Posttraumatic Stress Disorder (PTSD)
COURSE PRICE: $24.00
CONTACT HOURS: 3
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Provider approved by the California Board of Registered Nursing, Provider #12300.
Course Availability: Expires September 6, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Medical Disclaimer Legal Disclaimer Disclosures
NURSES IN WEST VIRGINIA: Take the WV version of this course.
Posttraumatic Stress Disorder (PTSD)
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to enable healthcare professionals to define posttraumatic stress disorder, understand its impact, and be prepared to intervene appropriately in assessment, diagnosis, treatment, and prevention of the disorder.
Upon completion of this course, you will be able to:
- Define posttraumatic stress disorder (PTSD).
- Summarize the prevalence of the disorder in the United States.
- Explain the etiology of PTSD.
- Identify risk factors for developing PTSD.
- Identify the symptoms of and diagnostic criteria for PTSD.
- Discuss medical and nursing procedures to screen patients when PTSD is suspected.
- Describe current PTSD treatment modalities.
- Recognize the principle outcome goals for patients and support persons dealing with PTSD.
- Discuss current PTSD prevention strategies.
TABLE OF CONTENTS
The Encyclopedia of Mental Disorders (EMD, 2014) defines posttraumatic stress disorder (PTSD) as “a complex disorder in which a person’s memory, emotional responses, intellectual processes, and nervous system have been disrupted by one or more traumatic experiences.” PTSD is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a “trauma and stressor-related disorder” and is the only psychiatric diagnosis (along with acute stress disorder) that depends on a factor outside the person—namely, a traumatic stressor that is outside the range of usual experience (APA, 2013a). The traumatic stressor often involves threats of death, traumatic death of another, or serious injury to self and others, causing feelings of intense fear, extraordinary helplessness or powerlessness, or horror (Black & Andreasen, 2011).
AN ANCIENT MALADY
History is replete with accounts of individuals who have experienced or witnessed terrifying events; felt intense fear, helplessness, and horror; and suffered ongoing emotional distress.
- One of the oldest records of such psychological torment was found in Egypt, circa 1900 B.C.E., where a physician described a peculiar response to earlier trauma (Veith, 1965).
- In 1606 A.D., Shakespeare portrayed the gruesome dreams, mental anguish, and hallucinations of Macbeth and his wife after the bloody murder of Duncan, King of Scotland.
- In 1864, John Erichsen published a medical study of people who had survived railway crashes and thereafter developed “railway spine,” an ongoing fear of speeding trains (Trimble, 1981).
- Following the Civil War (1861–1865), veterans who had developed emotional distress were diagnosed as having “soldier’s heart” (Lamprecht & Sack, 2002).
- In 1901, a physician described a man who survived an industrial explosion and thereafter suffered “traumatic reminiscences” (Lamprecht & Sack, 2002).
- After World War I (1914–1918), veterans with ongoing emotional distress were said to suffer “shell shock”; following World War II (1939–1945), such distress was described as “battle” or “combat” fatigue (Jones, 2005).
- In 1956, Hans Selye wrote The Stress of Life, in which he described how stressors such as extreme fear disrupt the normal balance of life in a process he called the general adaptation syndrome (GAS).
- Between 1959 and 1973, in the jungles of Vietnam, Laos, and Cambodia, U.S. soldiers fought a terrifying guerilla war in which 58,200 died and thousands suffered injuries. Ongoing psychological distress was common, but veterans had difficulty obtaining disability benefits because there was no accepted psychiatric diagnosis for such emotional and behavioral anguish (Jones, 2005).
- In 1980, in the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the American Psychiatric Association (APA) classified posttraumatic stress disorder (PTSD) as one of several anxiety disorders. In 2013 DSM-5 reclassified PTSD as a trauma and stressor-related disorder.
- In 1989, because of a recognized need, the National Center for Posttraumatic Stress Disorder was established within the U.S. Department of Veterans Affairs. Its mission was and is “to advance the clinical care and social welfare of America’s Veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders” (National Center for PTSD, 2011a).
- Beginning in 2001 in Afghanistan and 2003 in Iraq, military action brought increased evidence of the long-term effects of urban warfare and of other terrifying events upon the human psyche. As a result, posttraumatic stress disorder has become the focus of intensive scientific study.
In the United States, about 60% of men and 50% of women experience at least one trauma in their lives. Women are more likely to experience sexual assault and child sexual abuse, and men are more likely to experience accidents, physical assault, combat, disaster, or to witness death or injury. A small percentage of those persons experiencing trauma go on to develop PTSD (ADAA, 2014).
- In the United States, about 7 or 8 of every 100 people will have PTSD at some point in their lives.
- About 5.2 million adults will experience PTSD during any given year.
- Women are twice as likely to be diagnosed with PTSD as men.
- Currently 7.7 million Americans age 18 and older suffer from this disorder.
- Those exposed to mass violence as opposed to natural disasters or other types of traumatic events have been shown to develop PTSD at a higher rate.
- People who have experienced previous traumatic events run a higher risk of developing PTSD when confronted with another traumatic event.
PTSD and Military Personnel
The U.S. Army Office of the Surgeon General reports that among those who had been deployed to Iraq or Afghanistan, 12,632 suffered from PTSD in 2013. This includes 2,988 who had been diagnosed prior to deployment and whose PTSD is believed to have resulted from an event that occurred prior to deployment (Fischer, 2014). Twenty percent of female veterans have been diagnosed with PTSD (Lee, 2013).
PTSD and Suicide
Suicide risk is higher in trauma survivors, and studies show that suicide risk is also higher in persons with PTSD (NCPTSD, 2014b). Among people who have had a diagnosis of PTSD at some point in their lifetime, approximately 27% have also attempted suicide (Tull, 2014a). Veterans make up 7% of the American population but account for 20% of its suicides. In 2012, more U.S. military personnel died by their own hands than in battle. Suicide was the number one cause of death among U.S. troops that year (Lee, 2013).
PTSD in Children and Adolescents
Studies show that about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma. Of those children and teens who have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Studies also indicate that children may have a higher prevalence of PTSD than adults in the general population.
There are three risk factors that are known to raise the risk of PTSD development in children and adolescents: how severe the trauma is, how the parents react to the trauma, and how close or far away the child is from the trauma. The more severe a trauma and the more traumas a child experiences, the higher the risk for PTSD (NCPTSD, 2014c).
Posttraumatic stress disorder occurs only following exposure to a terrifying, stressful, or frightening event or after prolonged traumatic experience. Types of events that can lead to the development of PTSD include:
- Physical assault by a stranger. Violent acts such as beatings, stabbings, and attempted strangulation by a person who is not well known to the victim.
- Rape and sexual assault. Nonconsensual oral, anal, or vaginal sexual penetration of the victim, made possible with threats, physical force, or incapacitating drugs. Sexual assault usually refers to any forced sexual contact short of rape.
- Military combat. A wide range of violent and traumatic experiences that cause injury or death.
- Torture. Beatings, sleep deprivation, electric shock, burning, near strangulation, drowning, crushing, breaking bones, being forced to engage in humiliating acts, sensory deprivation, and threat of death or mutilation.
