Approximately 20% to 29% of Americans have experienced at least one traumatic event, and PTSD affects 5 million people each year. Lifetime prevalence of PTSD is estimated at 24% among trauma victims and 27% among women, and up to 58% of at-risk individuals (combat veterans, volcano eruption survivors, or victims of criminal violence) have PTSD.1,3 About a third of these have chronic PTSD. Those involved in certain occupations, such as firefighting, law enforcement, or emergency medical services, may have an increased risk of PTSD.
PTSD consists of persistent hyperarousal with intrusive thoughts about the trauma and a compelling need to avoid situations related or similar to the trauma. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV) defines trauma as an event outside the range of normal human experience that would distress almost anyone, and also takes into account the objective characteristics of the stressor and the victim's subjective experiences.4 Examples of a traumatic event that might trigger PTSD might be robbery, armed conflict, rape, a natural disaster, or a terrorist attack. These patients continue to experience the trauma repeatedly after the event is over and may have painful memories of the event if they are exposed to or hear about an event similar to that which they have experienced. These symptoms may interrupt education or job success, financial independence, and relationships, and precipitate mood disorders, substance abuse, and suicide.
Without treatment, patients with PTSD risk complications and may encounter problems with quality of life, social interactions, daily functioning, and psychological issues. PTSD leads to sick days, poor job performance, costly medical and emergency care visits, mental health visits, and greater reliance on disability or welfare. Some patients may contemplate suicide. Diagnosis requires that the symptoms of reexperiencing, avoidance, and arousal occur for at least 1 month. Routine use of screening instruments and careful assessment are the keys to evaluation.
Pathophysiology
Stress activates the hypothalamic-pituitary-adrenal (HPA) axis and the arousal/sympathetic system. It activates the corticotropin-releasing hormone, arginine vasopressin, the pro-opiomelanocortin-derived peptides alpha-melanocyte-stimulating hormone and beta-endorphin, the glucocorticoids, and the catecholamines norepinephrine and epinephrine. The stress system is necessary for well-being, functioning, and social interactions. It may also hinder growth and development and lead to endocrine, metabolic, autoimmune, and psychiatric disorders. The severity of these disorders may reflect the individual's genetic vulnerability, environmental stressors, and timing of the stressful event(s).
Screening for PTSD
Routine use of PTSD screening inventories help providers detect the risk for PTSD and associated mental health disorders such as depression and suicide risk, and identify those who may need further evaluation. These instruments document symptoms and can improve diagnostic accuracy. They also track treatment outcomes to provide evidence to third-party payors, policymakers, and research-funding agencies and show which treatments work effectively for specific patients.5
One screening tool is the PTSD Checklist (PCL), which is a 17-item, self-assessment based on DSM-IV symptoms, and it takes about 5 minutes to complete. The Primary Care PTSD Screen (PC-PTSD) comprises four questions and has both civilian and military screens. Answering yes to three of the four questions indicates a need for further evaluation.6,7 The Impact of Events Scale-Revised (IES-R) is another screening tool with 22 self-assessment questions. It has a sensitivity of 0.89, positive predictive power of 0.89, and overall efficiency of 0.89.8 Another instrument, the Posttraumatic Diagnostic Scale (PDS), is a 49-item, self-report tool that measures the severity of PTSD, as well as the effects on the patient's current quality of life.
Although all patients can be at risk for PTSD, veterans are more likely than civilians to have PTSD. When assessing veterans, be careful to note the patient's age (50 to 64); if they ever served in a war zone; poor functioning score on the Short Form (36) Health Survey (SF-36), which assesses physical and mental well-being; or if they are experiencing musculoskeletal pain, a greater percentage of persistent reexperiencing or avoidance/numbing symptoms, and a previously diagnosed substance use disorder.9
Assessment
A focused history and physical examination can elicit reports of trauma and possible relationship between symptom onset and duration. Symptoms of PTSD usually occur within 3 months of the trauma and include flashbacks of the event; shame or guilt; upsetting dreams or nightmares about the event; avoiding thoughts of the event; feeling numb, irritable, or angry; self-destructive behavior; sleep and appetite disturbances; memory problems; poor concentration; being easily startled; and a lack of pleasure regarding activities once previously enjoyed. History should include questions about symptom onset, duration, frequency, and associated symptoms. There may also be trauma associated with symptom onset. Sleep disturbances affect approximately 70% of patients with PTSD.
