Post-Traumatic Stress Disorder in Primary Care Practice by Joanne L
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1 Post-Traumatic Stress Disorder in Primary Care Practice by Joanne L. Miller A manuscript submitted in partial fulfillment ofthe requirements for the degree of Master ofNursing Washington State University College ofNursing Vancouver, Washington May, 2000 2 To the Faculty ofWashington State University College ofNursing: The members ofthe committee appointed to examine the manuscript ofJOANNE L. MILLER find it satisfactory and recommend that it be accepted. Renee Hoeksel, RN, PhD, Chair Carol Brown, ARNP, PhD Lorna Schumann, ARNP, PhD 3 Acknowledgements (.,. The author would like to acknowledge the assistance and support ofthe clinical faculty ofWashington State University, Vancouver, Family Nurse Practitioner Program, especially Renee Hoeksel & Carol Brown, and Lorna Schumann, clinical faculty at ICNE, Spokane. Many thanks also go to family, friends, and co-workers who have been supportive and encouraging during the writing ofthis paper and completion ofthe FNP Program. 4 Table of Contents Signature Page . 2 Acknowledgements . 3 Abstract '" .. 5 List oftables . 6 List offigures . 7 Manuscript '" , , . 8 5 Abstract Post-traumatic stress disorder (PTSD) is one of many psychiatric problems that may be evaluated, diagnosed, and managed by the primary care practitioner. Patients with PTSD are being diagnosed and treatment is being sought in a variety ofsettings. There are numerous patient populations that have been identified as having the potential for developing this disorder. PTSD is a disorder where psychological and physiological reactions are closely related. The practitioner must be aware ofdiagnostic criteria and options for treatment for this disorder. 6 List ofTables ew. 1. Diagnostic Criteria for 309.81 Posttraumatic Stress Disorder ... ... ... ... ... ... ..... 27 2. Suggested Screening Questions for Posttraumatic Stress Disorder... ...... .. ...... 30 3. SUD-PTSD Patient Management... ... ... ... ... ..... .... ...... ...... ... .. .. 31 4. Medications for Treatment ofPTSD 32 5. Interviewing Torture Survivors ... ... 34 6. Simple versus Complicated Trauma... ... ... ... ...... .. .... ...... 36 7 List ofFigures 1. Acute Trauma Response '" 37 8 Introduction Post-traumatic stress disorder (PTSD) is one ofmany psychiatric problems that may be evaluated, diagnosed, and managed by the primary care practitioner. The world continues to be a stressful and often violent place to live. New patients with PTSD are being diagnosed daily. Treatment is being sought in a variety ofclinical settings, including inpatient, outpatient, general and psychiatric practices. PTSD is a disorder where psychological and physiological reactions are intertwined. The practitioner must be aware ofdiagnostic criteria and options for treatment for this disorder. Diagnosis PTSD is the best-known psychiatric sequela oftrauma. It was first established as a diagnosis in 1980 and consists ofthree clusters ofsymptoms: reexperiencing, avoidance, and hyperarousal (American Psychiatric Association, 1994). DSM-IV ofthe American Psychiatric Association (pp. 427-429) states: The essential feature ofPTSD is the development ofcharacteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience ofan event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity ofanother person; or learning about unexpected or violent death, serious harm, or threat ofdeath or injury experienced by a family member or other close associate. Peebles-Kleiger and Zerbe (1998) state that whether or not psychiatric symptoms develop depends on the characteristics ofthe traumatic event, a person's psychological health before the trauma and age at the time ofthe trauma, the unique meaning ofthe 9 event to the person, and the support systems during recovery. Table 1 lists all DSM-IV diagnostic criteria for this disorder (American Psychiatric Association, 1994). In addition to these criteria, it must be specified that this episode ofPTSD is acute, chronic or delayed onset. PTSD is acute if the duration ofsymptoms is less than three months. PTSD is chronic ifduration ofsymptoms is three months or more. Delayed onset is diagnosed when onset ofsymptoms is as least 6 months after the traumatic stressor. Williams (1987) describes a theoretical model for understanding acute and chronic PTSD. The acute trauma model (Figure 1) delineates three distinct phases of acute post-trauma reactions: the shock phase, the impact phase, and the recovery phase. The practitioner may encounter a patient at any place along this continuum. Zimmerman and Mattia (1999) found that PTSD is frequently overlooked in routine clinical practice when symptoms ofPTSD