Post-Traumatic Stress Disorder: Diagnosis and Treatment

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Post-Traumatic Stress Disorder Diagnosis and
Treatment a Public Health approach

• Physicians for Global Survival
• Facing off for Justice Conference
• 26 March 2011
• Ottawa, Ontario
• Canada
• D. C. Lougheed MD and Dale Dewar MD

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PTSD Diagnosis, Treatment and Prevention

• History of PTSD
• Case Presentation
• Diagnosis
• Military Context
• Civilian Context
• Making the Diagnosis
• Resources
• Challenges to Family Doctors
• Prevention
• Thanks to Dr Colin Cameron and Dr Chantal Whelan,
  Ottawa, ON.

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Criterion A Stressor

• The person has been exposed to a traumatic event
  in which both of the following have been present
• The person has experienced, witnessed, or been
  confronted with an event or events that involve
  actual or threatened death or serious injury, or
  a threat to the physical integrity of oneself or
  others.
• The person's response involved intense fear,
  helplessness, or horror.

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Criterion B Intrusive Recollection

• The traumatic event is persistently
  re-experienced in at least one of the following
  ways
• Recurrent and intrusive distressing recollections
  of the event, including images, thoughts, or
  perceptions.
• Recurrent distressing dreams of the event.
• Acting or feeling as if the traumatic event were
  recurring (includes a sense of reliving the
  experience, illusions, hallucinations, and
  dissociative flashback episodes, including those
  that occur upon awakening or when intoxicated).
• Intense psychological distress at exposure to
  internal or external cues that symbolize or
  resemble an aspect of the traumatic event.
• Physiologic reactivity upon exposure to internal
  or external cues that symbolize or resemble an
  aspect of the traumatic event

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DSM IV Post Traumatic Stress Disorder
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Criterion C Avoidance/numbing

• Persistent avoidance of stimuli associated with
  the trauma and numbing of general responsiveness
  (not present before the trauma), as indicated by
  at least three of the following
• Efforts to avoid thoughts, feelings, or
  conversations associated with the trauma
• Efforts to avoid activities, places, or people
  that arouse recollections of the trauma
• Inability to recall an important aspect of the
  trauma
• Markedly diminished interest or participation in
  significant activities
• Feeling of detachment or estrangement from others
  
• Restricted range of affect (e.g., unable to have
  loving feelings)
• Sense of foreshortened future (e.g., does not
  expect to have a career, marriage, children, or a
  normal life span)

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Impact of Events scale
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Criterion D Hyper arousal

• Persistent symptoms of increasing arousal (not
  present before the trauma), indicated by at least
  two of the following
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hyper-vigilance

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Criterion E DurationCriterion F Functional
Significance

• Criterion E duration
• Duration of the disturbance (symptoms in B, C,
  and D) is more than one month.
• Criterion F functional significance
• The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• Specify if
• Acute if duration of symptoms is less than three
  months
• Chronic if duration of symptoms is three months
  or more
• Specify if
• With or Without delay onset Onset of symptoms at
  least six months after the stressor

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PTSD

• What can physicians do?
• Public Health Approach
• Primary prevention prevent the illness eg
  vaccination polio
• Secondary prevention diagnose and treat with
  the goal of full recovery and prevention of
  serious complications eg strep throat
• Tertiary prevention treat with the goal of
  reducing the burden of chronic illness or
  disability eg osteoarthritis
• What are the implications for prevention of the
  disease called PTSD?

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PTSD Military Populations

• Diagnostic issues
• Stigma
• Acute stress
• Concurrent disorders substance, mood, other
• Public Health model
• Innocculation basic training, training in
  hostage situations
• Acute proximity, immediacy, expectation of
  return to function
• Military resources for treatment
• Debriefing
• OSI clinics Ottawa (ROH), Halifax, others
• Vets groups self referral

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PTSD Special Civilian Populations

• Immigrant and Refugee Populations
• Cross-cultural issues
• Is it depression, schizophrenia, bipolar illness,
  substance abuse, dementia
• Physical symptoms
• Stigma,
• Cultural explanations of illness
• Challenges for interpretors
• Chronic and severe mental illness
• Dramatic symptoms of psychosis that are difficult
  to treat
• May end up on ACT teams or with MH case managers
• High doses of neuroleptic medications with mood
  symptoms not treated
• Shelter clients refugees, borderline
  intellectual abilities, language issues, cultural
  experience of illness
• Consider differential diagnosis including mood
  disorders

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PTSD - Conclusions

• When the response to treatment is poor, check for
  history of trauma
• Consider the diagnosis of PTSD in unusual
  presentations of psychosis, especially in refugee
  populations
• Consider the use of a cultural interpreter.
• Use a rehabilitation (recovery) model of
  treatment
• 1. assess state of change-readiness
• 2. Help the patient set goals and review personal
  strengths
• 3. Emphasise gradual improvement if chronic,
  rapid return to functioning if acute
• 4. Importance of return to meaningful social
  roles

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With thanks to Grandchildren of Marvin N.
Lougheed MD FRCPC