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Posttraumatic Disorder Early Detection is Key

Posttraumatic Disorder Early Detection is Key

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09/06/2012

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www.tnpj.com
26
The Nurse PractitionerVol.31,No.3
A
n the morning ofSeptember 11th,2001,the mostdeadly ofterrorist attacks occurred in the UnitedStates.People were distraught.Lives were lost.Thestage was set for “a perfect storm”:posttraumatic stress dis-order (PTSD).Known as “shell shock”during World War I,PTSD usually is associated with combat trauma.Many otherindividuals may be susceptible,however.This disorder hasbeen a worldwide problem and is currently reaching alarm-ing proportions in the United States due to war,abuse,vio-lence,kidnappings,natural disasters,and terrorism.TheGlobal Burden ofDisease Project predicted that war,vio-lence,depression,and road traffic accidents would increasein their current ranks by 2020.Each ofthese conditions canincrease the risk ofPTSD.
1
Most individuals with PTSD,however,do not seek treatment in a mental health clinic,butrather a primary care clinic.Unfortunately,individuals withPTSD are often undiagnosed,which highlights the impor-tance ofproper recognition,assessment,and diagnosis.Providers need a quick,readable,accessible reference guideand annual education on the characteristics,diagnosis,andtreatment ofPTSD.Three-quarters ofthe U.S.population have experienceda traumatic event that could lead to PTSD.
2
This potentially devastating disorder can have a negative impact on physicaland mental health,causing significant distress and impact-ing every area oflife.An individual with PTSD will experi-ence work impairment on at least 1 day per week andapproximately 20 years ofactive symptoms.This results in a$3 billion annual productivity loss in the United States.At-tempted suicide rates are as high as 19% among individuals
 
O
Karen F. Guess, APRN, BC, ANP, PMHNP
Early Detectionis Key 
3.0
CONTACT HOURS
 
suffering from PTSD.
1
The goals ofhealthcare practitionersare to save lives and improve quality oflives.Practitionerscan achieve this by promptly identifying and diagnosing in-dividuals suffering from PTSD,so that early referral for spe-cialized mental healthcare can be made.
Prevalence
The lifetime prevalence rates ofPTSD for women and menare 10% and 5% respectively.
3
The lifetime prevalence rateis higher for women,possibly due to increased vulnerability for being victims ofabuse,violence,and sexual assault.Ap-proximately one-quarter ofthe individuals exposed to a trau-matic event will develop PTSD.
4
Several studies have investigated the prevalence of trauma exposure and rates ofPTSD.Schlenger and colleaguesassessed symptoms ofadults (n = 2,273) in the New Yorkand Washington D.C.areas after the September 11th attacksand found elevated rates ofprobable PTSD.Two months af-ter the attacks,11.6% ofthe American population were ex-periencing significant psychological distress.
5
One-quarterofthe sample of500 patients seen in an outpatient clinicalpractice met the criteria for PTSD.
6
Breslau and colleaguesfound 89.6% ofrespondents (n = 2,181) in a Detroit study had been exposed to a traumatic event defined by the Diag-nostic and Statistical Manual ofMental Disorders-IV-TextRevision (DSM-IV-TR) at some time in their life.
7,8
Exposure to traumatic events may worsen one’s physi-cal and mental health and result in an increased need formedical care.Patients with histories oftraumatic events areoften seen in primary care settings with a variety ofphysicaland psychiatric complaints;however,there is often no recog-nition ofthe common denominator—trauma—causing thecomplex symptomology.
10
According to the National Am-bulatory Medical Survey,90% ofpa-tients with PTSD are seen in primary care.
11
Direct costs oftreatment andmedical evaluation account for muchofthe cost ofPTSD,which exceedsthat ofother anxiety disorders.Un-fortunately,the rate ofPTSD recog-nition by healthcare providers islow—as few as 4% ofindividuals with PTSD.Furthermore,approximately 70% ofindividuals with PTSD have seen ageneral medical practitioner within the past 6 months.
1
Samson and colleagues assessed a sample of296 pa-tients from an outpatient primary care clinic.The patientspresented with symptoms ofdepression or anxiety and wereassessed using a diagnostic tool.Patients who scored posi-tive for a psychiatric disorder were sent for an intensive 1-hour assessment by a psychologist.Results indicated 114(38.5%) out ofthe 296 patients met the DSM criteria forPTSD.In addition,125 met the criteria for three psychiatricdisorders (43%),115 met criteria for two disorders (40%),and 56 met criteria for one psychiatric disorder (19%).Pa-tients with PTSD increased their use ofmedical services 12months prior to the study.
9
Misdiagnosis and lack ofPTSDrecognition result in ineffective management,leading to anegative impact on compliance with treatment,response totreatment,patient satisfaction,and level ofhealthcare uti-lization and cost.Routine assessment is the key to minimiz-ing these negative consequences.
Biologic Aspects
Individuals who suffer from PTSD are not psychologically weak or people who cannot deal with stress.Posttraumaticstress disorder is a serious and potentially chronic psychi-atric condition,and is comparable to a serious chronic med-ical illness.The biologic changes and the neurocircuitry involved in the pathophysiology ofPTSD have been studiedextensively.Neuroendocrine and neuroanatomic changesrelated to the stress after trauma exposure have been demon-strated.
12-14
The amygdala,medial prefrontal cortex,and an-terior cingulated cortex within the limbic region ofthe brain(the region responsible for the generation and modificationofmemories,and the seat ofall emotions) play a role in theperception,processing,and regulation ofemotion.
15
Theamygdala,as well as frontal cortical regions,have been im-plicated in PTSD symptom generation,emotional experi-ence,and response.
16,17,12
Liberzon and colleagues studied combat veterans diag-nosed with PTSD (n = 16),combat veterans without PTSD(n = 15),and age-matched healthy control subjects (n = 15)during script-driven imagery ofpersonalized traumaticevents along with emotionally neutral events.Positron emis-sion tomography scans ofthese subjects revealed differentblood flow patterns in the amygdala,insula,and medial pre-frontal cortex during emotional recall in PTSD patients com-pared to controls.
17
Other biologic changes implicated in PTSD are low lev-els ofcortisol and increased pituitary-adrenal and autonomicresponses to stress.
18,19
Levels ofnorepinephrine and thyroidhormone are increased in individuals with PTSD,as well aselevated reactivity ofalpha-2 adrenergic receptors,whichmay explain the increased incidence ofsomatic complaints
 Mental Health Care
www.tnpj.com
The Nurse PractitionerMarch 2006 
27
 Direct costs oftreatment and medical evaluationaccount for much ofthe cost ofPTSD,whichexceeds that ofother anxiety disorders.
 
