Transcript What are the diagnostic criteria for PTSD?

Post-Traumatic
Stress Disorder (PTSD)
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DFAPA
November 29, 2011
Why is this important?
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Terrible things happen.
People cope with these things in
different ways.
When exposed to trauma, some
people1,2 will develop
Posttraumatic Stress Disorder, a
potentially disabling affliction
involving feelings of helplessness,
fear and dread that result in
avoidance and isolation.
The lifetime prevalence in the
general population is 1 to 3percent.
It can occur at any age, but it is
more common in adults.
Full recovery is the rule for acute
PTSD, but chronic PTSD is much
more difficult to treat.
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After mastering the information in
this presentation, you will be able
to
– Describe how patients with Panic
Disorder often present,
– Detail the diagnostic criteria,
– Describe some of the associated
features,
– List some differential diagnoses,
– Write a preliminary treatment
plan, and
– Identify some of the frequent
treatment challenges.
People vary greatly in their reactions to trauma. A woman struck while sleeping in a car developed full-blown PTSD.
mother lost two sons to drunk drivers and moved on.
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How might a patient with PTSD
present?
• This is a truck driver with a 21year history of accident-free
driving.
• “Four years ago I was involved
in an accident.”
• “The other truck driver was
trapped and burned to death”
• “I tried to get him out but I
couldn’t.”
• “I started having nightmares
right away.”
• “I was afraid to go to sleep and
I didn’t want to talk about what
happened.”
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• “My family says I have been
irritable and detached ever
since.”
• “When I was released to return
to work, I couldn’t bring myself
to drive again.”
• “I tried counseling but it didn’t
help.”
• “I took medication but it just
made my sleepy.”
• “I mostly just stay at home.”
• “I don’t drive and I don’t get
into a car if I can’t help it.”
• “It still upsets me to watch
accidents on TV.”
• “This has ruined my life.”1,2
of these patients become negative, bitter and difficult. Know when to say “no” to difficult patients.
A patient threatened to sue me, but I helped his lawyer with a crazy neighbor.
Slide 1 of 2
What are the diagnostic criteria for
PTSD?
• The person has been exposed
to a traumatic event in which
both of the following were
present:
• The traumatic event is
persistently re-experienced in
one (or more) of the following
ways:
– The person experienced,
witnessed or was confronted
with an event that involved
actual or threatened death,
serious injury or loss of
physical integrity of self or
others
– The person’s response
involved intense fear,
helplessness1,2,3 or horror.
– Recurrent and inclusive
recollections
– Recurrent distressing dreams
– Acting or feeling as if the
traumatic event were
reoccurring
– Intense psychological distress
at exposure to internal or
external cues
– Physiological reactivity to
exposure to cues
Pay careful attention when any complainer insists that the problem is always someone’s else’s fault.
A physician was sure that I was refusing to let people work with him in surgery.
3 Understand the concept of “locus of control.”
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Slide 2 of 2
What are the diagnostic criteria for PTSD?
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Persistent avoidance of stimuli
associated with the trauma and
numbing of general responsiveness
as indicated by three or more of
the following:
– Efforts to avoid thoughts, feelings
or conversations about the trauma
– Efforts to avoid activities, places or
people that trigger recollections of
the trauma
– Markedly diminished interest or
participation in significant
activities
– Feeling of detachment or
estrangement from others
– Restricted range of affect
– Sense of foreshortened future
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Persistent symptoms of increased
arousal (since the trauma) as
indicated by two (or more)
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Duration of more than one
month1,2,3
Clinically significant distress or
impairment
You can listen to a patient’s story
here.
Acute=duration < one month
Chronic=duration> three months
3 With Delayed Onset=symptoms begin > six months after the trauma
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
What associated features might you
see?
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“Survival guilt” is not uncommon.
Avoidance behaviors may trigger work problems, marital problems or other
interpersonal problems.
Auditory hallucinations and paranoia can be present.
The following constellation of symptoms is more common following child
physical or sexual abuse or domestic battering:
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Impaired affect modulation1
Self-destructive and impulsive behavior
Dissociative symptoms
Somatic complaints
Feelings of ineffectiveness, shame, despair or hopelessness
And so on
PTSD is associated with increased rates of psychiatric comorbid conditions.
Increased autonomic functioning may be found.2,3
Physical injuries may be present.
“Splitting” normally occurs in early childhood, but persists in Borderline Personality Disorder.
I was amazed at the level of arousal during the prison riot.
3 The calm medical student I left behind diagnosed a heart attack clinically.
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What other diagnoses might you include in
the differential diagnosis?
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Normal anxiety
– Discomfort following a stressor that is not extreme (spouse
leaving, being fired)
– Adjustment disorder (not coded as a mental disorder but
sufferers make seek treatment)
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Other anxiety disorders
– Comorbid and preexisting disorders should be considered.
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Anxiety secondary to a general medical condition
– Comorbid and preexisting disorders should be considered.
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Substance-induced anxiety
– Substance abuse often complicates the picture.1
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Anxiety secondary to other psychiatric disorders
– Any of them might be present.
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I once treated a man who engaged in “burn parties” with his friends. He even burned his penis.
What might a typical treatment plan look
like?
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Acute anxiety
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Real or fantasy graduated exposure in
safe environment may be helpful.
(It may also be overwhelming.)
Antidepressant medications should be
considered.
Prescribe benzodiazepines routinely
with great caution.
Beta-blockers may be helpful with
tremor.
Unstructured psychotherapy is only
temporarily helpful.
Generalized anxiety
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Other comorbid disorders
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Diagnose and treat these conditions
vigorously.
Maladaptive attitudes and behaviors
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Chronic anxiety
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Provide reassurance.
Provide support.
Avoid sedation.
Discourage adoption of the patient role.
Arrange for graduated reexposure.1
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Consider cognitive behavioral
psychotherapy (CBT)
Set and pursue incremental, realistic
goals.2
Education and self help
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Provide educational resources.
Recommend a daily exercise regimen.
Recommend a healthy diet.
Suggest healthy distractions.3
Recommend meditation.
Recommend online resources with
caution.
Recommend self help groups with
caution.
Consider buspirone 15 mg twice per
day.
Graduated exposure to traumatic environment can be very helpful.
Your patients’—and your own—lack of motivation will drive you nuts. Remember whose life it is, anyway.
3 It does not help to shame, preach or nag. I relearned that with my sons.
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What are some of the treatment
challenges you can expect?
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These patients are often sullen, resistant and noncompliant.
They are often suspicious and unable to build and sustain a
therapeutic relationship.
The trauma may become the organizing principle of their
lives.1
They often complain that the medicine the physician has
prescribed is ineffective, but they are unwilling to taper it.2
They are often miserable and they make those around them
miserable.
Persuading them to adopt healthy distractions is one of the
most helpful strategies.
These people tolerate confrontation very poorly.3
Mothers who have lost children may become bitter, lifelong activists who are more annoying than effective.
Taking the same approach you take with chronic pain patients is sometimes helpful.
3 A patient once told me that my role was to listen and accept, never to challenge or confront.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Justin Greenlee, DO
OUCOM 2004
Jeffrey Hill, DO
OUCOM 1987
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