This action might not be possible to undo. Are you sure you want to continue?
Early Detection is Key
Karen F. Guess, APRN, BC, ANP, PMHNP
n the morning of September 11th, 2001, the most deadly of terrorist attacks occurred in the United States. People were distraught. Lives were lost. The stage was set for “a perfect storm”: posttraumatic stress disorder (PTSD). Known as “shell shock” during World War I, PTSD usually is associated with combat trauma. Many other individuals may be susceptible, however. This disorder has been a worldwide problem and is currently reaching alarming proportions in the United States due to war, abuse, violence, kidnappings, natural disasters, and terrorism. The Global Burden of Disease Project predicted that war, violence, depression, and road traffic accidents would increase in their current ranks by 2020. Each of these conditions can increase the risk of PTSD.1 Most individuals with PTSD, however, do not seek treatment in a mental health clinic, but
rather a primary care clinic. Unfortunately, individuals with PTSD are often undiagnosed, which highlights the importance of proper recognition, assessment, and diagnosis. Providers need a quick, readable, accessible reference guide and annual education on the characteristics, diagnosis, and treatment of PTSD. Three-quarters of the U.S. population have experienced a traumatic event that could lead to PTSD.2 This potentially devastating disorder can have a negative impact on physical and mental health, causing significant distress and impacting every area of life. An individual with PTSD will experience work impairment on at least 1 day per week and approximately 20 years of active symptoms. This results in a $3 billion annual productivity loss in the United States. Attempted suicide rates are as high as 19% among individuals www.tnpj.com
26 The Nurse Practitioner • Vol. 31, No. 3
Mental Health Care
suffering from PTSD.1 The goals of healthcare practitioners are to save lives and improve quality of lives. Practitioners can achieve this by promptly identifying and diagnosing individuals suffering from PTSD, so that early referral for specialized mental healthcare can be made.
■ Prevalence The lifetime prevalence rates of PTSD for women and men are 10% and 5% respectively.3 The lifetime prevalence rate is higher for women, possibly due to increased vulnerability for being victims of abuse, violence, and sexual assault. Approximately one-quarter of the individuals exposed to a trau■ Biologic Aspects matic event will develop PTSD.4 Individuals who suffer from PTSD are not psychologically Several studies have investigated the prevalence of weak or people who cannot deal with stress. Posttraumatic trauma exposure and rates of PTSD.Schlenger and colleagues stress disorder is a serious and potentially chronic psychiassessed symptoms of adults (n = 2,273) in the New York atric condition, and is comparable to a serious chronic medand Washington D.C. areas after the September 11th attacks ical illness. The biologic changes and the neurocircuitry and found elevated rates of probable PTSD. Two months afinvolved in the pathophysiology of PTSD have been studied ter the attacks, 11.6% of the American population were exextensively. Neuroendocrine and neuroanatomic changes periencing significant psychological distress.5 One-quarter related to the stress after trauma exposure have been demonstrated.12-14 The amygdala, medial prefrontal cortex, and anof the sample of 500 patients seen in an outpatient clinical 6 practice met the criteria for PTSD. Breslau and colleagues terior cingulated cortex within the limbic region of the brain found 89.6% of respondents (n = 2,181) in a Detroit study (the region responsible for the generation and modification had been exposed to a traumatic event defined by the Diagof memories, and the seat of all emotions) play a role in the nostic and Statistical Manual of Mental Disorders-IV-Text perception, processing, and regulation of emotion.15 The 7,8 amygdala, as well as frontal cortical regions, have been imRevision (DSM-IV-TR) at some time in their life. plicated in PTSD symptom generation, emotional experiExposure to traumatic events may worsen one’s physience, and response.16,17,12 cal and mental health and result in an increased need for Liberzon and colleagues studied combat veterans diagmedical care. Patients with histories of traumatic events are nosed with PTSD (n = 16), combat veterans without PTSD often seen in primary care settings with a variety of physical (n = 15), and age-matched healthy control subjects (n = 15) and psychiatric complaints; however, there is often no recogduring script-driven imagery of personalized traumatic nition of the common denominator—trauma—causing the events along with emotionally neutral events. Positron emiscomplex symptomology.10 According to the National Ambulatory Medical Survey, 90% of patients with PTSD are seen in primary Direct costs of treatment and medical evaluation care.11 Direct costs of treatment and medical evaluation account for much account