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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1 E-Resource March, 2014 POST-TRAUMATIC STRESS DISORDER PTSD Diagnostic Criteria PTSD Detection and Diagnosis PC-PTSD Screen PCL-C Screen PTSD Treatment Treatment Algorithm 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 t 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 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. 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 or visit for more information and to access a free virtual consultation for your patient.

2 This tool is in the public domain and can be freely duplicated.

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5 Simplified Algorithm for the Detection and Treatment of PTSD Patient experiences a traumatic event Brief assessment based on behavior and appearance Side te: 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 Is patient unstable, suicidal or homicidal? Assess for future environmental harms and ensure basic needs are met. Ensure safety and refer to emergency services (Use police if needed). Begin monotherapy with SSRI or SNRI (avoid first line use of benzodiazepines) and begin referral for counseling/ psychotherapy. (May benefit from consultation with psychiatrist.) Obtain history, physical exam, assess risk factors, and functional level. Follow 4-8 weeks to reassess symptoms and monitor progress. (Can use PCL-C to monitor progress) Does patient meet criteria for Diagnosis of PTSD Is patient progressing? Re-screen in 3-6 months. Provide secondary prevention education and support. Increase dosage or switch to another medication. Consider adjunctive treatment Refer to specialty or consider Virtual consultation. Continue course of treatment and consider stepping down pharmacologic treatments and increasing care management

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