- Mass violence. Acts of war, terrorism, shootings, and other events where there are multiple fatalities and/or injuries; caused by humans with the intention of killing or harming others.
- Natural disasters. Environmental events that adversely affect a significant number of people, including earthquakes, floods, hurricanes, tornados, and tsunamis. Fearing for one’s life or witnessing the injury or death of others is the traumatizing aspect of these events.
- Transportation or workplace disasters. Tragedies such as train derailments, airline crashes, shipwrecks, and auto accidents with multiple victims, high fatality rates, serious injuries, and long delays before rescue.
- Explosions and fires. May be caused by gas explosions, regional firestorms, and careless use of candles, cigarettes, and matches. Fires are especially traumatic because they often cause serious injuries requiring reconstructive surgeries, long recovery periods, and ongoing pain and suffering.
- Life-threatening epidemics and radiation. Widespread infectious diseases and radiation when the diagnosis and treatment are accompanied by ongoing fear, further injury, threat of imminent death, and possibility of a prolonged recovery time.
It is now recognized that repeated traumas or traumas of long duration may also produce symptoms of PTSD in survivors (EMD, 2014). Examples of this include:
- Child abuse. Includes physical, sexual, and psychological violence, ranging from severe spankings to life-threatening beatings, fondling/rape, neglect, and abandonment.
- Domestic violence. The physical or sexual assault by one adult upon another in an intimate, sexual, and often cohabitating relationship.
- Stalking and cyberstalking. Unwanted or obsessive attention by an individual or group toward another person that directly or indirectly communicates a threat or places the victim in fear.
- Being kidnapped or held hostage. Being held for hours, days, or even years and physically restrained, assaulted, and deprived of water and food; immediate threat of injury and death and helplessness to defend oneself.
- Cult membership. Effects similar to those of domestic abuse; being dominated and controlled by cult leaders through psychological, physical, or sexual abuse.
Although PTSD is always triggered by an external event, it may have roots in one’s biology as much as experience. Studies have shown there are biochemical, physiologic, and sociocultural causes as well as occupational factors and personal variables involved in the development of PTSD.
Physiology and Biology
It is not known why traumatic events cause PTSD in some people but not in others. It is known, however, that in persons with PTSD, the body continues to release stress hormones and chemicals beyond the time they typically return to normal levels (ADAM Medical Encyclopedia, 2013).
Through the use of brain imaging studies, scientists are learning about how the brain and mind function in relation to PTSD. For example, evidence shows that some persons with PTSD have a loss of volume in the brain’s hippocampus that may account for the memory deficits and other symptoms of PTSD. Evidence also indicates that the amygdala, which is involved in humans’ response to fear, is hyperactive in some people with PTSD, which can produce “false alarms” (Cohen, 2014a). Other changes in brain structure found in persons with PTSD occur in the anterior cingulated cortex, which is involved in attention, motivation, and modulation of emotions.
Neurochemicals may be involved in the development of PTSD. The hypothalamic-pituitary-adrenal (HPA) axis—which is involved in the normal stress reaction—is disrupted in persons with PTSD, again producing “false alarms.” Some researchers suggest that this disrupted HPA system harms the hippocampus in persons with PTSD (NHS, 2013).
A connection has also been found between PTSD and cannabinoid (CB1) receptors in the brain. Research shows that psychoactive chemicals such as cannabis and other naturally produced cannabinoid neurotransmitters can impair memory and reduce anxiety when they activate CB1 receptors in the brain. Persons with PTSD have been found to have lower concentrations of the neurotransmitter anandamide (the brain’s endogenous cannabinoid) than people without PTSD. This connection may be related to the greater relief of PTSD symptoms in those who use marijuana (a cannabinoid) versus other psychopharmacologic substances (Neumeister et al., 2013).
Other studies have shown that mice that did not make the protein stathmin, which is necessary to form memories, are less likely to “freeze” in response to danger and less likely to show innate fear than normal mice (Cao et al., 2013). Another study with mice showed that GRP (gastrin-releasing peptide) released during emotional events seems to control the fear response. Lack of this peptide may lead to formation of greater and more lasting memories of fear (Roesler & Schwartsmann, 2012).
Other researchers have found a genetic basis for the control of levels of serotonin related to mood that appears to fuel the fear response (Murrough et al., 2011).
Researchers believe that it may be possible in the future to predict the development of PTSD based on early psychological and neurochemical changes in persons exposed to a traumatic event (NHS, 2013).
Numerous causes beyond the precipitating trauma can increase the risk for development of PTSD.
Pretraumatic Risk Factors
- An earlier life-threatening event or trauma such as child abuse
- Childhood emotional problems before age 6 years
- Having another mental health problem
- Having a family member with mental health problems
- Recent loss of a loved one, especially if not expected
- Recent stressful life changes
- Choice of occupation (firefighter, police, EMS, military)
- Heavy use of alcohol
- Being female
- Being poorly educated
- Lower intelligence
- Lower socioeconomic status
- Minority racial/ethnic status
Peritraumatic Risk Factors
- Greater the severity of the trauma, greater the risk for PTSD
- Greater perceived threat to life
- Feeling helpless
- Uncontrollability of the event
Posttraumatic Risk Factors
- Little or no support from family and friends
- Life stressors following trauma
- Being male
- Younger age
- Heavy use of alcohol
(NCPTSD, 2014d; APA, 2013)
PTSD AND RISK BY GENDER
Differences in risk factors between males and females are being studied to determine why women have a higher pretraumatic risk and men a have higher posttraumatic risk for developing PTSD. Studies thus far show that:
- Are more prone to depression, which is known to increase risk
- Are socialized to feel responsible for being a victim
- Have a higher prevalence of sexual abuse and greater fear of sexual trauma
- Produce oxytocin, which buffers “fight or flight,” has a calming effect, and leads to “tending and befriending” behaviors in times of stress
- Are more willing than men to seek help after a traumatic event
- Produce oxytocin, but testosterone release in response to stress reduces its effects
- Respond to traumatic events with fight (aggression) and flight (social withdrawal, substance abuse)
- Experience stigma due to stereotypes that impact help-seeking early in the course of illness
People respond to trauma in remarkably different ways. When a group of unrelated individuals is exposed to the same traumatic event, one person may develop a full-blown stress disorder lasting for months or years, one may become depressed and suicidal, and another may experience only mild, transient symptoms.
Resilience is thought of as “bouncing back” from harm. It is the process of adapting well in the face of adversity, tragedy, trauma, or other significant threats or stress. Resilience involves behaviors, thoughts, and actions that can be learned and developed (APA, 2014b).
A substantial proportion of persons who experience serious trauma will develop some features of PTSD, but 80% to 90% will be resilient and recover spontaneously (Borton & Knott, 2013).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013a) divides PTSD symptoms into four clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity.