for much of the cost of PTSD, which of the cost of PTSD, which exceeds exceeds that of other anxiety disorders. that of other anxiety disorders. Unfortunately, the rate of PTSD recognition by healthcare providers is sion tomography scans of these subjects revealed different low—as few as 4% of individuals with PTSD. Furthermore, blood flow patterns in the amygdala, insula, and medial preapproximately 70% of individuals with PTSD have seen a frontal cortex during emotional recall in PTSD patients comgeneral medical practitioner within the past 6 months.1 pared to controls.17 Samson and colleagues assessed a sample of 296 patients from an outpatient primary care clinic. The patients Other biologic changes implicated in PTSD are low levels of cortisol and increased pituitary-adrenal and autonomic presented with symptoms of depression or anxiety and were assessed using a diagnostic tool. Patients who scored posiresponses to stress.18,19 Levels of norepinephrine and thyroid tive for a psychiatric disorder were sent for an intensive 1hormone are increased in individuals with PTSD, as well as hour assessment by a psychologist. Results indicated 114 elevated reactivity of alpha-2 adrenergic receptors, which (38.5%) out of the 296 patients met the DSM criteria for may explain the increased incidence of somatic complaints www.tnpj.com
The Nurse Practitioner • March 2006 27
PTSD. In addition, 125 met the criteria for three psychiatric disorders (43%), 115 met criteria for two disorders (40%), and 56 met criteria for one psychiatric disorder (19%). Patients with PTSD increased their use of medical services 12 months prior to the study.9 Misdiagnosis and lack of PTSD recognition result in ineffective management, leading to a negative impact on compliance with treatment, response to treatment, patient satisfaction, and level of healthcare utilization and cost. Routine assessment is the key to minimizing these negative consequences.
Mental Health Care
in individuals with PTSD.20-22 These biologic changes associated with PTSD may reveal reasons why some individuals recover from traumatic incidents without problems and others do not. Certain risk factors also predispose some individuals 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), terrorism, torture, serious medical problems, and natural disasters.5,10,23-28 Rescue workers and medical providers may also be at risk for secondary posttraumatic stress.29 Halligan and Yehuda examined four categories of factors related to PTSD: environmental, demographic, cognitive, and biologic risk factors.30 Environmental risk factors included: (a) a history of prior exposure to a trauma or a significant stress, especially at a young age; (b) type of trauma exposure; and (c) family instability. Demographic risk factors include: (a) female gender; (b) lower income and educational levels; and (c) being divorced or widowed. A history of prior psychiatric disorders as well as the occurrence of dissociation (an unconscious defense mechanism in which an idea, thought, or emotion is separated from the consciousness, usually because it is too disturbing or traumatic for the mind to process at the time) during the trauma are known risk factors for the development of PTSD. Cognitive risk factors may include lower intellectual functioning as well as preexisting neurodevelopment impairments known as neurologic “soft signs,” which are subtle neurologic abnormalities in language, motor coordination, and perception. Finally, biologic risk factors entail: (a) an elevated and prolonged catecholamine response posttrauma as evidenced by a prolonged increased heart rate; (b) chronically low levels of cortisol; and (c) alterations in the hypothalamic-pituitary-adrenal (HPA) axis.30 ■ Physical Health Problems Use of medical services increases after a traumatic event. Research reveals exposure to significantly stressful and traumatic events may culminate in detrimental physical symptoms and disease. Posttraumatic stress disorder is associated with higher rates of asthma, cancer, obesity, chronic pain, hypertension, fibromyalgia, irritable bowel syndrome, peptic ulcer disease, and ischemic heart disease.10,31 Mechanisms explaining the cause of poorer health outcomes in individuals with PTSD include biologic aspects (elevated norepinephrine and thyroid hormone, elevated reactivity of alpha-2 adrenergic receptors, altered HPA activity, and altered sleep physiology), and psychological and behavioral aspects, such as depression, hostility, poor coping, and poor health habits, such as smokwww.tnpj.com
D R E A M S
Detachment (generally numb emotional responsiveness) Reexperiencing the event (nightmares or flashbacks) Emotional effects (emotional distress, helplessness, fear) Avoidance (avoiding things that are reminders of the event) Months of duration Sympathetic hyperactivity and hypervigilance (insomnia, irritability, difficulty concentrating)
Acronym adapted from Lange J, Lange C, Cabaltica R: Primary care treatment of post traumatic stress disorder. Am Fam Physician 2000; 1035-1040.
