Posttraumatic stress disorder: Often missed in primary care

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Behavioral Health

Posttraumatic stress disorder: Often missed in primary care

J Fam Pract. 2017 October;66(10):618-623

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References

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2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.

3. Gradus JL. Epidemiology of PTSD. National Center for PTSD. Available at: http://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp. Updated 2017. Accessed August 16, 2017.

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6. Spoont MR, Williams JW Jr, Kehle-Forbes S, et al. Does this patient have posttraumatic stress disorder? Rational clinical examination systematic review. JAMA. 2015;314:501-510.

7. Woidneck MR, Morrison KL, Twohig MP. Acceptance and commitment therapy for the treatment of posttraumatic stress among adolescents. Behav Modif. 2014;38:451-476.

8. National Collaborating Centre for Mental Health (UK). Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. Available at: https://www.ncbi.nlm.nih.gov/books/NBK56494. Accessed August 16, 2017.

9. Greene T, Neria Y, Gross R. Prevalence, detection and correlates of PTSD in the primary care setting: a systematic review. J Clin Psychol Med Settings. 2016;23:160-180.

10. Gavranidou M, Rosner R. The weaker sex? Gender and post-traumatic stress disorder. Depress Anxiety. 2003;17:130-139.

11. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol. 2000;68:748-766.

12. SAMHSA’s Trauma and Justice Strategic Initiative. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Available at: http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf. Accessed September 13, 2017.

13. Mulick PS, Landes SJ, Kanter JW. Contextual behavior therapies in the treatment of PTSD: a review. Int J Behav Consult Ther. 2005;1:223-238.

14. Possemato K. The current state of intervention research for posttraumatic stress disorder within the primary care setting. J Clin Psychol Med Settings. 2011;18:268-280.

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17. United States Census Bureau. Facts for features: Veteran’s day 2016: Nov. 11. Available at: https://www.census.gov/newsroom/facts-for-features/2016/cb16-ff21.html. Accessed August 16, 2017.

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21. U.S. Department of Veterans Affairs. Life events checklist for DSM-5 (LEC-5). Available at: http://www.ptsd.va.gov/professional/assessment/te-measures/life_events_checklist.asp. Accessed September 13, 2017.

22. U.S. Department of Veterans Affairs. Primary care PTSD screen for DSM-5 (PC-PTSD). Available at: http://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp. Accessed September 13, 2017.

23. Spoont M, Arbisi P, Fu S, et al. Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review. Available at: https://www.ncbi.nlm.nih.gov/books/NBK126691/. Accessed Sept 13, 2017

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CASE

The physician screened Mr. W for trauma exposure as part of the differential. Mr. W revealed that he had blacked out at the bar, despite drinking only moderately, and that he awoke with anal pain. He believed he had been drugged and sexually assaulted. Further screening for PTSD symptoms related to this event confirmed multiple associated symptoms. He acknowledged that his epigastric pain had started soon after the trauma and, after further discussion, began to link his stomach pain and other new symptoms revealed by the PTSD screen (hypervigilance, avoidance, change in mood) to the trauma.

As happened in this case, most PTSD patients present with somatic complaints rather than reporting a traumatic experience and having associated effects. This in turn usually leads clinicians to consider only non-PTSD diagnoses.^6,9,15 Core avoidance symptoms are a major reason for such a presentation in PTSD patients.¹⁴ Patients avoid thoughts, feelings, and conversations that remind them of the trauma.¹³ As a result, they are less likely to voluntarily report trauma. They avoid thinking about how their current symptoms may be associated with their trauma and are reluctant to talk about their trauma with clinicians.^5,9,8,12

Another barrier to diagnosis is a belief that PTSD is primarily experienced by combat veterans¹ (TABLE 2^{2,4-6,8,9,12,14-18}). While PTSD is detected more often among veterans due to regular screening through the Department of Veterans Affairs,¹⁴ the vast majority of PTSD cases are related to civilian traumas such as sexual assault, child abuse, and car accidents.^5,9 In fact, the estimated 9% prevalence¹⁶ of PTSD among the 18.8 million US veterans¹⁷ (1.7 million veterans with PTSD) accounts for less than 10% of the total lifetime prevalence² of PTSD in the US population (27.9 million people with PTSD).¹⁸ 

SCREENING: WHAT TO LOOK FOR

Since individuals with PTSD mainly seek treatment for associated physical symptoms,¹⁴ primary care is particularly important for identification of PTSD and treatment access. The US Preventative Services Task Force does not yet have any recommendations for screening for PTSD. The American Psychiatric Association recommends that a trauma history be included in all initial psychiatric evaluations of adults.¹⁹ Screens can target high-risk populations and can be repeated across the lifespan,⁹ as traumas can occur at any age and symptoms may not emerge until years after the trauma.^2,4 Factors in a patient’s history associated with high risk of PTSD include the following:

known trauma exposure (eg, treatment at the emergency department following motor vehicle collision, natural disaster, assault),⁶
frequent medical visits or unexplained physical symptoms,^5,8
family members who are trauma victims,⁸
involvement in juvenile justice system,^4,12
sensitive or invasive exams (eg, pelvic exams) that trigger symptoms or contribute to retraumatization,^12,20 and
any medical condition (eg, hypertension, chronic pain, sleep disorder), self-destructive behavior (eg, drug or alcohol abuse, low impulse control), or social/occupational issues (eg, unemployment, social isolation, fighting) with a known link to PTSD.^2,4,6,8

The first step in screening. Given a patient’s reported symptoms, assess for trauma exposure to determine whether PTSD should be included in the differential diagnosis. Overlooking PTSD as a possible source of symptoms can result in misattributing them to other causes.^4,8 Listing common traumas, or using a standardized list such as the Life Events Checklist, can help identify patients with trauma exposure.^8,21 However, do not make the patient provide details of the traumatic event(s), as that can exacerbate symptoms if PTSD is present.⁶ It is sufficient to know the category of the trauma (eg, sexual assault) without making the patient describe who was involved and what happened.⁶

The second step in screening. If a patient reveals trauma exposure, consider using an instrument such as the Primary Care PTSD Screen (PC-PTSD) or the PTSD Checklist, both available online, to screen for PTSD symptoms related to the identified trauma.^6,9,21-23 Since these measures screen for symptoms but do not ask about trauma exposure, false positives can occur if a trauma is not first identified (such as through the Life Events Checklist) due to symptom overlap with other conditions (TABLE 1^2,8,13).²¹

Treatment is effective, even decades after a traumatic event

Provide anyone who has been traumatized with information about common after effects, symptoms of PTSD, and available treatments.⁸ Keep in mind that initial symptom severity after trauma exposure does not correlate with long-term symptoms,⁸ and about half of adults will recover without treatment within 3 months.^1,2,5 The first month of symptoms may be addressed with patient education and watchful waiting. But if symptoms don’t subside after a month, consider offering treatment¹ with the understanding that, for some individuals, symptoms may yet resolve on their own.

Detecting and treating PTSD early can decrease its deleterious effects on health and cut down on years of functional impairment.¹ Even decades after an initial traumatic event, PTSD treatments can be effective.⁸ Children may experience functional impairment without meeting full criteria for PTSD, and can also benefit from treatment.⁷