's personal, social, or occupational functioning.17

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Comorbidity and Cost 

In addition to its debilitating symptoms and impact on quality of life, PTSD is also associated with significant physical and psychological comorbidity.8, 19, 20 Current research holds that the pathophysiology of PTSD is multifaceted, with disruption of a variety of biological pathways including the prefrontal cortex, amygdale, and hippocampus21; the hypothalamic-pituitary-adrenal (HPA) axis22; noradrenergic and serotonin responses23; and the immune system.24 Resulting physical complaints range from a diagnosis of modified somatization disorder25 to individual physical complaints, which frequently include respiratory, gastrointestinal, musculoskeletal, and cardiovascular issues as well as pain and fatigue.19, 20, 26, 27

Patients are also more likely to smoke and abuse alcohol and drugs,28 as well as to have a higher body mass index (BMI),26, 29 thus are prone to health problems associated with these risk factors. Comorbid psychiatric diagnoses of depression, anxiety, or substance abuse are especially prevalent, occurring in 88% of men and 79% of women with PTSD.8 Further, the risky lifestyles associated with alcohol and drug abuse increase the body's susceptibility to physical illness as well as exposure to accidents and violence.

Functional impairment and poor quality of life are also sequelae of PTSD,30 and have been found to be exceptionally severe in patients with PTSD.31 Occupational issues including work impairment, poor productivity, high rates of absenteeism, disability, and unemployment arise.32

Research results have revealed that work disruption related to PTSD is similar to that associated with depression, and equates to an annual productivity loss in the United States of over $3 billion.9 Although many with mental health disorders would prefer to work, employment barriers, including insufficient formal education or vocational training, lower productivity, labor force discrimination, and employment disincentives such as disability payments all contribute to high unemployment rates and poverty level incomes.32

According to the Department of Veterans Affairs (VA), PTSD is the most common psychiatric condition identified by veterans applying for VA disability benefits.33 However, despite the fact that 50% of men and 80% of women seeking VA PTSD disability benefits attended college, they report significant work-related issues, unemployment rates of 21% in men and 33% in women, and a 40% poverty rate.34 Home and social life are also adversely impacted, with significant emotional toll on interpersonal relationships and reported high incidence of divorce and domestic violence.8

These problems often manifest in an increased utilization of health care services, which equates to increased health care costs. PTSD patients frequently utilize health care services, particularly in the 12 months immediately prior to PTSD diagnosis10 They average 30% more health care visits than patients with either partial or no PTSD symptoms, are at increased risk for car accidents and suicide, and are more likely to have an emergency room visit and an overnight hospitalization.35, 36 The extensive comorbidity that occurs with PTSD contributes to diagnostic uncertainty and frequent misdiagnosis. Patients are frequently seen numerous times for vague physical symptoms and somatic complaints before the relationship between the precipitating trauma and resulting physical complaints is identified. The increase in health care utilization has also been linked to the severity of PTSD symptoms, with much of the increased utilization of health care services in the areas of outpatient primary and specialty care rather than mental health services.35

In addition to the economic costs within the health care system, there are direct economic costs in other areas, including unemployment claims and disability payments. The VA reported that between 1999 and 2004, there was a 79.5% increase in the number of veterans receiving disability payments for PTSD, with the annual totals increasing 148.8% to $4.3 billion.37 This is in stark contrast to the 12.2% increase in recipients claiming other disabilities, which accounted for only a 41.7% increase in disbursement during this same time period.37 It is evident that the consequences of PTSD are pervasive, impacting not only victims of trauma but their families, the health care system, and society as a whole.

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Diagnosis 

PTSD frequently goes undetected and consequently untreated because it is often masked by the presentation of another comorbid condition, including depression, anxiety, substance abuse, functional impairment, physical ailment, or vague, somatic complaints11, 26 The avoidance behaviors inherent in PTSD also contribute to the diagnostic dilemma. These include the patient's avoidance of talking about the trauma or inability to recall pertinent details about the trauma. These avoidance behaviors may compromise the provider's ability to obtain an accurate and thorough health history. Additionally, the patient's avoidance of people and feelings of detachment from others may thwart the provider's ability to establish a trusting, therapeutic relationship with the patient. This not only impacts the amount and type of information shared by the patient but could also influence his/her willingness to cooperate with any proposed therapeutic intervention. To compensate for this predicament, primary care clinicians must maintain an awareness of the wide array of possible presentations in patients with PTSD. Complaints of sadness, loss of interest in activities, withdrawal from relationships, sleep disturbance, nightmares, nervousness, agitation, or somatic complaints should arouse suspicion and prompt the clinician to include PTSD in the differential diagnosis.

Another mechanism for improving PTSD diagnosis is to incorporate a trauma history into clinical interviews and patients' health histories. Reliable information regarding posttraumatic concerns can be readily elicited from patients,38 and a provider's willingness to ask about and openly discuss abuse have been identified as key components in eliciting the information as well as in establishing trust.39 Some clinicians may feel inadequately prepared to ask the difficult and sensitive questions necessary to obtain a trauma history, or they may feel constrained by time. Fortunately, several reliable trauma questionnaires, including the 24-item Trauma History Questionnaire (THQ)40 and 11-item Trauma Events Questionnaire (TEQ)41, 42 are available and can be independently completed by the patient prior to the visit or quickly administered by the provider during the visit. These questionnaires will alert the primary care provider to probable occurrences of a criterion A1 trauma.