ing and drinking alcohol.32 Individuals suffering from PTSD tend to seek treatment for multiple physical complaints, but often do not connect the current physical symptoms to past trauma. Unfortunately, many medical and psychiatric providers do not make this connection either due to the variability in presenting symptoms. Furthermore, highly comorbid mental disorders “mask” symptoms of PTSD and become the focus of treatment. Associated comorbid mental disorders include phobias, compulsivity, major depression, anxiety disorders, eating disorders, substance abuse, and delinquent or criminal behavior.9,6 The differentiating factor, the previous occurrence of a traumatic event and its relationship to the symptoms, is often unexplored and untreated.22,33 The connection between PTSD and physical health problems requires collaboration between primary care and mental health providers. ■ Assessment Patients with PTSD have a high rate of somatization, so frequent use of medical services and frequent complaints of multiple unexplained physical problems are clues to recognizing PTSD.1 Complaints tend to be gastrointestinal, cardiovascular, neurologic, and musculoskeletal in nature.34 Because of the high use of medical services among individuals with PTSD, obtaining a trauma history should be an important aspect in assessing people who make frequent office visits, somatizers, and those who have high emotional distress. Patient self-reported screening questionnaires and medical history paperwork are efficient ways to assess for PTSD. Because previous trauma can be a sensitive issue, self-report questionnaires are a more comfortable way to introduce the topic and increase the likelihood that the subject will be disThe Nurse Practitioner • March 2006 29
Mental Health Care
DSM-IV-TR Posttraumatic Stress Disorder (PTSD) Symptom Criteria
Reexperiencing Symptoms (1 required) • Intrusive memories • Nightmares • Feeling trauma is recurring • Hallucinations • Flashbacks • Distress and physiological reaction when exposed to triggers
Increased Arousal Symptoms (2 required) • Insomnia • Panic • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Increased startle response
Avoidance Symptoms (3 required) • Avoiding thoughts, feelings, activities, people, and places associated with trauma • Diminished interest in usual activities • Feeling detached or estranged from others • Emotional numbing • Sense of foreshortened future • Inability to recall important aspects of trauma
At least 1 month
Acute PTSD < 3 months
Copyright © Karen Guess, APRN, BC, ANP, PMHNP
Chronic PTSD > 3 months
Early Intervention and Prevention40
What to do immediately after exposure to an extreme stressor or trauma: • Help the patient understand that it is normal to be upset and have distressing symptoms shortly after a trauma. • Provide education about acute stress reactions and posttraumatic stress disorder. • Encourage the patient to talk with family and friends about the trauma and experience the feelings associated with it. • Educate family and significant others about the importance of listening and being tolerant of the person’s emotional reactions. • Help the patient and family accept the need for repeated retelling of the event in order to facilitate recovery. • Provide emotional support. • Relieve irrational guilt. • Refer to peer support group or trauma counseling.
