2.6 CONTACT HOURS Know the warning signs By Jessica Gill, RN, CRNP, PhD Leorey N. Saligan, RN, CRNP, PhD Wendy A. Henderson, CRNP, MSN, PhD Sarah Szanton, ANP, MSN, PhD osttraumatic stress disorder (PTSD) is an anxiety objective of this review is to provide rationale and tools disorder that commonly occurs in primary care for PTSD assessment and treatment in primary care settings, P patients. Patients with PTSD experience declines as well as a brief overview of physiologic changes in PTSD in physical and psychological health.Although these declines patients. are often observed by NPs and other primary care providers (PCPs), PTSD is not routinely assessed in primary care. ■ Incidence PTSD develops after exposure to a traumatic event and In the course of a lifetime, 90% of Americans experience a is associated with debilitating physical and psychological traumatic event from which most recover without experi- health declines. Symptoms of PTSD include re-experiencing encing PTSD.1,2 However, there are important characteris- the traumatic event through intrusive dreams or thoughts, tics that can increase the risk of PTSD. These include avoidance or arousal when the patient encounters stimuli assaultive trauma or trauma that occurs at an early age.11 that symbolize the event, numbing of feelings, and avoid- Rates for current PTSD in the general U.S. population range ance of thoughts, feelings, people, and activities that sym- from 2% to 4%.1,2,12 In primary care patients, rates for cur- bolize the event. PTSD has been recognized as an anxiety rent PTSD range from 8% to 30%.6,7 Women develop PTSD disorder that can impact any individual, resulting in lifetime at twice the rate of men.1,2,12 This vulnerability may be re- prevalence rates of 5% for men and 10% for women.1,2 Be- lated to an increased risk of experiencing assaultive events. cause people with PTSD suffer from multiple medical con- However, women are at a greater risk than men to develop ditions3,4 and a lower subjective health rating5, PTSD rates PTSD, independent of event type.1 in primary care settings are at least double the national rate.6,7 In addition, individuals with PTSD experience increased ■ Comorbid conditions medical care costs.8 More women with PTSD seek care for Individuals with PTSD may be more prominent in primary these symptoms in primary care settings compared with care settings due to greater use of outpatient services.8,13 In psychiatric settings.9 Although 8% to 30% of primary care addition, individuals with PTSD report at least one other patients present with PTSD, PCPs rarely assess for it.10 The medical condition when compared with traumatized and 30 The Nurse Practitioner • Vol. 34, No. 7 www.tnpj.com www.tnpj.com The Nurse Practitioner • July 2009 31 PTSD: Know the warning signs nontraumatized controls without PTSD, including chronic uals. If these patients are treated for medical complaints pain, diabetes, cardiovascular disease, autoimmune disor- without addressing the underlying psychological response ders, thyroid disorders, and gastrointestinal disorders.3-5,7 to trauma, the pattern of continued health visits without Therefore, PTSD is often associated with multiple medical symptom improvement is likely to continue. issues that may result in complex medical complaints, some of which may be treatment-resistant. Recognizing and treat- ■ Pathophysiology ing PTSD may help protect some patients from developing Patients with PTSD exhibit multiple alterations in biologic these health alterations. function, including the neurologic, endocrine, and immune Over 80% of individuals with PTSD have another psy- systems,all of which may contribute to health declines.Func- chiatric disorder.1,2,11 Common comorbid psychiatric disor- tioning of memory areas in the brain is altered, resulting in ders include major depressive disorder (MDD), generalized the development of many PTSD symptoms. Specific brain anxiety disorder, drug and alcohol abuse and dependence, areas implicated in PTSD include the amygdala, the hip- and obsessive compulsive disorder. MDD is well researched pocampus, and the prefrontal cortex (see Location of the in the primary care setting and healthcare providers are now amygdala and hippocampus). There is reduced volume of apt to recognize and intervene with MDD, however, its the hippocampus in adults and children with PTSD;15 comorbidity with PTSD may go undiagnosed. As an exam- however, return to normal hippocampal volume has been ple, one-third of depressed patients seen in primary care reported with treatment and symptom remission.16 Reduced who were previously assessed and not identified as having memory function has also been observed and related to PTSD were found to be positive for PTSD during a research functional alterations in brain activity in the amygdala, screening.10 In another recent study, only 11% of primary hippocampus, and other brain structures, indicating that care patients with current PTSD had a diagnosis of PTSD multiple neurologic alterations may be related to PTSD in their charts.14 Recognition and treatment of PTSD in symptoms.17 primary care settings may be the most effective way to The hypothalamic-pituitary-adrenal (HPA) axis pro- improve mental and physical health in traumatized individ- duces hormones in basal and stressed states that regulate immune, neural, and other bodily functions. Alterations in this complex Location of the amygdala and hippocampus set of hormonal feedback loops of the HPA axis alterations have been observed in PTSD patients.18 The hallmark of PTSD among combat veterans is low cortisol levels and a greater negative feedback system for cortisol as tested with pharmacologic and nonpharma- cologic stimulation, indicating alter- ations in HPA axis function. These findings were surprising considering patients with PTSD reported high levels of stress.18 Recent studies have reported con- trasting findings, suggesting that sex, duration of PTSD, and other factors may contribute to alterations in HPA axis function.19 However, independent Amygdala Brain stem and cerebellum of the direction of the observed alter- (beneath overlying cortex) removed and brain ation, any disruption in function of the rotated slightly HPA axis may result in the development Hippocampus of additional health conditions.20 (beneath overlying cortex) PTSD studies have reported evi- dence of increased inflammatory activ- Source: Bear MF, Connors BW, Parasido MA. Neuroscience - Exploring the Brain. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. ity in the immune system, including higher levels of stimulated and non- 32 The Nurse Practitioner • Vol. 34, No. 7 www.tnpj.com PTSD: Know the warning signs stimulated inflammatory cytokines,21-25 and a greater re- predictive of PTSD development, especially if events are on- sponse to antigens.26 These higher levels of inflammatory going (such as child abuse) or occurred in childhood.11 The activity have been linked to HPA axis abnormalities.21,25 A patient must have at least one symptom of re-experiencing chronically activated inflammatory response has been shown the trauma, three symptoms of avoidance or numbing re- to exert adverse reactions on many body systems. Specifically, lated to the traumatic event, and at least two symptoms of elevations of interleukin-6 (IL-6) have been associated with hyperarousal when reminded of the trauma (see Symptoms reports of chronic pain, arthritis, diabetes, cardiovascular of PTSD). These symptoms must have been present for at disease, and other medical conditions that have been associ- least 1 month, cause significant distress, and affect the pa- ated with PTSD.3,4,7,13 tient’s ability to function socially, occupationally, or domes- tically. If symptoms last for more than 3 months, a diagnosis ■ Development and progression of PTSD of chronic PTSD is established.27 To qualify for a PTSD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Common signs and symptoms the precipitating traumatic event must have occurred at least PCPs should assess for PTSD if the patient reports an ex- 3 months prior to assessment.27 If the precipitating event oc- perience of a traumatic event. State-mandated regulations curred less than 3 months prior, and the patient displays for reporting incidents of abuse should be followed. A pa- PTSD symptoms that cause distress, then the diagnosis of tient who divulges a recent event provides the PCP with an acute stress disorder may be appropriate. Traumatic events can be classified as an experienced event, a witnessed event, or an event that was learned of, and can range from being Symptoms of PTSD27 raped to learning that a family member or close friend was Re-experiencing symptoms (must have at least 1): injured (see Traumatic events). Assaultive events are most • Recurring memories of the event •Nightmares of the event • Intense fear, anxiety, or physical discomfort when Traumatic events27 patient is reminded of the event •Flashbacks; feeling or acting as if the event is Episodic assaultive violence: reoccurring while awake •Raped • Other sexual assault Avoidance of things that remind the patient of the event, and feelings of numbing (must have 3) • Shot or stabbed •Avoiding people, places, or things that remind the • Mugged or threatened with a weapon patient of the event •Badly beaten up •Avoiding thoughts or feelings that remind the patient of Repeated assaultive violence: the event • Combat exposure •Inability to recall certain things about the event • Intimate partner violence • Decreased activity in things previously enjoyed •Child physical abuse •Patient feels detached from other people; no one •Child sexual abuse understands • Sense of foreshortened future Other injury or shocking experience: • Restricted range of feelings •Serious car or motor vehicle accident • Any other kind of serious accident/injury Hyperarousal (must have 2) •Fire, hurricanes, or other natural disasters • Problems falling or staying asleep •Diagnosed with a life-threatening illness • Problems concentrating •A child diagnosed with a life-threatening illness •Irritability or outbursts of anger • Hypervigilance: The feeling of always having to be Witnessed events: ready to react.