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POST-TRAUMATIC STRESS DISORDER PTSD Diagnostic Criteria PTSD Detection and Diagnosis PC-PTSD Screen PCL-C Screen PTSD Treatment Treatment Algorithm

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E-Resource March, 2014

Post-traumatic Stress Disorder (PTSD) affects approximately 10% of women and 5% of men, though rates of PTSD in primary care are believed to be 2-3 times higher. Among women, sexual assault is the leading cause of PTSD while in men, violence (often combat-related) is the primary cause. The following provides useful information for detecting and managing PTSD in primary care.

- - - PTSD Diagnostic Criteria

First and foremost an exposure to a traumatic event, such as death, threatened death, actual or threatened serious injury or sexual violence, is required. The exposure to a traumatic event can occur in one of the following ways:

1. Direct exposure as a victim 2. Witnessing an event

3. Repeated or extreme indirect exposure to aversive events (such as first responders).

Signs and Symptoms

Post-traumatic stress disorder symptoms are generally grouped into three types: intrusive memories, avoidance and numbing, and increased anxiety or emotional arousal (hyperarousal). These symptoms include but are not limited to:

 Flashbacks, or reliving the traumatic event for minutes or even days at a time

 Nightmares of reliving the event

 Symptoms of avoidance and emotional numbing may include:

 Avoidance of thinking or talking about the traumatic event

 Feeling emotionally numb or hopeless

 Avoiding pleasurable activities

 Negative thinking about self and future

 Memory problems

 Trouble concentrating

 Difficulty maintaining close relationships

 Irritability or anger

 Overwhelming guilt or shame

 Self-destructive behavior, such as drinking too much

 Trouble sleeping

 Being easily startled or frightened

 Hearing or seeing things that aren't there

Not one of these symptoms alone is criteria for diagnosis of PTSD. The combination of multiple symptoms, the exposure of a recently traumatic event, and the impact of these symptoms on individual’s ability functional and complete activities of daily living are all required in order to diagnose an individual with PTSD.

About the Virtual Guidance Program

JPS Health Network is proud to offer a new behavioral health clinical guidance resource to all primary care providers in our region. The JPS Behavioral Health Virtual Resource service offers:

 Telephone consultation with a behavioral health clinical team member

 Referral to community resources benefiting behavioral health patients

 Online reference library of behavioral health education materials

 Educational opportunities to increase provider understanding and comfort level in treating behavioral health conditions

Call 1-855-336-8790 or visit www.JPSBehavioralHealth.org for more information and to access a free virtual consultation for your patient.

PTSD Detection and Diagnosis

There are 4 categories of PTSD: acute, chronic, delayed, and subclinical.

Without proper detection and treatment, cases of acute PTSD may become chronic. When PTSD is suspected, it is important to review risk factors including history of trauma, personal or family mental health problems, substance abuse, medically unexplained physical symptoms and pregnancy. Conversation initiated by the physician is important because patients often do not proactively discuss their symptoms due to the stigma associated with mental illness or because they know little about PTSD.

Screening for PTSD can be done using several screening instruments. The Primary Care PTSD Screen (PC-PTSD) is a 4 question screening instrument useful in identifying patients who may have PTSD (see page 2). It is always advised to follow up with a more detailed instrument, such as the PTSD Symptom Checklist (PCL-C, see pages 3-4) or a structured interview.

When a positive screen suggests a diagnosis of PTSD, the first step is to provide patient education (regarding the effects of trauma, treatment options for PTSD ) and answer questions the patient may have. Next steps include referral to psychotherapy, if necessary and prescribing medication.

PTSD Treatment

Though treatment of PTSD can be complicated due to its intricate features and wide range of symptoms, there are various treatment options including psychotherapy, medication, or a combination of the two. A detailed treatment algorithm is included on page 5.

Psychotherapy: effective techniques include Cognitive Behavioral Therapy, group therapy, and stress-inoculation therapy.

Medication:

Serotonergic agents, such as Selective serotonin reuptake inhibitors (SSRIs), effectively treat both PTSD symptoms and disorders that coexist frequently with PTSD. For instance, sertraline (Zoloft) helps reduce alcohol consumption while fluvoxamine (Luvox) reduces obsessional thoughts and insomnia.

Tricyclic antidepressants may help reduce symptoms of re-experiencing trauma but evidence of their effectiveness is mixed.

Monoamine oxidase inhibitors such as phenelzine (Nardil) lead to moderate to good improvement in re-experiencing and avoidance symptoms and may reduce frequency of nightmares; these drugs may put patients with tyramine in their diet at risk for hypertensive crisis.

Antiadrenergic agents, such as clonidine (Catapres), propranolol (Inderal) and guanfacine (Tenex) reduce nightmares, hypervigilance, startle reactions and outbursts of rage; blood pressure levels should be periodically checked while patients are taking these medications.

Benzodiazepines, such as alprazolam (Xanax) and clonazepam (Klonopin) effectively treat anxiety, insomnia and irritability but carry risks of dependency and withdrawal after discontinuation and are not recommended for first line use or long term therapy.

During treatment, it is important to encourage good sleep hygiene, routine exercise and a healthy diet. If PTSD symptoms persist despite multiple treatment interventions, the patient should be referred to a specialist.

POST-TRAUMATIC STRESS DISORDER

PTSD Diagnostic Criteria • PTSD Detection and Diagnosis • PC-PTSD Screen • PCL-C Screen • PTSD Treatment • Treatment Algorithm

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Simplified Algorithm for the Detection and Treatment of PTSD

Patient experiences a traumatic event

Brief assessment based on behavior and

appearance

Is patient unstable,

suicidal or homicidal? Ensure safety and refer to emergency services (Use po-

lice if needed).

Assess for future environ- mental harms and ensure

basic needs are met.

Yes

No

Obtain history, physical ex- am, assess risk factors, and

functional level.

Does patient meet criteria for Diagnosis

of PTSD

Begin monotherapy with SSRI or SNRI (avoid first line use of ben-

zodiazepines) and begin referral for counseling/ psychotherapy.

(May benefit from consultation with psychiatrist.)

Follow 4-8 weeks to reassess symptoms and monitor pro- gress. (Can use PCL-C to moni-

tor progress)

Is patient progressing?

Continue course of treatment and consider stepping down pharmacologic treatments and

increasing care management Yes

 Increase dosage or switch to anoth-

No

er medication.

 Consider adjunctive treatment

 Refer to specialty or consider Virtual consultation.

Yes

No

Re-screen in 3-6 months. Provide sec-

ondary prevention education and support.

Side Note:

Traumatic Events Include: Experiencing or witnessing a traumatic event or life-threatening situation. A traumatic event can be any situation that causes stress, horror, helplessness, serious injury, or the threat of serious injury or death which has impacted an individuals ability to function

Signs to look for during assessment:

Flashbacks, or nightmares of reliving the traumatic event..

Feeling emotionally numb, hopeless

Memory problems, difficulty concentrating

Irritability or anger

Overwhelming guilt or shame with possible suicidality

Trouble sleeping

Being easily startled or frightened, anxious

References

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