When The Emotional Stress Remains After The Trauma Or Injury - PTSD
27 Jul 2007
After the physical injury heals, after the surgery is completed, after the physical pain recedes, or even years after the funeral of a loved one the trauma victim often continues to suffer emotionally. Primary care doctors are becoming aware of the need to be sensitive to the patient who has posttraumatic stress disorder (PTSD).
PTSD has been defined as a psychological disorder affecting individuals who have experienced significant physical or emotional trauma and is characterized by recurrent flashbacks of the traumatic event, nightmares, eating disorders, anxiety, fatigue, forgetfulness, and social withdrawal.
Reviewing the current thinking of the medical community regarding this disabling condition may enable PTSD sufferers to obtain the help they need.
James Turnbull, MD,[1] clinical professor of psychiatry and family practice at East Tennessee State University and medical director of Frontier Health Inc, talked about PTSD and grief as part of the American Academy of Family Physicians Annual Clinical Focus, Mental Health 2000.
Posttraumatic stress disorder (PTSD) is best known to most people as "battle fatigue" or "shell shock" from its early descriptions in military personnel. However, PTSD can occur in anyone who is subjected to a serious trauma. Individuals who experience trauma can suffer major short-term and long-term effects on their health.
Many develop a characteristic set of posttraumatic symptoms that can endure for years after the original trauma.
Patients with PTSD may simultaneously have other psychiatric diagnoses, changes in health behavior, unexplained physical symptoms, and stress-related health problems. Studies in community samples report lifetime prevalence of posttraumatic stress disorder (PTSD) ranging from 7.8% to 12.3% in the general population.
The wide range of symptoms and high levels of other related problems can obscure the presence of the underlying trauma and its consequences. This makes it difficult for a doctor to accurately diagnose and effectively manage these problems in their patients. In addition, many patients with posttraumatic syndromes are high utilizers of healthcare resources and may be more likely to seek care from medical professionals than from mental health professionals. Thus, this is an extremely important clinical topic for primary care physicians.
Grief and Bereavement
Grief, the process of accommodating a loss, is a universal experience that can be very costly in terms of health. While grief does not typically cause full-blown PTSD symptoms, it can be viewed as part of the continuum of responses to trauma that includes PTSD.
People in mourning usually seek a general understanding of what they are going through, respect for the individual nature of their situation, and ways to deal with their helplessness. Physicians need to help patients get on with their lives by listening to the patients as they talk through what they are experiencing. Reminders of the death or of the loved one in general often can bring on delayed symptoms. Such reminders include the anniversary of the death, other deaths or losses, or the death of a pet. Grieving is an active process that goes through several steps. Patients must deal with the reality of the loss, work through the emotional turmoil that is produced, adjust to the environment where the deceased is absent, and "say good-bye" to the deceased.
Dr. Turnbull recommended two books for physicians to read and to recommend to their patients who are dealing with grief: When Bad Things Happen to Good People[2] by Rabbi Kushner and Man's Search for Meaning[3] by Victor Frankl.
When the death is a suicide, the process of bereavement may be much more difficult, complicated, and prolonged. The mourning period may commonly stretch out for 2 to 3 years rather than the 6 to 12 months seen after other types of deaths. After a suicide, family members and friends may feel shame, anger, and guilt, feeling that if only they had done something, they could have prevented the death. They may present to the office with symptoms of depression, somatized symptoms such as headaches, dizziness, or pain, and PTSD-like symptoms, including visualizing the moment of death and numbing of affect. Occasionally, the mourners of a suicide may actually have auditory or olfactory hallucinations and very vivid dreams. These symptoms should not be taken as a sign of psychosis. Instead, the patient should be reassured that this is part of the process of working through the suicide
Posttraumatic Stress Disorder
PTSD can be caused by a variety of major traumatic stressors, including combat, assault, rape, injury, natural disaster, sudden life-threatening illness, or witnessing violent episodes. It is seen in battered women, police officers who witness someone killed or who shoot someone, firefighters, medical personnel who deal with traumatic injuries, and military veterans. At times, close family members of people with PTSD may display PTSD symptoms.
Diagnostic Criteria and Related Symptoms
The diagnostic criteria for PTSD specify (1) that the person has been exposed to a traumatic event in which he/she experienced, witnessed, or was confronted with actual or threatened death or serious injury or a threat to the physical integrity of self or others and (2) that the person's response involved intense fear, helplessness, or horror. The traumatic event is then persistently experienced as recurrent and intrusive distressing recollections or dreams of the event, with the victim acting or feeling as if the event were recurring and/or having intensive distress and physiological reactivity on exposure to cues that symbolize or resemble an aspect of the event.
The person also should show persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, including three or more of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma, (2) efforts to avoid activities, places, or people that arouse recollections of the trauma, (3) inability to recall important aspects of the event, (4) markedly diminished interest or participation in significant activities, (5) feelings of detachment or estrangement from others, (6) restricted range of affect, or (7) sense of foreshortened future.
Finally, the person should have persistent symptoms of increased arousal, including at least two of the following: (1) difficulty falling or staying asleep, (2) irritability or angry outbursts, (3) difficulty concentrating, (4) hypervigilance, or (5) exaggerated startle response.
Obviously, these symptoms have somatic expressions that may prompt patients to see their primary care physician. The victims of trauma may also have other associated somatized symptoms that are not part of the diagnostic criteria for PTSD. Other data suggest that PTSD presents more somatically in primary care settings than in mental health settings. Biological findings that have been associated with PTSD include increased basic heart rate and elevated norepinephrine and cortisol secretion. Sleep problems are common, with longer sleep latency, more awakenings, less sleep time, and lower sleep efficiency. The use of alcohol or drugs to decrease PTSD symptoms commonly leads to substance abuse problems.
Treatment
There is no single optimal treatment for PTSD at this point. A number of medications have been shown in clinical trials to be of benefit, although none have proven universally effective. The selective serotonin reuptake inhibitors are probably the drugs of choice. Carbamazepine may be useful for impulse control, often a problem for patients with PTSD. Propranolol and clonidine have been used for the "shakes" associated with PTSD. Monoamine oxidase inhibitors can help with some of the symptoms, but are difficult to manage due to their adverse effects, drug interactions, and dietary restrictions. There are multiple problems with using benzodiazepines in PTSD patients, and they should be prescribed only for very select patients for short periods. The abuse potential with benzodiazepines is particularly problematic in PTSD patients, who may seek to numb the discomfort that they are feeling.
Essentially, no drugs are truly effective at treating all of the symptoms of PTSD, and a treatment strategy that involves more than just drugs is necessary.
Patients with PTSD need skilled counseling to relive the experience with support, talk through the trauma, gain some form of understanding of what happened, and eventually the symptoms of PTSD will be resolved. This type of counseling takes special skills and interest that are not shared equally by all mental health providers. Thus, primary care physicians need to choose their referral sources for PTSD very carefully.
Summary
Grief and trauma are virtually universal experiences among primary care patients. Patients' responses commonly include symptoms that lead them to visit their primary care physicians. Physicians need to be able to identify those people with unresolved or dysfunctional grief or PTSD symptoms, provide support, treat as indicated, and refer patients to the appropriate mental health providers when necessary.
References
Turnbull JM. The grieving or traumatized patient. Programs and abstracts from the 1999 Scientific Assembly of the American Academy of Family Physicians; September 16-19, 1999; Orlando, Fla. Abstract 507.
Kushner HS. When Bad Things Happen to Good People. 2nd ed. New York, NY: Schocken Books Inc; 1991.
Frankl VE. Man's Search for Meaning. 4th ed. Boston, Mass: Beacon Press; 1992.
The following is a National Center For PTSD Fact Sheet:
Trauma, PTSD, and the Primary Care Provider
Why are Trauma and PTSD Important in Healthcare?
At least 50% of all adults and children are exposed to a psychologically traumatic event (such as a life-threatening assault or accident, human-made or natural disaster, or war). As many as 67% of trauma survivors experience lasting psychosocial impairment, including post-traumatic stress disorder (PTSD); panic, phobic, or generalized anxiety disorders; depression; or substance abuse.
Symptoms of PTSD include persistent involuntary re-experiencing of traumatic distress, emotional numbing and detachment from other people, and hyperarousal (irritability, insomnia, fearfulness, nervous agitation).
PTSD is linked to structural neurochemical changes in the central nervous system which may have a direct biological effect on health, such as vulnerability to hypertension and atherosclerotic heart disease; abnormalities in thyroid and other hormone functions; increased susceptability to infections and immunologic disorders; and problems with pain perception, pain tolerance, and chronic pain. PTSD is associated with significant behavioral health risks, including smoking, poor nutrition, conflict or violence in intimate relationships, and anger or hostility.
When trauma leads to PTSD or other posttraumatic psychosocial problems, this places great biological strain upon the body and psychological strain upon personal self-care and interpersonal relationships. Thus it is not surprising that trauma survivors, especially those with lasting PTSD symptoms, frequently report high rates of problems with physical health involving a variety of bodily systems (e.g., the cardiovascular, pulmonary, neurological, and gastrointestinal systems).
Although research on this subject is underway and not yet completed, clinical observation suggests that the symptoms of PTSD or associated psychosocial problems often interfere with healthcare, causing difficulty in provider-patient communication; reducing patients' active collaboration in evaluation and treatment; increasing the likelihood of somatization; and reducing patient adherence to medical regimens
Studies show that many patients seeking physical health care have been exposed to trauma and experience post-traumatic stress symptoms, but have not received appropriate mental health care. As with other anxiety disorders and depression, most patients with PTSD are neither detected nor offered education, counseling, or referral for mental health evaluation.
What can the Healthcare Provider Do?
Recent evidence suggests that timely brief psychological assistance can prevent or greatly reduce the severity of PTSD. This is likely to enhance the patient's capacity to benefit from medical healthcare. Your role as a healthcare clinician need not involve any additional training or workload, because specialized PTSD treatment resources are readily available.
The first step is to identify a mental health or PTSD clinician specialist who is able to provide consultation to you, and education, assessment, and counseling for patients who show signs of PTSD. There is a substantial body of published research on PTSD symptoms and treatment options, and there are expert therapists from a range of disciplinary backgrounds: psychiatry, clinical psychology, social work, and psychiatric nursing. Patients whose experience of trauma raises the risk of PTSD, or those who present with physical or psychological symptoms consonant with the disorder, should be referred to one of these experts.
The second step is to discuss with the PTSD specialist how best to identify your patients with undetected PTSD. Educational brochures on stress and trauma are available for patients to read in clinic waiting areas. A brief (1-2 minute) screening questionnaire is available for patients to complete in the waiting area, on their own or with the help of a clerical or nursing staff person. In some cases, the PTSD specialist may be able to provide on-the-spot (or same-day) brief education and counseling for patients who are experiencing acute psychological distress. Pilot clinical studies indicate that healthcare patients find these types of information, screening, and counseling helpful and not disturbing.
The third step is to set up a plan for referring to the PTSD specialist those patients who show signs of potential PTSD and are amenable to receiving additional evaluation or counseling. A few words indicating your awareness of their possible difficulties with stress, and supportively advising them that specialized services can be of great help, is almost always sufficient to motivate patients to accept this referral. You need not, and in most cases probably should not, attempt to take a detailed trauma history or to make a diagnostic assessment of PTSD -- this can be done by the PTSD clinician specialist.
PTSD clinicians are able to provide a variety of therapeutic approaches that have been demonstrated to be of benefit with PTSD, including psychodynamic psychotherapy; exposure therapy; cognitive-behavioral therapy; pharmacotherapy; group, family, couples, and inpatient treatment; and combined PTSD and alcohol/substance abuse treatment.
No particular drug has emerged as a definitive treatment for PTSD, but medication is clearly useful for symptom relief, making it possible for patients to participate in psychotherapy. Matching medication to the complex combinations of PTSD and associated symptoms -- beyond palliative care for symptoms of anxiety or depression -- should be done by a PTSD specialist.
The fourth crucial step is to maintain ongoing contact with the PTSD clinician, so that you can monitor your patient's response to mental health care. Your observations about your patient's clinical and functional status at subsequent appointments provides the PTSD specialist with a valuable source of feedback and guidance in developing effective care for PTSD. In many cases you will observe improvements in your patient's participation in healthcare and in response to your medical treatment.
THIS FACT SHEET WAS BASED ON:
"Trauma, PTSD, and Physical Health," by Paula P. Schnurr, PTSD Research Quarterly 7(3): 1-6 (Summer 1996)
"The Relationship Between Trauma, Post-Traumatic Stress Disorder, and Physical Health," by Matthew J. Friedman and Paula P. Schnurr, in Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to Post-Traumatic Stress Disorder, edited by Matthew J. Friedman, Dennis S. Charney, and Ariel Y. Deutch (Philadelphia: Lippincott-Raven, 1995), pp. 507-524
"PTSD Diagnosis and Treatment for Mental Health Clinicians," by Matthew J. Friedman, Community Mental Health Journal 32(2): 173-189 (April 1996)
"Identifying and treating VA medical care patients with undetected sequelae of psychological trauma and post-traumatic stress disorder," by Julian D. Ford, Josef I. Ruzek, and Barbara L. Niles, NCP Clinical Quarterly 6(4): 77-82 (Fall 1996)