Intrusion is a core symptom of PTSD and can take the form of unwanted and obsessive thoughts, feelings, sensory experiences, or any combination of the three relating to the experienced trauma. These can include:
- Involuntary, recurrent, and intrusive memories
- Traumatic distressing dreams or nightmares
- Dissociative reactions (flashbacks) where the person feels or acts as if the traumatic event(s) were recurring
- Intense or prolonged distress post-exposure to internal or external cues symbolizing the event(s)
- Marked physiological reactivity post-exposure to internal or external cues
Efforts to avoid distressing trauma-related stimuli may persist, including:
- Trauma-related thoughts or feelings
- Trauma-related external reminders such as persons, places, activities, situations, or objects
Negative Alterations in Cognitions and Mood
Such alterations in cognitions and mood begin or worsen after the traumatic event, and include:
- Inability to recall important feature(s) of the event (dissociative amnesia)
- Persistent and often distorted negative beliefs and expectations about self or others
- Persistent blaming of self or others for the cause of the traumatic event or the consequences following the event
- Persistent negative emotions related to the trauma, such as fear, anger, guilt, shame, or horror
- Greatly reduced interest in normal activities
- Feeling detached or estranged from others
- Persistent inability to experience positive emotions
Alterations in Arousal and Reactivity
Alterations in arousal and reactivity begin or worsen after the traumatic event and include:
- Irritability or aggressive behavior
- Self-destructive or reckless behavior
- Exaggerated startle response
- Problems concentrating
- Sleep disturbance
Symptoms in Children and Adolescents
Classic PTSD symptoms apply to both adults and children, and PTSD is diagnosable beginning at one year of age. However, young children express symptoms differently. Because of the lack of language development, infants and young children often cannot talk about what happened. Instead, they may:
- Show fear of strangers or be afraid to leave a parent
- Develop sleep problems or nightmares
- Experience thoughts that focus on specific words or symbols that may or may not be directly related to the trauma
- Demonstrate play behaviors with repeated themes of the trauma, often in an agitated and frightened way
- Be more fussy, irritable, aggressive, or unsafe
- Have vague physical complaints, such as headaches or stomachaches
- Lose skills once attained, such as toilet training
- Experience bed wetting
- Forget how or be unable to talk
- Be unusually clingy with a parent or other adult
- Revert to earlier habits for comfort, such as thumb sucking
(Barnett & Hamblen, 2014)
Older children and teens can have extreme reactions to trauma and usually show symptoms more like those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. They may experience guilt for not preventing injury or deaths, and they may also have thoughts of revenge (NCPTSD, 2014b).
ONSET AND COURSE
The onset and course of PTSD is unpredictable, and the severity and timing of symptoms are different for each individual. Symptoms may appear immediately but generally present themselves within the first three months following exposure to trauma. There may, however, be a delay of months or even years before criteria are met for the establishment of a PTSD diagnosis. This is known as “delayed expression” (APA, 2013a).
The most active period for development of new PTSD symptoms is the first posttrauma month, and the most prevalent symptoms during this time are irritability or anger outbursts, insomnia, and psychological distress after reminders of the event (Whitman et al., 2013). The severity of symptoms two weeks after the trauma is a good predictor of the degree of severity at six months. PTSD symptoms may persist for many years after the event.
Alex Moore was brought to the emergency department (ED) by his sister. She awoke in the night and found him writing a suicide note at the kitchen table. The smell of alcohol was on his breath, and there were bottles of both pain and sleeping pills beside him. Five weeks earlier, Alex had left his wife in Texas and driven to his sister’s home in California. Three weeks after that he got drunk, wrecked his truck, and became dependent on his sister for transportation. When she confronted him at the kitchen table, he said, “I’m no damn good to anyone. You’ll all be better off without me.” After much pleading, his sister talked Alex into going with her to the local hospital’s ED.
In the ED Alex’s manner was subdued but somewhat hostile, especially when the staff decided to admit him to the hospital as a “danger to self.” His sister gave further history: For several years Alex had been a firefighter. He and his best friend and fellow firefighter were fighting a fire at a factory when there was an explosion. He saw his friend engulfed in flames and could not get to him. His friend died, but Alex survived and blamed himself for not saving him. Six months later, Alex walked off the job and hasn’t gone back since then. He has not been able to “settle down” or keep a job and has had frequent outbursts of anger, difficulties in his marriage, trouble sleeping, nightmares that he refuses to discuss, difficulty concentrating, and chronic fatigue.
In the hospital Alex was passive, withdrawn, and irritable. He sat stone-faced in group meetings, refusing to participate. He was easily startled by sounds, avoided news programs and movies containing violence, and wandered around the ward checking doors and windows.
COMORBIDITIES AND CONSEQUENCES
Persons with PTSD may have additional psychiatric and/or medical problems. In the U.S., 88% of men and 79% of women with lifetime PTSD have at least one comorbid diagnosis. Most common psychiatric problems include depression, substance abuse, and anxiety disorders (Schnurr, 2012). Men with PTSD are six times more likely to have depression and women with PTSD are four times more likely to have depression.
PTSD affects physical health negatively, with wide-ranging problems including cardiovascular and pain disorders. There may also be a higher risk for contracting infectious diseases, cancers, endocrine problems such as diabetes, and respiratory problems. Mild traumatic brain injury resulting from physical injury sustained, for example, in accidents or domestic violence has been shown to be associated with an increased risk for PTSD development (Schnurr, 2012).
PTSD seriously affects the patient’s functioning and quality of a person’s life. PTSD carries a 40-times higher risk for academic failure, 30-times higher risk for becoming a teenage parent, 60-times higher risk for marital problems, and 150-times higher risk for unemployment (NCPTSD, 2014e).
A serious consequence of PTSD can be suicide. Studies indicate that PTSD is significantly associated with suicidal ideation and attempts after controlling for comorbid disorders. However, no known study of the association between PTSD and completed suicide in a population-based sample has been reported. Research does demonstrate a correlation between PTSD and suicide, with evidence that traumatic events increase a person’s suicide risk. There is debate, however, about the reason, with some studies indicating the risk is higher due to the symptoms of PTSD while others state the risk is higher because of related psychiatric conditions (Hudenko, 2012).
IMPACT OF PTSD
Living and working with survivors of trauma suffering with PTSD symptoms can have profound effects on those closest to them and those who are caring for them.
Impact on Intimate Partners
Combat-related PTSD has been linked to elevated psychological distress in intimate partners. The terms secondary traumatic stress (STS) and secondary traumatic stress disorder (STSD) are increasingly being used to conceptualize this distress. Studies have suggested that most partners of service members/veterans with PTSD experience “generic” psychological distress that is not theoretically consistent with STS/STSD. Studies are underway to expand the understanding of the types of distress experienced by this population (Renshaw et al., 2011).
A study done to determine the association between PTSD and intimate partner relationship violence and emotional distress concluded that the partner’s perception of PTSD symptoms may play a key role in the spread of the PTSD symptoms to the partner. The study urges confirmation of these findings by larger studies in the general population (Meffert et al., 2014).
Impact on Family Members
PTSD can cause major difficulties within the family. PTSD symptoms make it difficult for family members to cope with and get along with the sufferer. Reactions of many family members can include:
- Sympathy. Family members may feel sorry for the person, which can be helpful initially. It can have a negative effect, however, when it leads to low expectations of the sufferer, eroding his or her confidence in the ability to recover from the trauma.