There are a variety of PTSD screening tools and self-report questionnaires available, ranging in length, complexity, and diagnostic accuracy, which can be quickly and easily administered. Two that are frequently utilized are the Primary Care PTSD Screen (PC-PTSD)43 and the PTSD Checklist (PCL).44 The former, developed by the National Center for PTSD for ease of use by primary care providers, is a 4-item “yes/no” questionnaire that has demonstrated a 78% sensitivity and 87% specificity in identifying PTSD if the patient answers 3 of the 4 questions affirmatively.43 The PCL is a 17-item instrument available in both a military and civilian version, which addresses the extent to which certain PTSD symptoms were present in the previous month, with each symptom ranked on a 5-point Likert scale.45 These self-report questionnaires are easy to administer and are advantageous in that no specialized training is needed to administer them.

If screening suggests the possibility of PTSD and formal diagnostic assessment is needed, it is best accomplished utilizing a comprehensive diagnostic interview such as the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1)46 or the Clinician Administered PTSD Scale (CAPS).47 The SCID-1 requires training to administer, is time consuming to complete, and addresses other psychiatric diagnoses. Alternatively, the CAPS, with its narrow focus on PTSD, is considered the gold standard for the diagnosis of PTSD because it identifies not only the severity of PTSD but also the acuteness or chronicity of the condition.11 The CAPS is also useful in monitoring a patient's improvement and recovery. However, this tool also requires training and approximately one hour to administer.

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Treatment 

Current research supports a combination of pharmacotherapy and psychotherapy for the treatment of PTSD.11, 48 The goal of pharmacotherapy is to reduce the core symptoms of PTSD, which has been demonstrated with a variety of medications, including benzodiazepines, tricyclic antidepressants (TCAs), atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, and anticonvulsants.48 Although several of these medications demonstrated effectiveness in treating specific, acute PTSD symptoms, SSRIs have proven to be the most effective in the management of PTSD symptoms and overall improvement in quality of life. The SSRIs paroxetine and sertraline are the only medications currently approved by the FDA for the treatment of PTSD.49

Numerous randomized controlled trials (RCTs) have been conducted examining the effect of various pharmaceutical interventions on PTSD. This pharmacologic research is being conducted not only to identify medications that will alleviate specific, individual symptoms once PTSD develops, but RCTs are also exploring medications to prevent the development or minimize the chronicity of PTSD. Several RCTs have demonstrated that prazosin is effective in the treatment of nightmares and sleep disturbance in PTSD,50, 51 while other trials have shown promise in the area of secondary prevention using other medications, including propranolol52 and hydrocortisone.53 However, additional research using larger sample populations is needed to establish the safety and efficacy of these interventions.

Psychotherapeutic modalities are also a cornerstone of PTSD treatment. Experts have theorized that avoiding reminders of the traumatic event, coupled with emotional separation, are the major roadblocks to recovery, and likewise, addressing these behaviors holds the key to recovery.54, 55 Specifically, the established cognitive-behavioral interventions of exposure therapy, stress inoculation therapy, and cognitive restructuring, all of which involve confronting the images of or reactions to traumatic, stressful events, have proven effective in the treatment of PTSD.56 Exposure therapy involves prolonged or repeated reliving of the trauma memory until the patient's negative responses are gradually diminished. Exposure therapy also requires learning about common trauma reactions and developing coping mechanisms, which assist the patient to gradually become better able to tolerate memories and feelings associated with the trauma. Stress inoculation training, also known as anxiety management training, focuses on developing skills to manage anxiety whenever it arises, such as relaxation training. Cognitive restructuring focuses on identifying the distorted or dysfunctional thought processes related to the trauma and replacing these with more positive, appropriate responses.

Other therapeutic interventions gaining recognition and acceptance include eye movement desensitization and reprocessing (EMDR), image rehearsal therapy (IRT), and acupuncture. EMDR involves recall of the traumatic memory and related physical responses and works to replace these with positive thoughts. The patient focuses on the trauma memory while simultaneously performing rapid eye movement and gradually replaces the stressful imagery and physical responses with more positive restructured thoughts and tolerable emotions.57 IRT focuses primarily on the PTSD symptoms of nightmares and disturbing images and is aimed at altering the subject matter of the patient's nightmare to allow the patient more control over the content, importance, and threat level of the images.58 It has shown promise in limited RCTs.59 Although these alternative therapeutic interventions have demonstrated promising results, several are beyond the scope of a primary care provider and require referral to a qualified psychiatric colleague. Acupuncture treatment has also been studied as a possible treatment option and early results show it to be effective in improving the symptoms of PTSD.60

Given the escalating rate of traumatic exposure due to war, violence, terrorism, accidents, and natural disasters, it is crucial that the health care system be prepared to address a corresponding escalation in patients developing PTSD. It is becoming increasingly important for primary care providers to familiarize themselves with PTSD, its diagnostic criteria, presenting signs and symptoms, comorbidities, and effective treatments. Equally critical is the utilization of effective, widely accessible screening tools for PTSD. Early recognition and treatment are the keys to breaking the devastating cycle of PTSD.

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 In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(08)00664-8

doi:10.1016/j.nurpra.2008.12.009

The Journal for Nurse Practitioners
Volume 5, Issue 7 , Pages 516-522, July 2009

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