Psychosocial and emotional factors such as hopelessness, anxiety, and depression should be assessed. Mood disorders and substance use can increase the perception of symptoms and can hinder recovery. A complete neurobehavioral mental status examination can help determine whether emotional symptoms are comorbid or consequences of the trauma and establish a baseline for treatment. For a complete neurobehavioral examination, cognitive and memory tests such as the Folstein Mini-Mental State Examination may be necessary.10
Patients should also be assessed for nonspecific symptoms of stress, such as gastric distress, headaches, pelvic pain, and insomnia. The clinician should ask about the severity of reaction to the trauma, any prior psychiatric conditions, family history of psychiatric illness, and whether previous psychosocial support was attained.
People with PTSD report diverse symptoms. In one study of 120 hospitalized injury survivors, trauma survivors expressed concerns regarding physical health (68%), work and finance (59%), social issues (44%), psychological issues (25%), medical issues (8%), and legal issues (5%). Those with three severe concerns immediately after the trauma had higher PTSD symptom levels over the course of the year. Greater initial concern severity independently predicted persistent PTSD symptoms 12 months after the injury.11,12 Aggression and irritability are common, and posttraumatic symptoms can contribute to aggressive behaviors in the elderly, medically ill, and cognitively impaired patients. Others with PTSD have described feeling so tense that anger exploded over insignificant situations. In a study of 32 elderly men with PTSD, long-term care patients reported feeling angry and irritable (47%), and these feelings significantly correlated with observed aggressive behaviors.13 Observed aggressive behaviors were significantly more frequent among those reporting past traumatic stressors, and the behavior was significant enough that it frightened others. These symptoms interfered with their activities, relationships, and quality of life.
If a patient discloses experiencing a traumatic incident, the clinician should use an empathetic approach when speaking, reassuring the patient that the emotions and accompanying symptoms the patient is now feeling are common and normal reactions from dealing with such an experience. Patients need to understand that feeling angry, embarrassed, or fearful is not uncommon.
Diagnosis
For a patient to be diagnosed with PTSD, he must have experienced or witnessed an event involving actual or threatened bodily injury or death or threat to physical integrity, and must have felt helpless, horrified, or terrified during the experience (see Diagnostic criteria).4 Examples can include war, disaster, accidents, and domestic violence. Diagnosis rests on identifying the major symptoms of PTSD, such as hyperarousal and numbing/avoidance behaviors. This diagnosis may lurk behind nonspecific symptoms such as headaches, insomnia, and stomachaches. Patients often have difficulty describing the problems. Patients can be reluctant to talk about their traumatic events, "battle fatigue," and nightmares of war, and may be unable to describe symptoms.
General medical conditions, such as head trauma or burns, may occur as a result of the trauma and require evaluation. Differential diagnosis includes mood disorders, agoraphobia, obsessive-compulsive disorder (OCD), social phobia, specific phobia, major depressive disorder, somatization disorder, and substance abuse and substance abuse-related disorders.
Misdiagnosis of PTSD is common. Presenting symptoms may include heart palpitations, shortness of breath, and chest pain that mimics cardiac conditions. When no medical cause is found, clinicians often refer patients to an internist or cardiac specialist, but they should also consider trauma and psychiatric causes. Symptoms of numbing, avoidance, and hyperarousal present before exposure to the stressor might be caused by a brief psychotic disorder, conversion disorder, or major depressive disorder. Acute stress disorder (ASD) symptoms occur within 4 weeks of the traumatic event and resolve in 4 weeks. OCD includes recurrent intrusive thoughts unrelated to the traumatic event. Flashbacks in PTSD need to be differentiated from psychotic symptoms, delirium, substance abuse, and psychotic disorders due to a general medical condition. In some instances, malingering will require consideration if the disorder offers financial gain or benefits. Practitioners should also understand that an adjustment disorder may create a similar pattern of symptoms caused by a less extreme stressor, such as a divorce or losing a job.