cussed.33 Clinicians who work in a mental health setting should pay attention to physical complaints that may be correlated with psychiatric diagnoses such as PTSD.35 Furthermore, clinicians need to differentiate PTSD and similar symptoms that occur in other disorders such as depression, anxiety, and psychosis. One assessment tool is the Posttraumatic Stress Disorder Checklist, a self-report questionnaire developed by the National Center for PTSD that is a time30 The Nurse Practitioner • Vol. 31, No. 3
saving and cost-effective method for ascertaining PTSD symptomology. The questionnaire consists of 17 questions, uses a 5-point Likert scale, and can be completed within 10 minutes. The questionnaire has excellent internal consistency (alpha = .97) and test-retest reliability (.96).36,37 To obtain a copy of this checklist, visit http://www.ncptsd.va. gov/publications/assessment. If the occurrence of a traumatic event is established, the assessment for PTSD can proceed. Assessment requires establishing and maintaining trust as well as a therapeutic alliance with the patient. Routine questioning, such as inquiring whether a trauma has occurred and whether the past trauma is still distressing the patient, is a suggested approach for uncovering a trauma and determining its impact.1 The PTSD Quick Reference Sheet can assist practitioners in ascertaining posttrauma symptomology according to DSM-IV-TR criteria in an efficient manner (see Figure: “DSM-IV-TR Posttraumatic Stress Disorder (PTSD) Symptom Criteria”). Posttraumatic stress disorder symptomology can also be identified by using the acronym “DREAMS” as a quick reference guide (see Figure: “DREAMS”).38 Routine questioning will result in optimization of health outcomes, enhanced patient satisfaction and quality of life, and reduction in costs.11 ■ Diagnostic Criteria Posttraumatic stress disorder is an anxiety disorder with multiple symptoms that are not limited to posttraumatic symptoms. Varying differences occur in the presentation of PTSD.10 The DSM-IV-TR8 contains the criteria used to diagnose PTSD. Four requirements must be met to make the www.tnpj.com
Mental Health Care
Posttraumatic Stress Disorder (PTSD) Treatment Protocol33,36,38,40
STEP 1 Assessment and Diagnosis: • Correctly assess for and identify PTSD. STEP 2 Initial Treatment: • Individual psychotherapy (60 minutes weekly or biweekly sessions) or combination of psychotherapy and medication. • If comorbid depression, bipolar, or anxiety disorder, combine psychotherapy and medication from the beginning. • Mild substance abuse—treat substance abuse and PTSD simultaneously. • Severe substance abuse—treat substance abuse first or treat both simultaneously. Specific Psychotherapy Techniques: • Exposure Therapy—desensitizing the anxiety caused by reminders of the trauma by progressive exposure – Intrusive thoughts – Flashbacks – Fear, panic, avoidance • Cognitive Therapy—correcting irrational beliefs, i.e. unrealistic guilt about the trauma – Numbing/detachment – Irritability – Guilt/shame – Comorbid depression – Bipolar – Personality disorder • Anxiety Management—relaxation training, breathing retraining, positive thinking and self talk, assertiveness training, and thought stopping – Anxiety – Sleep disturbances – Difficulty concentrating – Comorbid substance abuse Medication Management: • First line—Selective serotonin reuptake inhibitors (SSRIs)* All PTSD symptoms • May also consider—tricyclic antidepressants, mood stabilizers, or antiadrenergics (i.e. clonidine or betablockers). Use extreme caution when using a tricyclic medication in a severely depressed patient, as just a week’s supply of medication (approximately 1,000 mg) can be lethal in overdose. • Sleep disturbance—trazadone STEP 3 Only Partial Response: • Acute PTSD: symptoms 1-3 months 3A: Partial response to therapy alone—add medication and/or add or switch to other therapy technique. 3B: Partial response to medication alone—add therapy. 