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Case, Part 1

J. is a new patient to your practice. She is a 35-year-old female that you are seeing for a pap smear. You do ask about prior traumas, and she says no. You and your (female) nurse start the Pap smear. During the procedure however, you notice that she is trembling. When you ask her if everything is okay, she breaks down crying…

What are you going to do?

Epidemiology

How common is trauma? Trauma is very common, with 90% of the population has been exposed to a traumatic event (as defined by DSM-5) (Kilpatrick, 2013).

How common is PTSD?

Fortunately, most individuals who have been exposed to trauma do not develop PTSD. Various factors determine whether or not someone develops PTSD, such as:

• Resiliency factors such as having strong attachments and social supports reduce the likelihood of PTSD.
• Risk factors such as more severe trauma, or repeated trauma and  lack of social supports increase the risk of having PTSD.

Nonetheless, a significant percentage ranging from 5% in the general population, to between 12.5-25% of those in primary care settings do meet criteria for PTSD.

Types of Trauma That May Lead to PTSD

Anyone who has been victimized or has witnessed a violent act or who has been repeatedly exposed to a life-threatening situation is at risk of developing PTSD such as:

Presentation

Patients do not typically volunteer information about a traumatic event or their PTSD symptoms unless you directly ask.

Symptoms usually begin within the first 3 months following the trauma.

Symptoms can mimic anxiety and depressive disorders.

More rarely, there may be a delay of months or even years before criteria for the diagnosis are met. As a result, primary care providers can play a key role in early intervention by keeping a high index of suspicion in those at risk of developing PTSD.

Symptoms of PTSD

Consider the mnemonic “TRAUMA” to help you remember the symptoms of trauma:

Red Flags and Risk Factors

Keep an index of suspicion for PTSD with patients with these risk factors:

• Being female, for civilian populations (Spottwood, 2017)
• Being male, in veteran populations (Spottwood, 2017)
• Prior known exposure to violence or trauma (Spottwood, 2017)
• Personnel in first-responder professions (police, firefighters, paramedics and other public safety officers), and military personnel and veterans
• Alcohol and substance use

History and Screening questions

When seeing a patient at risk of PTSD, consider the following screening questions:

When discussing trauma, respect the patient’s coping:

• If the patient is unable to talk, avoid detailed exploration of any details that the patient does not want to discuss. You might say something like: “Thank you for letting me know. It’s okay if you don’t feel ready to talk much about what happened. After an event like this, the most important thing is to support you so that you can gradually get back into your life. If and when you are ready to talk more, we can do so.”
• If the patient is ready to talk, being able to do imaginal exposure is an important part of trauma therapy.

Screening Tools

Primary Care PTSD Screen

• 4-item self-report yes/no
• Sensitivity of 78% and specificity of 87% for PTSD in patients who answer ‘yes’ to ≥3 items
• Individuals that screen positive should be further assesses for PTSD diagnosis criteria (Richardson et al., 2010)

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

1)    Have had nightmares about it or thought about it when you did not want to?

2)    Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3)    Were constantly on guard, watchful, or easily startled?

4)    Felt numb or detached from others, activities, or your surroundings?

Screen is positive if patient answers ‘yes’ to any 3 items

PC-PTSD-5 screening tool

Trauma Screening Questionnaire (TSQ)

DSM-5 Criteria for PTSD

A.    Exposure to actual or threatened death, serious injury or sexual violence by:

1.     Directly experiencing the event

2.     Witnessing the event in person, as it occurs to others

3.     Learning that the traumatic event occurred to a close family member or close friend

4.     Experiencing repeated exposure to aversive details of traumatic events (police, first responders)
 

B.    The traumatic event is re-experienced, with one or more intrusive symptoms:

1.     Recurrent and involuntary distressing memories

2.     Recurrent distressing dreams

3.     Dissociative reactions (flashbacks)

4.     Intense or prolonged psychological distress when reminded of the trauma

5.     Marked physiological reactions when reminded of the trauma
 

C.    Persistent avoidance of stimuli or events associated with the trauma as evidenced by one or both :

1.     Avoidance of distressing memories, thoughts, or feelings

2.     Avoidance of external reminders (people, places, objects)
 

D.    Negative alterations in cognitions and mood when reminded of trauma including 2 (or more) of the following:

1.     Inability to remember an important part of the trauma

2.     Persistent negative beliefs about oneself, others or the world

3.     Blame oneself for the cause or consequences of the trauma

4.     Persistent negative emotional state (e.g. anger, guilt, shame)

5.     Diminished interest or participation in activities

6.     Feelings of detachment or estrangement from others

7.     Persistent inability to experience positive emotions
 

E.    Persistent symptoms of increased arousal and reactivity including 2 (or more) of the following:

1.     Irritable behaviour and angry outbursts

2.     Reckless or self-destructive behaviour

3.     Hypervigilance

4.     Exaggerated startle response

5.     Problems with concentration

6.     Sleep disturbance
 

F.    Duration of the disturbance (B,C,D and E) is more than one month
 

G.   Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
 

H.    Disturbance is not attributable to physiological effects of a substance or another medical condition.
 

Specifiers:

• With dissociative symptoms (depersonalization, derealisation)
• With delayed onset: full diagnostic criteria are not met until at least 6-months after the event

DDx

There are other conditions that can present with similar symptoms, but are different from PTSD, such as:

Comorbidity

In adults

In children:

Management: Role of Primary Care Providers

Is it within 4-weeks following a trauma?

• Address any basic needs
  • E.g. if your patient has been assaulted by a partner, does the patient need a safe place to live? Do police need to be involved? Does CAS need to be involved for any children?
• Watch and monitor symptoms.
  • Follow-up closely to monitor symptoms 
  • Symptoms will often resolve on their own (NICE Guidelines, 2005.)

Is it beyond 1-month following a trauma?

• Screen for PTSD
• Provide directions and referrals to mental health services and supports (e.g. peer support groups). 

Does it appear to be mild to moderate PTSD without significant comorbidity?

• Provide primary care interventions if you feel comfortable
• Provide or refer to psychotherapy prior to considering medications (Richardson et al., 2010)

Does it appear to be severe and chronic PTSD?

• Refer to psychiatry
• Medications may be required to stabilize medications prior to psychotherapy (Richardson et al., 2010)

Principles

• Given that PTSD can cause autonomic arousal, be cautious around medications that increase adrenaline such as stimulants.
• Validate that if the person does not want to talk about the event, this is their attempt to cope. Do not insist that the patient ‘needs to talk about it’.
• Manage any comorbidities such as psychiatric or medical such as
  • Anxiety
  • Depression
  • Sleep problems
• Provide psychoeducation for patients and families, with key points such as:
  • Having PTSD symptoms does not mean you are ‘going crazy’
  • The reactions seen after trauma are simply a normal response to an abnormal event.
  • If one does have PTSD, note that it is a common condition (~10% in the general population) and it is treatable.

Management: Psychological Interventions

The following are examples of therapeutic interventions for trauma:

Anxiety Management Training

Teaching skills to handle anxiety such as

• Progressive muscle relaxation (PMR)
  • Anxiety BC PMR for adults
  • https://www.anxietybc.com/sites/default/files/MuscleRelaxation.pdf
  • Anxiety BC PMR for children/youth
  • https://www.anxietybc.com/parenting/how-do-progressive-muscle-relaxation
  • MindMasters 2 (http://www.cheo.on.ca/en/MindMasters)
     
• Breathing retraining
  • Calm Breathing for Adults
    https://www.anxietybc.com/adults/calm-breathing
  • Anxiety BC “Calm Breathing” for Children/Youth
    https://www.anxietybc.com/parenting/tools/learning-relax-calm-breathing
  • MindMasters 2 (http://www.cheo.on.ca/en/MindMasters)
     
• Distraction techniques
  • Cornell University http://www.selfinjury.bctr.cornell.edu/perch/resources/distraction-techniques-pm-2.pdf
     
• Grounding techniques
  • Links pending
     
• Acceptance and mindfulness
  • Links pending

Trauma-focused CBT

• Focuses on memories, thoughts, and feelings that an individual has about the traumatic event
• Helps to understand how these feelings, thoughts and behaviours fit together and affect one another
• Exposure which may be
  • Imaginal Exposure: Exposure to the traumatic memories in a gradual fashion reduces the distress caused by the memories
  • In-Vivo Exposure: Involves home work involving exposure to avoided activities, done in a hierarchical fashion. Can pair with muscle relaxation and mindfulness. Must stay in the activity until anxiety subsides

Eye Movement Desensitization and Reprocessing (EMDR)

• EMDR is a type of ‘subcortical’ treatment that aims to reprocess one’s traumatic memories from emotionally distressing memories, to less distressing and emotionally laden memories.
• Patients are asked to think about their traumatic memory, while being undergoing bilateral stimulation (which may be visual, auditory or tactile).
• Related ‘subcortical’ treatments that show promise include brainspotting and progressive counting. 

Management: Psychological Interventions in Primary Care

For patients with mild to moderate symptoms (i.e. non-complex PTSD), many primary care providers may feel comfortable providing elements of trauma care.

For example, a patient who is unable to drive following a motor vehicle crash.

Management: Pharmacotherapy

Consider medications if psychotherapy has already been tried, but has not been successful.

First-line medications
 

Second-line medications
 

Third-line

• Amitriptyline, aripiprazole, bupropion SR, buspirone, carbamazepine, desipramine, duloxetine, escitalopram, imipramine, lamotrigine, memantine, moclobemide, quetiapine, reboxetine, risperidone, tianeptine, topiramate, trazodone

Adjunctive Therapy

• Second-line: eszopiclone, olanzapine, risperidone
• Third-line: aripiprazole, clonidine, gabapentin, levetiracetam, pregabalin, quetiapine, reboxetine, tiagabine

The following are not recommended:

• Bupropion SR, guanfacine, topiramate, zolpidem
• Alprazolam, citalopram, clonazepam, desipramine, divalproex, olanzapine, tiagabine

Medications for Sleep

Assuming non-medication strategies such as sleep hygiene, grounding strategies, etc. have been tried, one might consider the following medications:

PRN Medication

For episodic agitation

• Once on an SSRI if the patient requires a PRN medication, consider:
• Methotrimeprazine (Nozinan) 5-10 mg qid prn, or
• Quetiapine (Seroquel) 12.5-25 mg tid prn
• Performance anxiety?
• Consider propranolol 20 mg given before the event

References: Katzman M: The Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic stress and Obsessive-compulsive disorders, 2014; dosage information from the Compendium of Pharmaceuticals and Specialties (CPS).

When to Refer

Case, Part 2

Given your patient’s distress during procedure, you stop the exam. You acknowledge and validate her distress. You leave her with your (female) nurse. Your nurse leaves after a few minutes to give your patient some time to recollect herself. After a few minutes, your nurse comes back out and speaks with you discreetly. The patient is apologetic and has disclosed to your nurse that she was sexually abused as a child by a relative.

When she is feeling calmer, you see her again, accompanied by your nurse. She tells you that she would like to get help and support for her issues in her childhood, which she now realizes are getting in the way of her life…

You thank her for her disclosure and ensure that she books a longer follow-up appointment in order to discuss how you might be helpful to her. At the visit, she gives you a history consistent with symptoms of PTSD. You provide her information about local services and supports for past trauma. You make a notification in her medical record so that all staff in the clinic can provide trauma-informed care.

Quiz

1.     PTSD may follow after an event such as:

a.     Witnessing a car accident

b.     Military combat

c.     Violent personal assault

d.     Traumatic child birth

e.     All of the above

2.     Most people who have lived through dangerous events develop PTSD

a.     True

b.    False

3.     Which medication has been shown to be effective for reducing trauma nightmares in patients with PTSD?

a.     Trazodone

b.     Benzodiazepines

c.     Prazosin

d.     Mirtazapine

e.     None of the above

4.     M. was walking home alone after a night out and suffered a physical assault in a dark alley. Months later, she refuses to go out at dark alone. She is constantly on red alert, especially when crossing the road. What symptom of PTSD does this best indicate?

a.     Dissociation

b.     Nightmares

c.     Hypervigilance

d.     Emotional detachment

5.     You are seeing your patient who has experienced a traumatic event. The most important thing to do is:

a.     Encourage your patient to talk about it.

b.    Support your patient’s coping.

Clinical Practice Guidelines

Katzman et al.: Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 2014 14(Suppl 1): S1.

https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-14-S1-S1

Post-traumatic stress disorder: management, 2005. NICE Guideline.

https://www.nice.org.uk/guidance/cg26

Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. American Psychological Association, 2017. Retrieved May 25, 2017 from https://www.apa.org/about/offices/directorates/guidelines/ptsd.pdf. 

PTSD Pocket Guide - VA/DoD Clinical Practice Guidelines, 2013.

https://www.healthquality.va.gov/guidelines/MH/ptsd/PTSDPocketGuide23May2013v1.pdf

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th ed. Washington: American Psychiatric Publishing.

Brewin CR, Rose S, Andrews B, et. al (2002).Brief screening instrument for post-traumatic stress disorder. British Journal of Psychiatry, 181:158–162.

Cohen, H. (2016). Differential Diagnosis of PTSD Symptoms. Psych Central. Retrieved on June 11, 2017, from https://psychcentral.com/lib/differential-diagnosis-of-ptsd-symptoms/

Freedy JR, Brock CD. Spotting and treating PTSD in primary care. The Journal of Family Practice. 2010; 59(2): 75-80.

Holmes EA, James EL, Kilford EJ, Deeprose C (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus verbal Pub Quiz. PLoS One, 5(11):e13706.

Kessler RC, Sonnega A, Bromet E et. al (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52:1048–1060.

Kilpatrick D et al.: National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV and DSM-5 Criteria, J. Trauma Stress. 2013 Oct; 26(5): 537-457.

doi: 10.1002/jts.21848

Kung S, Espinel Z, Lapid M (2012). Treatment of nightmares with prazosin: a systematic review. Mayo Clinic Proceedings, 87(9):890 - 900.

Lange JT, Lange CL, Cabaltica RBG. Primary Care Treatment of Post-traumatic Stress Disorder. Am Fam Physician. 2000; 62(5): 1035-1040.

Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). [Measurement instrument].

Richardson JD, McIntosh D, Stein MB, Sareen J. Post traumatic Stress Disorder: Guiding Management with Careful Assessment of Comorbid Mental and Physical Illness. CANMAT: Mood and Anxiety Disorders Rounds. 2010; 1(6).

Spottswood M, Davydow DS, Huang H. (2017). The Prevalence of Posttraumatic Stress Disorder in Primary Care: A Systematic Review. Harvard Review of Psychiatry, May 26.                      

Wallace D, Cooper J. Update on the management of post-traumatic stress disorder. Australian Prescriber. 2015; 38(2): 55-59.

About this Document

Written by Omar Anjum (University of Ottawa Medical Student, Class of 2018), Dr. Jakov Shlik (Psychiatrist, Royal Ottawa Mental Health Centre), Dr. Jon Davine (Psychiatrist, McMaster University), Talia Abeccasis (uOttawa Medical Student, Class of 2017). Reviewed by the eMentalHealth.ca Team.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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