Psychopharmacology and cognitive-behavioral therapy
Effective treatment strategies include a combination of psychotherapy, such as cognitive-behavioral therapy (CBT), and psychosocial and medication treatments. Other therapies, including prolonged exposure (PE), cognitive processing therapy (CPT), and skills training, are used for many patients with PTSD (see Common alternative therapies for PTSD).3,4 However, the Institute of Medicine reports that evidence is inadequate to support the efficacy of PE, CPT, and eye movement desensitization and further research is needed.14 Medication is usually recommended for psychiatric comorbidities, suicidal ideation, severe and continued symptoms, continued difficulty functioning, and if psychotherapy is ineffective. Pharmacotherapy includes antidepressants and newer antianxiety or mood-stabilizing medications.
Among veterans with PTSD, 80% were prescribed some type of psychotropic medication; 89% were prescribed antidepressants, 61% received anxiolytics/sedative-hypnotics, and 34% received antipsychotics. Medications were likely to be prescribed for those with greater mental health service use and comorbid psychiatric disorders. Comorbidities effectively predicted use of each of the three medication subclasses (depressive disorders were associated with antidepressant use, anxiety disorders with anxiolytic/sedative-hypnotic use, and psychotic disorders with antipsychotic use), and were targeted at specific symptoms, such as insomnia, anxiety, nightmares, and flashbacks. Use of anxiolytics/sedative-hypnotics and antipsychotics in the absence of a clearly indicated diagnosis was substantial.
One treatment explored the effect of childhood threat on treatment outcome in a three-stage psychodynamically oriented inpatient treatment program (PITT). The study followed a 6-week treatment group of 84 inpatients compared with controls. The experimental group reported an improvement in depression, anxiety, somatization, and self-soothing compared to the control group.15 Other researchers have explored early trauma-focused cognitive-behavioral therapy (TFCBT) as a preventive intervention for people at risk for developing chronic PTSD. Evidence suggests that TFCBT is effective in preventing chronic PTSD in patients with an initial ASD diagnosis.16 Other psychological treatments have been used, including hypnosis for insomnia and eye movement desensitization.17
Cognitive-behavioral therapy
Practice guidelines recommend CBT and selective serotonin reuptake inhibitors as primary treatments for PTSD.18 CBT is an effective, directive, time-limited approach used to change irrational thoughts, assumptions, and beliefs. Cognitive therapy emphasizes being present in the moment, problem solving, and rational thinking. It targets negative viewpoints and automatic and negative-thinking patterns such as the future is bleak, the world is barren, and the self is worthless. Patients need to discuss negative or irrational thoughts that influence relationships, intimacy, reality perception, survivor guilt, and sexual behavior.
Cognitive techniques include questioning idiosyncratic meanings, reevaluating automatic conclusions, examining options and alternatives, and reattributing responsibility for things beyond the patient's control. It also explains how irrational and negative-thinking patterns, such as irrational fears about death, being unloved, or survivor guilt, may cause needless distress and interfere with treatment itself as well as quality of life. This cognitive reframing helps the patient identify and reexamine automatic thoughts and learn to reverse these thoughts by distraction, discussion, positive self-talk, or relaxation.
According to one study, effective treatments focus on the patient's memory for the trauma and its meaning.19,20 Cognitive distortions often keep people from disclosing a psychiatric disorder. Patients can learn to correct overgeneralizations or catastrophic expectations. Women veterans who received prolonged CBT were more likely than the control group to eliminate PTSD symptoms.9
Conclusion
Patients need to understand that PTSD is an anxiety disorder that responds to treatment with therapy and medications for anxiety and depression. Patients need to be active in the treatment process, learning strategies for calming and reducing anxieties such as meditation, yoga, self-hypnosis, and visualization strategies. Encourage good sleep hygiene, routine exercise, and a healthy diet. Support group that focuses on anxiety and anger management may also be useful.
Those with PTSD present to primary care for various symptoms. When a clinician asks whether the symptoms began after any type of trauma and uses a screening inventory, diagnostic accuracy improves. Treatment should be symptom specific, such as targeting mood disorders, insomnia, and headaches. Patients with PTSD should maintain regular follow-up visits with their healthcare provider. Referral to a psychiatrist is recommended for patients with treatment resistant disorders such as major depression or suicidal ideation. In many cases, it is helpful for NPs to co-manage patients with PTSD with a mental health specialist and arrange schedules so both providers can see the patient on the same day.
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