3C: Partial response to combined therapy and medication—add or switch to another medication and/or add or switch to therapy technique. • Chronic PTSD: symptoms > 3 months – Partial response to therapy alone—same as step 3A – Partial response to medication alone—add therapy and/or add another medication** – Partial response to combined therapy and medication—same as step 3C or increase dose of medication STEP 4 No Response: • Acute and Chronic PTSD – No response to psychotherapy—add medication and/or switch to another psychotherapy technique – No response to medication alone—add psychotherapy and/or switch to another medication – No response to combined psychotherapy and medication—switch to another medication and/or switch to or add another therapy technique. STEP 5 No Response to Multiple Previous Treatment: • Assess for substance abuse and psychiatric or medical comorbidities • Reevaluate diagnosis of PTSD • Combine medications – Antidepressant + mood stabilizer – Antidepressant + antidepressant – Antidepressant + antipsychotic – Antidepressant + antipsychotic + mood stabilizer – Adjunct benzodiazepine or trazadone • Combine psychotherapy techniques • Add social skills training, vocational rehabilitation, or family therapy • Hospitalize if risk of suicide or harm to others STEP 6 Maintenance Treatment Phase After Good Response: • Psychotherapy—3-6 months with booster sessions every 2-4 weeks • Medication—Acute PTSD: 6-12 months Chronic PTSD: 12-24 months or longer • Medication follow-up visits—Monthly for first 6 months, every 1-2 months for 2nd 6 months, then every 3 months thereafter
* Sertraline, paroxetine, fluoxetine, fluvoxamine, citalopram, escitalopram ** If initial treatment was: SSRI—add mood stabilizer or tricyclic antidepressant (TCA); nefazodone—add mood stabilizer; venlafaxine—add mood stabilizer; mood stabilizer—add SSRI, another mood stabilizer, Trazodone, nefazodone, venlafaxine, or TCA)
The Nurse Practitioner • March 2006 31
Mental Health Care
PTSD present with a myriad of symptoms, treatment should be individually tailored.Treatment also depends on the severity and duration of the disorder. Early intervention posttrauma is vital and will likely be more beneficial than care provided after the PTSD symptomology has become chronic. Education and posttrauma debriefing involves normalizing the stress reaction, discussing the neurobiology of PTSD, and encouraging the individual to talk about his or her traumatic experience4 (see Table: “Early Intervention and Prevention”).40 If PTSD symptoms have lingered for longer than 1 month, the individual should be referred for psychotherapy, which includes anxiety management, cognitive therapy, and exposure therapy. If symptoms are severe, persistent, and interfere with daily functioning, pharmacotherapy should be initiated. An antidepressant is the predominant A history of prior psychiatric disorders as well medication prescribed to treat PTSD as dissociation during the trauma are known since depression is a major component risk factors for the development of PTSD. of the disorder.A variety of other medications, such as benzodiazepines, clonidine, and beta-adrenergic blocktoms of increased arousal include increased startle response, ers are used to decrease the autonomic arousal exhibited in irritability, insomnia, and hypervigilance (a higher-thanPTSD (see Table: Posttraumatic Stress Disorder (PTSD) normal focus and attention to all internal and external stimTreatment Protocol).40 The PTSD treatment protocol is a uli). The final cluster includes avoidance-type behaviors such combination of published recommendations in a condensed, as emotional numbing, derealization (a sense the environconcise version to provide increased feasibility of use in clinment is strange or unreal), depersonalization (an individical practice.33,36,38,40 ual’s subjective sense that he or she is unreal or strange), and REFERENCES avoidance of situations that trigger thoughts of the trauma. 1. Davidson J. Recognition and treatment of post traumatic stress disorder. A diagnosis of PTSD is established when these symptoms JAMA. 2001;286(5):584-590. last longer than 1 month and when social, occupational, or 2. Rogers P, Liness S. Post traumatic stress disorder. Nurs Stand. 2000;14(22): 47-52. cognitive functional impairment exists.8 Posttraumatic stress 3. Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, et al. Screening for disorder can be delineated as acute or chronic. The diagnoserious mental illness in the general population. Arch Gen Psychiatry. 2003;60(2):184-189. sis of acute PTSD is made when symptoms last 3 months or 4. Schnurr PP, Friedman MJ, Bernardy NC. Research on post traumatic stress less; the diagnosis of chronic PTSD is made when symptoms disorder: Epidemiology, pathophysiology, and assessment. J Clin Psychol. 2002;58(8):877-89. last longer than 3 months. The degree and severity of PTSD 5. Schlenger W, Caddell J, Ebert L, et al. Psychological reactions to terrorist is usually related to the type of trauma. Despite treatment, attacks. JAMA. 2002;288(5):581-588. approximately one-third of individuals with PTSD have un6. Bruce SE, Weisberg RB, Dolan RT, Machan, JT, Kessler RC, Manchester G, Culpepper L, Keller, MB.Trauma and post traumatic stress disorder in priremitting symptoms.3 Zlotnick and colleagues found residmary care patients. J Clin Psychiatry. 