are not the presenting complaint. In this prospective study, the investigators sampled 1000 patients for PTSD in a psychiatric outpatient practice. The first 500 were administered a diagnostic screening questionnaire that included a PTSD subscale. In this first group, 7.2% were diagnosed with PTSD and an additional 18.6% ofthe same sample screened positive for PTSD on the questionnaire, but were not diagnosed with PTSD. The next 500 patients were interviewed with the Structured Clinical Interview for DSM-IV (First, Spitzer, Williams & Gibbons, 1997). The diagnosis ofPTSD was two times higher (14.4% vs. 7.2%) in this second group. The strength ofthis study is the large sample size and that it included psychiatric professionals who are trained in use ofthe instruments. 10 The investigators concluded that practitioners might limit their attention to a patient's presenting complaint ofdepression or panic attacks and fail to inquire about a trauma history and symptoms ofPTSD. From the pharmacological perspective, improving the recognition ofPTSD might not have that great an impact, as medications that are effective for depression and anxiety are the same ones that have also been shown to reduce symptoms ofPTSD. The difference in treatment may be in the realm of cognitive-behavioral therapy. IfPTSD is not appropriately recognized, patients may not receive this potentially effective form oftreatment. Even in a specialty such as psychiatry PTSD is often underdiagnosed (Zimmerman & Mattia, 1999). Samson, Bensen, Beck, Price and Nimmer (1999) studied patients in an outpatient primary care facility in a large health maintenance organization (HMO). The sample was drawn from 7444 patients who visited the facility during the study period. A computerized psychiatric screening questionnaire was administered to patients with symptoms ofdepression or anxiety. As a result ofthe screening questionnaire, 296 patients were referred for consultation with a structured interview. Ofthe 296 patients interviewed 114 (38.6%) met criteria for PTSD. The investigators concluded that PTSD is often unrecognized among patients in a primary care setting. Diagnosis ofPTSD can be complicated by several factors. Symptoms can occur months or years after the traumatic event and can persist for years. Symptoms can go away, only to recur years or decades later, often triggered by events psychologically or temporally related to the original incident (peebles-Kleiger & Zerbe, 1998). PTSD can be cyclic and progressive (Samson, Bensen, Beck, Price & Nimmer, 1999). 11 The majority ofpatients with PTSD seek treatment in primary care settings, not mental health settings. In the medical setting, a patient may present with an array of apparently unrelated problems. Andreski, Chilcoat, and Breslau (1998) found that there is a strong association between PTSD and somatization symptoms. In this prospective study a random sample of1200 patients was drawn from the list ofall twenty-one to thirty year-old members ofa large HMO. A total of1007 respondents (84% ofthe sample) were interviewed in their hom~s. Approximately three years after the initial interview, a follow-up interview was conducted that involved 979 ofthe original respondents. Five-year follow-up interviews were also conducted with 979 ofthe 1007 respondents. The investigators concluded that persons with PTSD were at least twice as likely as those with other disorders to have a history ofmultiple somatization symptom groups. Dickinson, deGruy, Dickinson, and Candib (1998) found neither the patient nor practitioner may be aware that the current distress may be linked to events that occurred during developmental years. Since most practitioners do not ask their patients about past abuse, the underlying trauma may likely go unrecognized and treatment ofthe presenting problem may prove inadequate and achieve only transient improvement in the patient's condition. Some patients may be inappropriately diagnosed with personality disorders. Medical service utilization increases after a traumatic event. PTSD patients have more somatic complaints than other patients do. These complaints include musculoskeletal, gastrointestinal, cardiovascular, neurological, and gynecological symptoms. Patients usually seek treatment for specific physical complaints and often do not recognize the connection between the past trauma and present symptoms. 12 Additionally, there is much symptom overlap between PTSD and other psychiatric disorders such as depression, anxiety, substance abuse, and personality disorders. Practitioners may identify symptoms ofanxiety or depression and treat them with medication without diagnosing and specifically treating PTSD. Samson, Bensen, Beck, Price and Nimmer (1999) suggest