 Mental Health Care
in individuals with PTSD.
20-22
These biologic changes asso-ciated with PTSD may reveal reasons why some individualsrecover from traumatic incidents without problems and oth-ers do not.Certain risk factors also predispose some indi-viduals to develop PTSD.
Risk Factors
Exposure to traumatic events is a major risk factor for PTSD.Traumatic events that may precipitate the development of PTSD are war,rape,abuse (usually sexual or physical),ter-rorism,torture,serious medical problems,and natural dis-asters.
5,10,23-28
Rescue workers and medical providers may alsobe at risk for secondary posttraumatic stress.
29
Halligan and Yehuda examined four categories offac-tors related to PTSD:environmental,demographic,cogni-tive,and biologic risk factors.
30
Environmental risk factorsincluded:(a) a history ofprior exposure to a trauma or asignificant stress,especially at a young age;(b) type oftraumaexposure;and (c) family instability.Demographic risk fac-tors include:(a) female gender;(b) lower income and edu-cational levels;and (c) being divorced or widowed.A history ofprior psychiatric disorders as well as the occurrence of dissociation (an unconscious defense mechanism in whichan idea,thought,or emotion is separated from the con-sciousness,usually because it is too disturbing or traumaticfor the mind to process at the time) during the trauma areknown risk factors for the development ofPTSD.Cognitiverisk factors may include lower intellectual functioning aswell as preexisting neurodevelopment impairments knownas neurologic “soft signs,which are subtle neurologic ab-normalities in language,motor coordination,and percep-tion.Finally,biologic risk factors entail:(a) an elevated andprolonged catecholamine response posttrauma as evidencedby a prolonged increased heart rate;(b) chronically low lev-els ofcortisol;and (c) alterations in the hypothalamic-pitu-itary-adrenal (HPA) axis.
30
Physical Health Problems
Use ofmedical services increases after a traumatic event.Re-search reveals exposure to significantly stressful and traumaticevents may culminate in detrimental physical symptoms anddisease.Posttraumatic stress disorder is associated with higherrates ofasthma,cancer,obesity,chronic pain,hypertension,fibromyalgia,irritable bowel syndrome,peptic ulcer disease,and ischemic heart disease.
10,31
Mechanisms explaining thecause ofpoorer health outcomes in individuals with PTSDinclude biologic aspects (elevated norepinephrine and thy-roid hormone,elevated reactivity ofalpha-2 adrenergic re-ceptors,altered HPA activity,and altered sleep physiology),and psychological and behavioral aspects,such as depression,hostility,poor coping,and poor health habits,such as smok-ing and drinking alcohol.
32
Individuals suffering from PTSD tend to seek treatmentfor multiple physical complaints,but often do not connectthe current physical symptoms to past trauma.Unfortu-nately,many medical and psychiatric providers do not makethis connection either due to the variability in presentingsymptoms.Furthermore,highly comorbid mental disorders“mask”symptoms ofPTSD and become the focus oftreat-ment.Associated comorbid mental disorders include pho-bias,compulsivity,major depression,anxiety disorders,eating disorders,substance abuse,and delinquent or crimi-nal behavior.
9,6
The differentiating factor,the previous oc-currence ofa traumatic event and its relationship to thesymptoms,is often unexplored and untreated.
22,33
The con-nection between PTSD and physical health problems re-quires collaboration between primary care and mental healthproviders.
Assessment
Patients with PTSD have a high rate ofsomatization,so fre-quent use ofmedical services and frequent complaints of multiple unexplained physical problems are clues to recog-nizing PTSD.
1
Complaints tend to be gastrointestinal,cardio-vascular,neurologic,and musculoskeletal in nature.
34
Becauseofthe high use ofmedical services among individuals withPTSD,obtaining a trauma history should be an importantaspect in assessing people who make frequent office visits,somatizers,and those who have high emotional distress.Patient self-reported screening questionnaires and med-ical history paperwork are efficient ways to assess for PTSD.Because previous trauma can be a sensitive issue,self-reportquestionnaires are a more comfortable way to introduce thetopic and increase the likelihood that the subject will be dis-
www.tnpj.com
The Nurse PractitionerMarch 2006 
29
DREAMS
D
Detachment (generally numb emotionalresponsiveness)
R
Reexperiencing the event (nightmares orflashbacks)
E
Emotional effects (emotional distress,helplessness, fear)
A
Avoidance (avoiding things that are reminders ofthe event)
M
Months of duration
S
Sympathetic hyperactivity and hypervigilance(insomnia, irritability, difficulty concentrating)
Acronym adapted from Lange J, Lange C, Cabaltica R: Primary care treatmentof post traumatic stress disorder.
Am Fam Physician 
2000; 1035-1040.

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