2001;3(5):211-217. ual symptoms still existed 2 years after the trauma in a sample 7. Weisberg RB, Bruce SE, Machan JT, Kessler RC, Culpepper L, Keller, MB. Nonpsychiatric illnesses among primary care patients with trauma histories of 84 primary care patients.39 Most individuals who have reand post traumatic stress disorder. Psychiatr Serv. 2002;53(7):848-54. covered from PTSD still have problematic subthreshhold 8. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Associasymptoms of the disorder years later. Similar to the goal of tion; 2000. cancer treatment, the goal of treatment for PTSD is com9. Gillock KL, Zayfert C, Hegel MT, Ferguson RJ. Post traumatic stress disorder in primary care: Prevalence and relationships with physical symptoms plete remission of symptoms. ■ Management Current treatment strategies for PTSD involve a combination of posttrauma debriefing, education, pharmacotherapy, and psychotherapy. Because individuals suffering from
32 The Nurse Practitioner • Vol. 31, No. 3
and medical utilization. Gen Hosp Psych. 2005;27(6):392-399. 10. Ramaswamy S, Madaan V, Qadri F, Heaney CJ, North TC, Padala PR, Satar SP, Petty F. A primary care perspective of post traumatic stress disorder for the Department of Veterans Administration. J Clin Psychiatry. 2005;7(4): 180-187. 11. Boscarino JA, Galea S, Adams RE, Ahern J, Resnick H, Vlahov D. Mental health services and medication use in New York City after September 11,
diagnosis. The first is the experience of a traumatic event with the component of actual or threatened death or injury. The individual must react with intense fear, helplessness, or horror. The remaining three diagnostic criteria are clusters of symptoms: reexperiencing symptoms, increased arousal symptoms, and avoidance symptoms. To meet DSM-IV-TR criteria for PTSD, an individual must have one reexperiencing symptom, two increased arousal symptoms, and three avoidance symptoms.8 Individuals suffering from PTSD often admit to the occurrence of intrusive thoughts and memories of the trauma. Memories manifest as flashbacks, in which the individual feels as if the trauma is reoccurring, and nightmares, in which the individual reprocesses the trauma during sleep. Symp-
Mental Health Care
2001 terrorist attack. Psychiatric Serv. 2004;55(3):274-283. 12. Liberzon I, Britton J, Phan K. Neural correlates of traumatic recall in posttraumatic stress disorder. Stress. 2003;6(3):151-156. 13. McEwan BS. The neurobiology and neuroendocrinology of stress implications for post-traumatic stress disorder from a basic science perspective. Psych Clinics North Amer. 2002;25:469-494. 14. Pittman RK, Shin LM, Rauch SL. Investigating the pathogenesis of posttraumatic stress disorder with neuroimaging. J Clin Psychiatry. 2001;62:47-54. 15. LeDoux J. Emotion circuits in the brain. Annu Rev Neurosci. 2000;23:155184. 16. Bremner JD. Effects of traumatic stress on brain structure and function: Relevance to early responses to trauma. J Trauma Dissociation. 2005;6(2):5168. 17. Liberzon I, Britton JC, Phan KL. Neural correlates of traumatic recall in post traumatic stress disorder. Stress. 2003;6(3):151-156. 18. Lauc G, Zvonar K, Vuksic-Mihaljevic Z, Flogel M. Short communication: Post-awakening changes in salivary cortisol in veterans with and without PTSD. Stress and Health. 2004;20:99-102. 19. Heim C, Newport J, Heit S, Graham Y, Wilcox M, Bonsall R, et al. Pituitaryadrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000;284(5):592-597. 20. Yehuda R. Clinical relevance of biological findings in PTSD. Psychiatr Quart. 2002;73(2):123-133. 21. Friedman MJ, Wang S, Jalowiec JE, McHugo GJ, McDonagh-Coyle A. Thyroid hormone alterations among women with post traumatic stress disorder due to childhood sexual abuse. Biol Psychiatry. 2005;57(10):1186-1192. 22. Yehuda R. Post traumatic stress disorder. N Engl J Med. 2002;346(2):108114. 23. deJong J, Komproe I, Ommeren M, Masri M, Araya M, Khaled N, et al. Lifetime events and post traumatic stress disorder in 4 post conflict settings. JAMA. 2001;286(5):555-562. 24. Acierno R., Gray M, Best C, Resnick H, Kilpatrick D, Saunders B, et al. Rape and physical violence: Comparison of assault characteristics in older and younger adults in the national women’s study. J Trauma Stress. 2001;14(4): 685-695. 25. Lang AJ, Rodgers CS, Laffaye C, Satz LE, Dresselhaus TR, Stein MB. Sexual trauma, post traumatic stress disorder, and health behavior. Behav Med. 2003;28(4):150-158. 26. Silver R, Holman E, McIntosh D, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA. 2002; 288(10):1235-1244. 27. North CS, Pfefferbaum B, Tivis L, Kawasoki A, Reddy C, Spitznagel EL. The course of post traumatic stress disorder in a follow-up study of survivors of