- Depression. Changes in how the family functions because of the effects of PTSD symptoms on the sufferer can lead to feelings of pain or loss, increasing the risk for the development of depression.
- Fear and worry. When a PTSD sufferer is worried, fearful, and preoccupied with trying to feel safe, it can make others in the family feel unsafe also. Fear is also experienced when the PTSD sufferer is angry or aggressive.
- Avoidance. Family members may avoid talking about the traumatic event and avoid the same things the PTSD sufferer does because they don’t want to cause further pain or are fearful of the person’s reactions.
- Guilt and shame. A family member may feel guilt or shame for many reasons, but especially if he or she feels responsible in same way for the trauma, for example, being unable to protect the person from the trauma.
- Anger. Family members may feel angry about the trauma, its effect on their lives, and with whomever is believed to be responsible for the event. They also may feel anger toward the PTSD sufferer who cannot “get beyond the trauma and move forward in life.”
- Negative feelings. Family members may begin to feel the person is no longer the same one they knew before the trauma. They may feel negatively about behavior exhibited by the sufferer both during and following the traumatic event.
- Sleep problems. When the person with PTSD cannot sleep, it may be difficult for family members to sleep as well. Sleep problems may also be due to depression.
- Health problems. With extended stress, family members are more likely to develop stomach or bowel problems, headaches, muscle pain, and other health problems.
(Carlson & Ruzek, 2014)
Impact on Healthcare Professionals
Research has shown that health professionals working with trauma patients may experience PTSD symptoms as an indirect response to their patients’ suffering. This has been referred to as compassion fatigue or vicarious traumatization, which describes the profound emotional and physical erosion that occurs when persons in the helping professions are unable to replenish and rejuvenate.
The term vicarious trauma has been used to describe the major shift that these workers experience in their worldview when they work with patients or clients who have experienced trauma. Helpers recognize that their fundamental beliefs about the world are altered and possibly damaged by being repeatedly exposed to traumatic material. It is believed that the cumulative emotional impact of hearing their patients’ stories may be transmitted via unconscious empathy (Babbel, 2012).
ASSISTING SUPPORT PERSONS
Primary support persons are family members or close friends or who play the roles of advocate, confidant, and “cheerleader.” Healthcare workers are often involved with primary support persons assisting them to help with treatment and cope with the patient’s symptoms, as well as to take care of themselves. It is beneficial if support persons are assisted to:
- Become educated about PTSD. The more the support persons know about the symptoms, the effects of PTSD, and the treatment options, the better they can understand what the patient is going through and keep things in perspective.
- Avoid pressure but be willing to listen. Support persons should understand that patients may have difficulty talking about their traumatic experiences, and in some cases, talking can make things worse. They can be encouraged to be ready to listen when the patient is ready to speak.
- Be patient. It is important for support persons to understand that the process of recovery takes time and that there are often setbacks; the important thing is to remain positive and be patient.
- Recognize that withdrawal is part of the disorder. Often the patient may resist help. When this occurs, the support person should allow “breathing room” and let the patient know they are available when he/she is ready to accept help.
- Offer to attend medical appointments. A support person’s attending appointments along with the patient can increase understanding and assistance with treatment.
- Encourage participation. Even though it may be difficult for the patient, it is important to encourage him or her to return to a normal routine that includes socialization and celebrating with friends and family.
- Make personal health a priority. By eating a healthy diet, getting enough exercise and rest, taking time to be alone or with others involved in activities that are rejuvenating, it is easier for support persons to maintain a positive attitude.
- Seek help if needed. Support persons who are having difficulty coping should speak with their healthcare providers, who may refer them to a counselor or therapist.
- Stay safe. Recognizing that safety may become an issue, a plan should be in place for the support person and other vulnerable members of the family in the event the patient becomes violent or abusive.
Source: Mayo Clinic, 2014.
ASSESSING PATIENTS WITH KNOWN OR SUSPECTED PTSD
There is a wide range of professionals who interact with people at risk for developing PTSD and those who have PTSD whether or not they have already been diagnosed. Healthcare providers are critical in facilitating the recovery process if they routinely incorporate the following into practice:
- Being alert to recognize and identify PTSD symptoms
- Utilizing screening tools for PTSD as part of a general health assessment (e.g., Primary Care PTSD Screen, Trauma Screening Questionnaire, PTSD Checklist)
- Exploring the possibility of PTSD as an underlying problem when appropriate
- Being familiar with local referral options for further assessment and directing patients to appropriate referrals when necessary
- Offering support to patients and families
Individuals who screen positive for PTSD are referred for additional evaluation, which is typically a face-to-face interview by a health professional trained in diagnosing psychiatric disorders. Face-to-face interview is the optimal method of assessment to determine a PTSD diagnosis. Clinical interviews can be structured, semi-structured, or unstructured.
- Structured interviews require adherence to a very exacting set of rules, with no variation from the protocol. The interviewer may also be required to be consistent in behavior, and reactions to the patient’s responses are to be kept to a minimum or avoided entirely.
- Semi-structured interviews are more relaxed. The interviewer is expected to cover every question in the protocol, but there is room to explore participant responses. The interviewer is allowed to be more friendly and sociable. This type of interview is useful when discussing a topic that is very personal to the patient.
- Unstructured interviews are the most relaxed. The interviewer requires only a checklist of topics to be covered. There is no order and no script. The interaction between the patient and the interviewer is more like a conversation than an interview.
Formal Assessment Tools
Structured and semi-structured interviews are most often conducted utilizing a formal assessment tool. Because of the many changes to DSM-5 in 2013, the National Center for PTSD is revising and validating a number of PTSD assessments. In 2014, the following measures were approved to assess the DSM-5 criteria for PTSD.
- Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). This is the “gold standard” in PTSD assessment. It is a 30-item structured interview designed to be administered by clinicians and appropriately trained paraprofessionals. The interview is used to make a current or lifetime diagnosis of PTSD and to assess PTSD symptoms over the previous week. The full interview takes 45 to 60 minutes to administer (Weathers et al., 2013a).
- PTSD Checklist for DSM-5 (PCL-5). This is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. It is used to monitor symptom change during and after treatment, screen for PTSD, and make a provisional PTSD diagnosis. This tool takes 5 to 10 minutes to complete and can be completed by patients in a waiting room (Weathers et al., 2013b).
- Life Events Checklist for DSM-5 (LEC-5). This is a self-report measure that screens for potentially traumatic events in a patient’s lifetime. It assesses exposure to 16 events known to have the potential to result in PTSD and includes one additional item to assess for any other extraordinarily stressful event not captured in the first 16 items. There are three formats for LEC-5, including the standard self-report that establishes whether an event has occurred, the extended self-report that establishes the worse event if more than one, and the interview to establish if Criterion A (stressor) has been met (Weathers et al., 2013c).
For children and adolescents, the following psychological tests may be helpful when assessing for PTSD.
- Child and Adolescent Psychiatric Assessment: Life Events Section and PTSD Module (CAPA-PTSD)
- Children’s PTSD Inventory (CPTSDI)
- Child PTSD Symptom Scale (CPSS)
- Abbreviated UCLA PTSD Reaction Index
- Trauma Symptom Checklist for Children (TSCC)
- Impact of Events Scale
- Screen for Child Anxiety Related Disorders (SCARED)
(See “Resources” at the end of this course for a link to the National Center for PTSD’s list of assessment measures.)
Any patient presenting with symptoms of PTSD should have a complete history and physical examination to rule out any other causes for symptomatology, such as endocrine, cardiovascular, and neurological disorders. A review of systems and social history should also address the use of over-the-counter medications and mood-altering substances such as prescribed medications, alcohol, marijuana, or other substances of abuse.
A medical diagnosis is the naming of a disorder based on an assessment of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. The DSM-5 establishes the criteria required in order to make the medical diagnosis of PTSD, as described in the table below.
|Source: APA, 2013a.|
|A. Stressor||Must be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Must have one of the following:
|B. Intrusion||Must have one of the symptoms in this symptom cluster (see “Symptoms” earlier in this course)|
|C. Avoidance||Must have one of the symptoms in this symptom cluster (see “Symptoms” earlier in this course)|
|D. Negative alterations in cognitions and mood that worsened after the traumatic event||Must have two of the symptoms in this cluster (see “Symptoms” earlier in this course)|
|E. Alterations in arousal and reactivity that began or worsened after the traumatic event||Must have two of the symptoms in this cluster (see “Symptoms” earlier in this course)|
|F. Duration||Symptoms having persisted for more than one month|
|G. Functional||Must be significant symptom-related distress or functional impairment in activities of daily living such as socialization and occupation|
|H.||Disturbance not due to medication, substance use, or other illness|
|Specify whether the person experiences dissociative symptoms||
|Specify if with delayed expression||Diagnostic criteria not met until at least 6 months after the event|
The mental health team evaluated Alex. His physical examination was within normal limits, and a structured interview was conducted using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).
An assessment for PTSD diagnostic criteria revealed that Alex was directly exposed to a stressor when he was involved in the fire and explosion that took the life of his firefighting partner and friend. He was found to have:
- One intrusive symptom (nightmares that he refused to discuss)
- One avoidance symptom (not watching news programs and violent movies)
- Three negative alterations in cognitions and mood that have worsened after the traumatic event (increasing negative thoughts about himself and his self-worth, passivity and withdrawal, and refusing to participate in group meetings)
- More than two symptoms of alteration in arousal and reactivity (contemplating self-destruction, irritability and outbursts of anger, trouble sleeping, inability to concentrate, startles easily, hypervigilance in checking doors and windows)
- Duration of symptoms persisting for longer than one month
After review of his history it was determined that Alex did not meet the criteria for PTSD until six months after exposure, resulting in the specifier delayed expression. Alex also met the criteria for functional difficulties, as he is unable to “settle down” or keep a job and has relationship problems.
A medical diagnosis of “posttraumatic stress disorder with delayed expression” was given to Alex after determining that his symptoms met the criteria as set forth in DSM-5.
NANDA International (2014) defines a nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.”
Nursing diagnoses that are appropriate to the patient suffering from PTSD include, but are not limited to:
- Ineffective coping
- Sleep pattern disturbance
- Dysfunctional grieving
- Impaired social interaction
- Ineffective relationships
- Impaired individual resilience
- Risk for suicide
On admission to the hospital, a nursing assessment was completed, which included information obtained by interviewing both Alex and his sister, by observations of his behaviors, and by consultation with other members of the team. A nursing care plan was developed for Alex, including the following nursing diagnoses:
- Risk for suicide related to his feelings of helplessness, hopelessness, and worthlessness, as evidenced by his written suicide note and verbal statements to his sister about her being better off without him
- Ineffective coping related to PTSD, as evidenced by his inability to keep a job, abruptly leaving his wife, drinking, wrecking his vehicle, and dependence on his sister
- Sleep pattern disturbance related to his recurring and distressing dreams of fire and explosion as evidenced by verbal statements about having nightmares he refuses to discuss, irritability, and chronic fatigue
- Dysfunctional grieving related to the death of his friend in a traumatic event as evidenced by quitting his job and his inability to resume normal activities and responsibilities beyond six months of bereavement
- Ineffective relationships related to cognitive and mood alterations as evidenced by irritability, outbursts of anger, marital problems, and leaving his wife
Planning care involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment.
Goals and Outcomes
The following are the optimal goals and outcomes for a patient diagnosed with PTSD:
- Patient and others (including family and friends) will remain safe.
- Patient will receive treatment for comorbid conditions, such as alcohol/drug addiction, depression, anxiety disorders, and panic attacks.
- Patient will attend support group meetings.
- Patient will expand social support network.
- Patient will have increased restful sleep periods.
- Patient will have fewer nightmares and flashbacks.
- Patient will express decreased irritability.
- Patient will demonstrate effective anxiety-reducing techniques, either cognitive or behavioral.
In planning for Alex’s treatment, the most urgent problem is his risk for suicide, followed by a disturbed sleep pattern that impairs thinking. His dysfunctional grieving and ineffective coping should be addressed as he works through and resolves the distressing feelings and memories of the explosion, fire, and death of his friend.
The goals and outcomes for each of Alex’s nursing diagnoses are as follows:
- Risk for suicide: Alex will refrain from attempting suicide.
- Ineffective coping: Alex will begin to identify available resources and support systems, describe and initiate alternative coping strategies, and describe positive results from new behaviors.
- Disturbed sleep pattern: Alex will sleep at least seven hours per night without nightmares.
- Dysfunctional grieving: Alex will be able to talk about his lost friend in a therapy group.
- Ineffective relationships: Alex will exhibit appropriate affect and decreased lability.
Interventions for PTSD are generally divided into psychotherapy and pharmacology, with psychotherapy being the primary choice. There are a number of treatment modalities. Some patients respond well to one treatment modality, while others may require a combination of modalities. The goal for patients with PTSD is to regain a sense of control over life.
Cognitive-Behavioral Therapy (CBT)
The psychotherapeutic intervention of choice for PTSD is cognitive-behavioral therapy. Research has shown that CBT is the most effective type of counseling for PTSD. Survivors of trauma, especially those who have suffered interpersonal violence, are prone to harbor negative beliefs and perceptions about themselves, such as shame and guilt. Cognitive-behavioral therapy involves reevaluating those beliefs and perceptions and replacing them with more affirming and empowering views. The central goal of cognitive therapy is to assist clients to explore and “think through” their beliefs within the context of when and how those beliefs developed. The process involves talking about a traumatic event and gaining a better understanding of one’s reasoning.
There are several forms of CBT that seek to change irrational and intrusive thoughts and drive out any negative emotions associated with the traumatic experience.
COGNITIVE PROCESSING THERAPY (CPT)
This form of CBT focuses on examining and challenging thoughts about the traumatic event(s) the person experienced. It is based on the assertion that by changing thoughts, feelings can be changed. CPT has four main parts:
- Education about PTSD symptoms and how treatment can help
- Developing awareness of thoughts and feelings
- Learning new skills for challenging thoughts and feelings (cognitive restructuring)
- Learning about and developing an understanding about the common changes in beliefs that occur after going through trauma
This form of therapy requires regular meetings with a therapist as well as completing practice assignments at home to help improve skills outside of therapy (NCPTSD, 2013f). Assignments often include hand writing impact statements that address topics such as why the traumatic event occurred and what it means to the patient that a particular person was killed.
PROLONGED EXPOSURE THERAPY (PE)
Prolonged Exposure therapy is a cognitive-behavioral treatment for adult men and women ages 18 to 65+ that has been shown to produce clinically significant improvement in about 80% of patients with chronic PTSD and to significantly reduce PTSD symptoms among male and female veterans of war and veterans with combat-related and non-combat-related PTSD. Results also show it to be effective in reducing symptoms of depression (NREPP, 2014; Eftekhari et al., 2013).
Prolonged Exposure can be done all at once, called “flooding,” or gradually to build up tolerance, called “desensitization,” and consists of four main parts:
- Education about treatment symptoms to assist the person to understand the goals of treatment
- Breathing retraining to aid in relaxation and help in the short-term management of distress
- In vivo exposure to real-world situations that are safe but have been avoided due to their relationship to the trauma, which over time lessens trauma-related stress
- Imaginal exposure, involving the repetitive talking through of the trauma, revisiting it over and over aloud and in detail. The narrative is recorded and the patient listens to it between sessions to maximize its therapeutic effect. Talking through the trauma helps gain control of thoughts and emotions about the trauma, make sense of it, and have fewer negative thoughts about it.
PE treatment is individualized and conducted by social workers, psychologists, psychiatrists, and other therapists trained in the use of the PE Manual, which specifies the agenda and treatment procedures for each session. Standard treatment consists of 8 to 15 sessions conducted once or twice a week for 90 minutes each. Duration of treatment can be shortened or lengthened according to the needs of the patient and their rate of progress (NREPP, 2014).
TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY
Trauma-focused cognitive-behavioral therapy is the most well-supported and effective treatment for children with PTSD. It is a combined child-and-parent psychotherapy approach incorporating trauma-sensitive interventions with cognitive, behavioral, and family principles and techniques. Children and parents learn new skills such as stress management and relaxation techniques for processing thoughts and emotions related to life events and for managing and resolving distressing thoughts, feelings, and behavior. This therapy is short-term, lasting 12 to 16 sessions. Over 80% of traumatized children show significant improvement after this period of time (Staggs, 2013).
EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)
EMDR is another form of CBT that can help change how a person reacts to memories of a traumatic event. It is a fairly new and often-debated form of therapy, and the theories behind it continue to be developed. No one yet knows how this process works, but it is known to help, and the belief is that getting positive results are the most important thing.
EMDR involves a course of 4 to 12 sessions focusing on hand movements or tapping while talking about the traumatic event(s). The idea is that rapid eye movements make it easier for the brain to work through traumatic memories. EMDR has four main parts:
- Identification of a target memory, image, and belief about the trauma
- Desensitization and reprocessing by focusing on mental images while doing guided eye movements taught by the therapist
- Installing positive thoughts and images by focusing on a new and positive thought while doing guided eye movements until it replaces the negative thoughts or images
- Body scan, focusing on tension or unusual sensation in the body to identify additional issues that need to be addressed in later sessions
Cognitive hypnotherapy is fundamentally a cognitive-behavioral intervention used in conjunction with evidence-based practices for the treatment of PTSD (Lynn et al., 2012). There is no solid evidence to support the efficacy of hypnotherapy for PTSD, but many sufferers have experienced success with the treatment (Hypnotherapy Directory, 2014).
Hypnosis can be an effective modality because it releases stored emotion so that the trauma can be revisited and explored from different perspectives. It helps people see events in a more detached way. Most practitioners use cognitive hypnotherapy or analytical hypnotherapy, both of which function at a deeper level than suggestion hypnotherapy to work with the unconscious mind to explore negative beliefs. By examining a situation from various points of view, the subconscious mind is able to store it in different way.
Play therapy is most commonly used with children ages 3 to 8. Play therapy is a cognitive-behavioral therapy technique in which a child’s natural ways of expression (namely, play) are used as a therapeutic method to assist the child to cope with emotional stress or trauma. Play therapy sessions usually last about 45 minutes a week for several months (NCPTSD, 2014h).
Play therapy for children is effective because feelings are often inaccessible at a verbal level. Instead of verbalizing thoughts and feelings that may be too threatening for a child to express directly, they can be safely projected through self-chosen toys (Landreth, 2012).
MINDFULNESS-BASED COGNITIVE THERAPY (MBCT)
Mindfulness-based cognitive therapy involves learning to fully live in the present moment. When engaged in any activity, the person focuses his/her full attention on what is taking place. If negative thoughts and feelings arise while engaged in the activity, they learn to let them go without judging. This form of therapy is being utilized with combat PTSD and helps to change the way people react to powerful emotions and traumatic memories. Over time, these become easier to process and less powerful. A recent study has shown that short-term (eight weeks) group mindfulness-based therapy improved PTSD symptom severity, avoidance symptoms in particular, and thoughts of shame (Croft, 2014).
A pilot study conducted at the Veterans Administration suggests that group MBCT is an acceptable brief intervention/adjunctive therapy for combat PTSD, with the potential for reducing avoidance symptom cluster and PTSD cognitions. Further studies are recommended to identify factors that influence acceptability and efficacy (King et al., 2013).
Alternative and Complementary Medicine (CAM) Treatments
Alternative and complementary medicine refers to treatments not considered standard in current practice. Alternative treatments are those used instead of conventional practices. Complementary treatments refer to the use of these techniques in combination with conventional practices.
Although CAM treatments merit consideration, there is very limited empirical evidence of their effectiveness other than for acupuncture, so they are often best applied in conjunction with other first-line PTSD treatments.
Acupuncture is a modality practiced in Chinese medicine using pins to stimulate prescribed points in the subcutaneous tissue. The original theory is that this allows energy to move through the tissues in a smooth fashion. Western researchers have yet to determine a scientific basis for acupuncture’s effectiveness, but it is theorized that there is a release of endorphins as well as serotonin, dopamine, and various other neurotransmitters. Studies suggest that evidence for the effectiveness of acupuncture for PTSD is encouraging but not convincing. Further qualified trails are needed to confirm whether acupuncture is effective for PTSD (Kim et al., 2013).
OTHER ALTERNATIVE MEDICINE CLASSIFICATIONS
Other classifications of CAM being used in conjunction with first-line PTSD treatments include:
- Natural products such as herbal and dietary supplements
- Mind-body medicine including meditation, yoga, exercise therapy, and relaxation therapy
- Manipulative and body-based practices such as massage and spinal manipulation
- Movement and energy therapies
- Animal-assisted therapies
- Whole medicine systems such as traditional Chinese medicine and Ayurvedic medicine
PTSD can be debilitating, with negative impacts in many areas of a person’s life, making it difficult to carry out the normal activities of daily living. Broad areas affected can include health and safety, money management, self-care, transportation, work, relationship duties, and community participation. PTSD also affects a person’s executive planning abilities such as time management and concentration or paying attention.
Occupational therapy helps PTSD sufferers to recover, compensate, or adapt so they can once again perform the necessary activities of daily living. Interventions include teaching coping strategies, training in adaptive self-care, planning daily routines, modification of home for posttraumatic physical disabilities, and relapse prevention. Occupational therapy teaches patients to break down tasks into smaller, more manageable steps.
Occupational therapists effectively assess the impact PTSD has on a patient’s vocation, and a gradual return-to-work plan may be developed to begin in the home and transition eventually to the workplace. Interventions include work hardening, ergonomics, work simulations, and physical conditioning, all of which are vital to the person’s successful return to work.
Occupational therapy can be done in both individual and group therapy sessions. In a one-on-one setting, patients may work on individualized skill training with a therapist, and in a group setting, they may work on social skills that are impacted by PTSD.
Several times during his hospitalization, Alex met with a social worker, who provided education about the PTSD symptoms he was experiencing and explained how treatment could help him restore control over his life. During his sessions with the social worker, he began to develop an awareness of thoughts and feelings that he had not previously understood were related to his trauma.
The multidisciplinary team’s plan of care involved Alex in cognitive-behavioral therapy. Two forms of therapy were felt to be good choices for Alex—Cognitive Processing Therapy and Prolonged Exposure therapy, which are two of the most common CBT methods used to treat PTSD. A psychologist met with Alex and discussed the theory behind Prolonged Exposure therapy to help him understand why he would be asked to do something as scary as reliving his trauma. He was told he would be talking about and reacting to the memories of his traumatic experience, but in the absence of any danger.
During the next session, Alex struggled at first, but with the psychologist’s promptings and urgings began talking about the fire and explosion and how his best friend, Loren, had been killed. He remembered his frantic efforts to try to reach his friend through the flames and smoke. He remembered screaming Loren’s name over and over as he watched his friend go up in flames. Again he felt the fear and frustration of being trapped and helpless as he tried to fight his own way out of the blaze.
During the telling of the event, Alex experienced intense distress and fear and responded physiologically as if he were actually living through the trauma again. He cried softly as he described the death of his friend and repeatedly said, “I’m sorry, I’m so sorry, Loren! I should have saved you. I wish it had been me.” During this session the psychologist recorded his description of the trauma and emotional response. Alex was instructed to listen to this recording sometime during the day and told that they would repeat the session again the following morning.
Alex also began attending group sessions with an occupational therapist. Here he learned about the struggles other patients were having trying to move forward to assume normal activities of daily living and responsibilities. He began opening up and talking more freely. The occupational therapist made an appointment with Alex to complete an assessment of the effects PTSD has had on his ability to work.
With continued treatment, Alex gradually experienced less and less fear, anger, and guilt. He was able to remember his experience without reacting to it negatively and began the slow process of incorporating the event into his other lifetime memories.
Psychotherapy using cognitive-behavioral techniques is the primary modality for treatment of PTSD, and medications may treat some of the symptoms associated with the disorder, but they will not affect the flashbacks or feelings associated with the original trauma.
PTSD AND OFF-LABEL USE OF MEDICATIONS
Currently there are only two medications approved by the FDA for treatment of PTSD. All other uses of medications prescribed for treatment of PTSD are “off label,” which means “the medication is being used in a manner not specified in the FDA’s approved packaging label, or insert. This label includes a written report that provides detailed instructions regarding approved uses and doses, which are based on the results of clinical studies that the drug maker submitted to the FDA.”
Source: Miller, 2014.
The two FDA-approved medications for PTSD are sertraline (Zoloft) and paroxetine (Paxil), both of which belong to the class of antidepressants known as serotonin reuptake inhibitors (SSRIs). Besides the two FDA-approved SSRIs, there is strong evidence to support the use of two other antidepressants: the SSRI fluoxetine (Prozac) and the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor), used in the treatment of depression and anxiety (Jeffreys, 2014).
These medications decrease anxiety, depression, and panic associated with PTSD in many patients, and they may also help reduce aggression, impulsivity, and suicidal thoughts. They have been found to be useful when there is a history of alcohol or other substance use. Generally, these drugs take 6 to 8 weeks to become effective, and relapse of PTSD is less likely if they are prescribed for at least a year (Cohen, 2014b).
MOOD STABILIZERS (ANTICONVULSANTS)
Some mood stabilizers are less effective than antidepressants but have the potential to help manage PTSD in those who fail first-line pharmacology. These include the anticonvulsants lamotrigine (Lamictal), tiagabine (Gabitril), and valproic acid (Depakote). These medications are used to reduce impulsivity and emotional lability and are also useful with patients who have comorbid bipolar disorder (Jeffreys, 2014).
The antihypertensive medications clonidine (Catapres) and propranolol (Inderal) are used to help reduce the physical symptoms associated with PTSD. Clonidine has also shown to be useful in pediatric patients for several other PTSD symptoms, including aggression, hyperarousal, and sleep disturbances. There is as yet no data on its effectiveness in adults (Tull, 2014b).
Prazosin (Minipress) acts to reduce the level of activating neurochemicals in the brain and is believed to depress neurological pathways that are overstimulated in persons with PTSD. It is often used for treatment of PTSD-related nightmares, but there is still more evidence needed to support its effectiveness (Gore, 2014).
Beta-blockers such as propranolol have been shown to relieve exaggerated startle responses, explosiveness, nightmares, and intrusive thoughts in some PTSD patients.
Atypical antipsychotics use in PTSD treatment is controversial at this time; however, risperidone (Risperdal), olanzapine (Zyprexa), and quetiaprine (Seroquel) can be useful for treating agitation, dissociation, hypervigilance, intense suspiciousness, or brief breaks with being in touch with reality (Cohen, 2014b).
Benzodiazepines such as clonazepam (Klonopin) and alprazolam (Xanax) are used in PTSD patients for the short-term to relieve anxiety or insomnia. They do not work on the core symptoms of PTSD. Careful use is recommended, as these drugs can cause disinhibition, difficulty integrating the traumatic experience, and interference with the mental processes required to benefit from psychotherapy. They also have the potential for misuse and addiction (Jeffreys, 2014).
EVALUATION OF INTERVENTIONS
Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. The primary outcome is symptom reduction. This is evaluated using clinician-rated and self-reported measures that address the symptoms the patient presented with, and asks if they have lessened, remained the same, or increased. Other goals to be evaluated include:
- Have comorbid medical or psychiatric conditions been prevented or reduced?
- Has there been a remission of all symptoms?
- Has the patient’s quality of life improved?
- Has the patient effectively dealt with disability/functional impairment?
- Has the patient returned to work or to active duty?
Six months after he began treatment, Alex meets with his healthcare provider. In evaluating his treatment, she determines that he has achieved the following goals:
- He no longer has thoughts of suicide.
- His symptoms have lessened to a great extent, and most days he is functioning well.
- He has not reported any signs or symptoms of depression or anxiety.
- His sleep has improved, and most nights he sleeps undisturbed for 6 to 7 hours.
- He no longer feels angry and has not had any outbursts for over 3 months.
- Alex has returned to his wife, and they are now involved in family counseling.
- He is able to talk about the loss of his friend and recognizes he was not to blame for his death.
- Although he continues to have a drink now and then, he has refrained from abusing alcohol or other substances.
- Alex reports he still has memories of the trauma, but he no longer responds physiologically to them. Emotionally he says that he “just feels sad” when he remembers.
- Last month he returned to his former place of employment as a part-time dispatcher. As he continues to improve, he is hopeful that he once again can work in the department as a firefighter.
The best way to lessen the damage and suffering caused by PTSD, of course, would be to have the ability to prevent its development following exposure to traumatic events. Both pharmacological and psychological approaches have been and continue to be evaluated for this purpose.
The medication showing the most potential is propranolol (Inderal), a beta-blocker often used to treat hypertension, headaches, and performance anxiety. Propranolol has been shown to reduce the intense physiological arousal and subsequent memory for new or recalled emotional material in healthy adults, but further studies are warranted (Lonergan et al., 2013).
Two different psychological prevention strategies have been used to reduce the suffering that may occur due to PTSD:
- Psychological first aid (Universal Prevention) delivers interventions to all people exposed to trauma, regardless of symptoms or risk of developing PTSD. It may or may not have beneficial effects and can even have adverse effects on mental health among trauma survivors, and more studies should be conducted.
- Targeted prevention is the identification of those who are high risk of developing PTSD and intervening only with those at high risk. This technique is based on the fact that although many people experience some symptoms of PTSD after trauma, only a small percentage develop the disorder and its associated disability (U.S. DHHS, 2013).
Despite evidence that some early interventions such as debriefing are not effective for preventing PTSD or might even cause harm, they are still widely used. The U.S. Department of Health & Human Services reviewed strength of evidence (SOE) for the use of debriefing as a prevention for PTSD and concluded SOE was low and debriefing not significantly different than control at multiple follow-up assessment across two trials. Debriefing may be harmful due to the potential of preventing the natural grief process, and hindering recovery by encouraging survivors to relive and discuss traumatic events (U.S. DHHS, 2013).
There are studies underway to develop a drug that can be used to vaccinate people entering a stressful situation or to treat people already suffering from PTSD. It is believed that persons experiencing chronic stress have a persistent elevation of the “hunger hormone” produced by the stomach (called “ghrelin”), and this elevation makes the brain more vulnerable to traumatic events, predisposing people to PTSD. By using a drug to block ghrelin receptors, susceptibility to fear is reduced (Trafton, 2013).
There is much to learn about how and why PTSD occurs in some persons and not others. Researchers continue to probe for answers and develop ways to prevent or reduce the severity of PTSD symptoms.
Evidence shows that there are numerous and variable situations that can lead to a person developing PTSD, as well as a variable time span in which the disorder may make itself known. It is important that healthcare professionals, regardless of the specialty or clinical situation in which they work, have a baseline understanding of how this disease presents and what interventions are available to both patients and support persons.
Changes in PTSD diagnostic criteria (PDF) (American Psychiatric Association)
Assessment measures (U.S. Department of Veterans Affairs, National Center for PTSD)
PTSD (National Alliance on Mental Illness, Veterans Resource Center)
PTSD (National Institute of Mental Health)
PTSD resources (American Psychiatric Nurses Association)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
ADAM Medical Encyclopedia. (2013). Post-traumatic stress disorder. Retrieved from http://www.ncbi.nlm.nih.gov
American Psychiatric Association (APA). (2013a). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Washington, DC: Author.
American Psychological Association (APA). (2014b). Road to resilience. Retrieved from http://www.apa.org
Anxiety and Depression Association of America (ADAA). (2014). Posttraumatic stress disorder (PTSD). Retrieved from http://www.adaa.org
Babbel S. (2012). Somatic psychology: compassion fatigue. Psychology Today. Retrieved from http://www.psychologytoday.com
Barnett ER & Hamblen J. (2014). Trauma, PTSD, and attachment in infants and young children. Retrieved from http://www.ptsd.va.gov
Black DW & Andreasen N. (2011). Introductory textbook of psychology (5th ed.). Washington, DC: American Psychiatric Publishing.
Borton C & Knott L. (2013). Post-traumatic stress disorder. Retrieved from http://www.apa.org
Cao C, Wang L, Wang R, Dong C, Quing Y, Zhang X, Zhang J. (2013). Stathmin genotype is associated with re-experiencing symptoms of posttraumatic stress disorder in Chinese earthquake survivors. Prog Neuropsychopharmacol Boil Psychiatry, 44, 296–300. Retrieved from http://www.ncbi.nlm.nih.gov
Carlson EB & Ruzek J. (2014). PTSD and the family. Retrieved from http://www.ptsd.va.gov
Cohen H. (2014a). What causes PTSD? Retrieved from http://psychcentral.com
Cohen H. (2014b). Treatment of PTSD. Retrieved from http://psychcentral.com
Croft H. (2014). Mindfulness-based therapies for combat PTSD. Retrieved from http://www.healthyplace.com
Eftekhari A, Ruzek JI, Crowley JJ, Rosen CS, Greenbaum MA, Karlin BE. (2013). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry, 70(9), 949–55. Doi: 10.1001/jamapsychiatry.2013.36.
Encyclopedia of Mental Disorders (EMD). (2014). Retrieved from http://www.minddisorders.com
Fischer H. (2014). CSR report for Congress. A guide to U.S. military casualty statistics. Retrieved from http://www.fas.org
Gore, AT. (2014). Posttraumatic stress disorder medication. Retrieved from http://emedicine.medscape.com
Hudenko W. (2012). PTSD and suicide. Retrieved from http://www.ptsdsupport.net
Hypnotherapy Directory. (2014). Hypnotherapy for post-traumatic stress disorder. Retrieved from http://www.hypnotherapy-directory.org.uk
Jeffreys M. (2014). Clinicians’ guide to medications for PTSD. Retrieved from http://www.ptsd.va.gov
Jones E. (2005). Shell shock to PTSD: military psychiatry from 1900 to the Gulf War (Maudsley Monograph). New York: Psychology Press.
Kim YD, Heo I, Shin BC, Crawford C, Kang HW, Lim JH. (2013). Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials. Evid Based Complement Alternat Med, 13, 615857. Retrieved from http://www.ncbi.nlm.nih.gov
King AP, Erickson TM, Giardino ND, Favorite T, Rauch SA, Robinson E, Kulkarni M, Liberzon I. (2013). A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Retrieved from http://www.ncbi.nlm.nih.gov
Lamprecht F & Sack M. (2002). Posttraumatic stress disorder revisited. Psychosom Med, 64(2), 222–37.
Landreth G. (2012). Play therapy: the art of the relationship (3rd ed.) New York: Routledge.
Lee J. (2013). Charts: suicide, PTSD and the psychological toll on America’s vets. Retrieved from http://www.motherjones.com
Lonergan MH, Olivera-Figueroa LA, Pitman RK, Brunet A. (2013). Propranolol’s effects on the consolidation and reconsolidation of long-term emotional memory in healthy participants: a meta-analysis. J Psychiatry Neurosci, 38(4), 222─31. Doi: 10.1503/jpn.120111.
Lubit RH. (2014). