Post-traumatic stress disorder (PTSD) can affect a wide range of patients in family practice, regardless of culture, age, sex or socioeconomic class. Busy clinicians need to be aware of its possible diagnosis to provide compassionate and effective care to affected patients or to initiate preventive interventions to those at risk.
The overall prevalence of this disease in the U.S. population is estimated to be between 1 and 12 percent.1 In populations at risk, it ranges from 0.2 percent in postpartum women to 18 percent in professional firefighters, 34 percent in adolescent survivors of motor vehicle crashes, 48 percent in female rape victims and 67 percent in prisoners of war.2–5
The clinical course is variable. Symptoms may emerge immediately and disappear after several months, or they may take longer than six months to appear and last indefinitely. In prevalence studies, one half of those suffering from PTSD have been estimated to still meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), after one year, and up to one third still have weekly symptoms 10 years after the trauma.1,6 This article provides strategies for primary care physicians to diagnose, treat and refer patients with PTSD.
Four categories of criteria are needed to accurately diagnose PTSD (Table 1). First, a traumatic event occurred in which the person witnessed or experienced actual or threatened death or serious injury and responded with intense fear, horror or helplessness. Second, on exposure to memory cues, the person has reexperiencing symptoms, such as intrusive recollections, nightmares, flashbacks or psychologic distress. Third, the patient avoids trauma-related stimuli and feels emotionally numb. Fourth, the person has increased arousal, manifested by hypervigilance, irritability or difficulty sleeping. The symptoms persist for at least one month and significantly disturb the patient's social or occupational functioning (or both).6
Acute stress disorder (ASD), an anxiety disorder, is similar to PTSD in that it occurs after exposure to a traumatic event. Symptoms of ASD appear within four weeks of the trauma and last from two days to four weeks. As with PTSD, they include reexperiencing, avoidance and increased arousal. However, fewer symptoms are required in each category to make a diagnosis. ASD is distinguished from PTSD by having more dissociative symptoms; that is, patients describe feeling “as if in a daze” or have temporary amnesia about the trauma. ASD may progress to PTSD but is more responsive to treatment, emphasizing the need for early recognition and intervention.
Up to 80 percent of patients with PTSD have a comorbid psychologic disorder.7 Having had a psychiatric diagnosis before a trauma increases a person's risk for developing PTSD. Also, having PTSD increases the risk of later developing psychiatric problems.8 The most common diseases that occur with PTSD are major depression, dysthymia, generalized anxiety disorder, substance abuse, somatization, panic disorder, bipolar disorder, phobias and dissociative disorders.7 Any coexisting psychiatric conditions should be treated simultaneously with PTSD because the particular psychologic issues cannot be separated.
Diagnosing PTSD in an office visit can be challenging. The diagnosis is frequently missed because patients do not typically volunteer information about the traumatic event or the stereotypic PTSD symptoms. Although direct questioning is necessary, making the diagnosis requires more than checking off a list of symptoms. It often requires a nonjudgmental approach and expressions of empathy and interest. Patients differ in their perception of trauma. Gently probing for symptoms facilitates the rapport patients need to be more forthcoming about their distress.
To ensure that the diagnosis is not missed, a brief trauma history should be included in all evaluations for anxiety or depression. Traumatic events of adulthood can be asked about directly: for example, “Have you ever been physically attacked or assaulted? Have you ever been in a severe accident? Have you ever been in a war or disaster?” A positive response should alert the examiner to inquire further about the relationship between the event and the current symptoms. Traumatic childhood experiences require reassuring statements of normality to put the patient at ease: “Many people continue to think about frightening aspects of their childhood. Do you?”9
The mnemonic DREAMS can help elicit pertinent details after the trauma history has been obtained (Table 2). With each event, the examiner should determine if the patient appears emotionally Detached (called alexithymia), either from the event or in relationships with others. It may also manifest as a general numbing of emotional responsiveness. The patient Reexperiences the event in the form of nightmares, recollections or flashbacks. The Event involved substantial emotional distress, with threatened death or loss of physical integrity, and feelings of helplessness or disabling fear. The patient Avoids places, activities or people that remind the patient of the event. The symptoms have been present longer than one Month, and the patient experiences Sympathetic hyperactivity or hypervigilance, which may include insomnia, irritability and difficulty concentrating. As with all psychiatric interviews, assessing imminent danger of the patient to self or others is essential.
|Reexperiencing the event|
|Event had emotional effects|
|Month in duration|
|Sympathetic hyperactivity or hypervigilance|
The diagnosis and treatment of PTSD are complicated. The wide range of symptoms and intricate psychobiologic features make therapy difficult. The three arms of treatment are patient education, pharmacotherapy and psychotherapy. Nearly every patient can benefit from education, which is started at the time of diagnosis. Families may also welcome education about PTSD. The National Alliance for the Mentally Ill (NAMI) has excellent resources and lists of local support groups for patients with PTSD (as well as other mental illness). They can be contacted by calling 800-950-NAMI or on the Internet at http://www.NAMI.org. State affiliates of NAMI list local support groups at http://www.apollonian.com/namilocals/default.asp.
If symptoms are severe enough to prevent effective trauma-focused therapy, pharmacotherapy is warranted as a next step. Pharmacotherapy and psychotherapy have been shown to alleviate the three clusters of PTSD symptoms: reexperiencing, avoidance and hypervigilance.10
Studies have consistently shown that serotonergic dysregulation can create avoidance, hypervigilance and other associated symptoms.11 Selective serotinin reuptake inhibitors (SSRIs) have the broadest range of efficacy—being able to reduce all three clusters of PTSD symptoms.11 In addition, these agents are used to treat many diseases that often coexist with PTSD. Patients taking sertraline (Zoloft) have reduced alcohol consumption, and those taking fluvoxamine (Luvox) have had a reduction in obsessional thoughts and the elimination of insomnia.11,12
Trazodone (Desyrel) at doses of 50 to 200 mg has SSRI properties and serotonin blockade action. It reverses the SSRI-induced insomnia; augments the antidepressant effects of SSRIs; promotes sleep through its sedative properties; and suppresses rapid eye movement sleep, thus reducing the nightmares associated with PTSD.10
The effectiveness of tricyclic antidepressants in relieving symptoms of PTSD has been mixed. In several studies, their use resulted in modest lessening of the symptoms of reexperiencing and minimal or no effect on avoidance or arousal symptoms. Patients treated with tricyclic antidepressants have not shown greater improvement than those treated with SSRIs, so the newer agents have replaced the antidepressants in pharmacotherapy for PTSD.13
MONOAMINE OXIDASE INHIBITORS
Monoamine oxidase (MAO) inhibitors irreversibly inhibit monoamine oxidase, the enzyme responsible for the degradation of serotonin and related molecules. They have been used primarily as an effective antidepressant for refractory depression, but their use has been curtailed because of the dangerous side effect of hypertensive crisis in patients whose diets contain tyramine. Patients with PTSD who have received phenelzine (Nardil) have shown moderate to good improvement in reexperiencing and avoidance symptoms, but the drug has had little effect on the symptoms of hyperarousal. Insomnia ceases to be a problem in these patients, and they have a modest reduction in the frequency of nightmares.14 However, there are substantial risks with the use of these agents because patients with PTSD frequently ingest alcohol and other contraindicated or illegal substances.
Because autonomic hyperactivity may be a problem in patients with PTSD, antiadrenergic agents may be effective pharmacotherapy. Three agents in particular—clonidine (Catapres), propanolol (Inderal) and guanfacine (Tenex), have successfully reduced nightmares, hypervigilance, startle reactions and outbursts of rage. Most patients respond to treatment with clonidine, 0.2 mg three times a day, titrated from 0.1 mg at bedtime. Patients' blood pressures should be checked periodically when this agent is used for long-term therapy.9
Historically, benzodiazepines were the primary agent in PTSD treatment. Alprazolam (Xanax) and clonazepam (Klonopin) have been used extensively, but the efficacy of benzodiazepines against the major PTSD symptoms has not been proven in controlled studies.10 These agents are effective against anxiety, insomnia and irritability, but they should be used with great caution because of the high frequency of comorbid substance dependence in patients with PTSD. Patients should be fully informed of the risks and benefits of these medications, including the risks of dependency and of withdrawal after abrupt discontinuation.
Medications are used to relieve the most distressing symptoms, allowing the patient to concentrate on psychotherapy.10 Any medication regimen should be part of a psychotherapeutic process. Attention to a range of issues, including the effects on the family, education about the disease and treatment options, is paramount.
The goal of therapy is to break the pattern of self-defeat by reexamining the traumatic event and the patient's response to it. Education about the disease and recognition of cues or situations that trigger symptoms are invaluable. Improving the patient's coping mechanisms, such as relaxation techniques, can also foster the patient's relationships with others.
PTSD can have devastating effects on the family, and family therapy may be warranted. Cognitive-behavioral therapy, group therapy and stress-inoculation training (systematic desensitization) are helpful against reexperiencing and avoidance symptoms. Substance abuse programs, if needed, are vital before a patient engages in therapy.
Formal psychotherapy is difficult in a brief office visit. Because psychotherapy is frequently required to resolve PTSD, referral to a mental health professional should be considered if symptoms are not quickly relieved with medication.
A prudent approach tailors each treatment plan to the needs of the patient. A good first-line treatment plan is thorough education about the disorder and enrollment of the patient into a local PTSD group. If the physician has time constraints or other difficulties providing supportive therapy, referral to a mental health professional should be considered. Any substance abuse issues should be addressed as an adjunct to therapy. Some PTSD symptoms are difficult for patients to tolerate, and rapid pharmacologic treatment may be helpful. More than one class of medications may be needed to control the diverse symptoms.
SSRIs are efficacious against the broadest range of symptoms, and the number of agents available helps to target patients' symptoms. Although a therapeutic response is usually evident in two to four weeks, any SSRI should be given a minimum of six to eight weeks at therapeutic dosages before it is declared a treatment failure.10
If insomnia continues to be a predominant complaint, trazodone augmentation is a useful and safe alternative to hypnotic agents. Persistent insomnia accompanied by significant hyperarousal and reexperiencing symptoms should be treated with clonidine. The major symptoms of PTSD can be alleviated with the combination of an SSRI, trazodone and clonidine.10 If symptoms persist despite these initial interventions, psychiatric consultation should be obtained before sedative or hypnotic agents are given.
The primary prevention of PTSD is vital and should include support and advocacy of community and national efforts to prevent violence and curb its sequelae. Gun control and educational efforts to prevent rape, child abuse and domestic violence are primary preventive strategies that may reduce the incidence of PTSD.
Although secondary prevention has not been well studied, one technique, Foa's brief prevention program, has shown promise in reducing PTSD when started within 14 days of the trauma.15 Victims are educated about common responses to assault and taught breathing and muscle relaxation techniques. They are asked to confront their fear by reliving the assault, and their irrational beliefs about the trauma are challenged. Two months after the treatment, PTSD symptom severity in a treated group was one half that in a group whose symptoms were not treated. Ten percent of the treated subjects met criteria for PTSD, whereas 70 percent of untreated subjects still met the diagnostic criteria, demonstrating that early interventions substantially reduce the morbidity of PTSD.15
Debriefing on the stress of the critical incident is a prevention method being used with more frequency for groups such as military personnel and victims of natural disasters. A group of participants discusses the key elements of a traumatic incident soon after it is over, verbalizing their emotions and examining their reactions to the witnessed events. Although long-term studies have not proven the efficacy of these stress debriefings in preventing PTSD, in the short term they have decreased anxiety and enhanced feelings of empowerment.16
Family physicians are likely already caring for patients with PTSD. There are simple strategies to screen and manage those at risk for the disorder. Interventions should be undertaken as soon after the traumatic event as possible with empathic communication and confrontation of irrational beliefs, as needed. The DREAMS mnemonic can help make the diagnosis when it is being considered. Because of the wide range of populations at risk and the many possible approaches to therapy, no one therapeutic approach has been proven the most effective for those who suffer from PTSD. Therefore, prevention and treatment must be tailored to the patient and the available community resources. Although primary care physicians can adequately care for these patients, a multidisciplinary approach will enhance their efforts.