the Oklahoma city bombing. Ann Clin Psychiatry. 2004;16(4):209-215. 28. Kwekkeboom D, Seng J. Recognizing and responding to post-traumatic stress disorder in people with cancer. Oncology Nursing Forum. 2002;29(4):643650. 29. Collins S, Long A. Working with the psychological effects of trauma: consequences for mental health-care workers – a literature review. J Psychiatric Ment Health Nurs. 2003;10:417-424. 30. Halligan S, Yehuda R. Risk factors for PTSD. NCP Quart. 2000;11(3):1-8. 31. Gillock KL, Zayfert C, Hegel MT, Ferguson RJ. Post traumatic stress disorder in primary care: Prevalence and relationships with physical symptoms and medical utilization. Gen Hosp Psychiatry. 2005;27(6):392-399. 32. Schnurr PP, Green BL. Understanding relationships among trauma, post traumatic stress disorder, and health outcomes. Adv Mind Body Med. 2004;20(1):18-29. 33. Lanterbach D, Vora R, Rakow M. The relationship between PTSD and selfreported health problems. Psychosom Med. 2005;67(6):939-947. 34. Clum G, Nishith P, Resick P. Trauma-related sleep disturbance and self-reported physical health symptoms in treatment seeking female rape victims. J Nerv Ment Dis. 2001;189:618-622. 35. Green B, Schnurr P. Trauma and physical health. NCP Quart. 2000;9(1):2-5. 36. Keane T, Weathers F, Foa E. Effective treatments for post traumatic stress disorder: Practical guidelines from the International Society for Traumatic Stress Studies. Guilford Press, 2000;18-36. 37. Ruggiero K, Ben K, Scotti J, Rabalais A. Psychometric properties of the PTSD checklist—civilian version. J Trauma Stress. 2003;16(5):495-502. 38. Lange J, Lange C, Cabaltica R. Primary care treatment of post traumatic stress disorder. Amer Fam Physician. 2000;1035-1040. 39. Zlotnick C, Rodriguez B, Weisberg R, Bruce S, Spencer M, Culpepper L, et al. Chronicity in post traumatic stress disorder and predictors of the course of post traumatic stress disorder among primary care patients. J Nerv Ment Dis. 2004;192:153-159. 40. Foa E, Davidson J, Frances A. Expert consensus guideline series: Treatment of posttraumatic stress disorder. J Clin Psychiatry. 1999;60(16).
The author has disclosed that she has no significant relationship or financial interest in any commercial companies that pertain to this education activity.
ABOUT THE AUTHOR
Karen F. Guess is a Nurse Practitioner at a private practice in Arlington,Texas. She is also pursuing a doctorate at the University of Texas at Arlington.
Earn CE credit online:
Go to http://www.nursingcenter.com/CE/NP and receive a certificate within minutes.
Posttraumatic Stress Disorder: Early Detection is Key
TEST INSTRUCTIONS • To take the test online, go to our secure Web site at http://www.nursingcenter.com/ce/NP. • On the print form, record your answers in the test answer section of the CE enrollment form on page 34. Each question has only one correct answer. You may make copies of these forms. • Complete the registration information and course evaluation. Mail the completed form and registration fee of $22.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. • You will receive your CE certificate of earned contact hours and an answer key to review your results. There is no minimum passing grade. • Registration deadline is March 31, 2008. DISCOUNTS and CUSTOMER SERVICE • Send two or more tests in any nursing journal published by LWW together and deduct $0.95 from the price of each test. • We also offer CE accounts for hospitals and other health care facilities on nursingcenter.com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION: Lippincott Williams & Wilkins (LWW), the publisher of The Nurse Practitioner, will award 3.0 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 3.0 contact hours. LWW is also an approved provider by the American Association of Critical-Care Nurses (AACN 00012278, CERP Category A), Alabama #ABNP0114, Florida #FBN2454, and Iowa #75. LWW home study activities are classified for Texas nursing continuing education requirements as Type 1. Your certificate is valid in all states.
The Nurse Practitioner • March 2006 33
Mental Health Care
34 The Nurse Practitioner • Vol. 31, No. 3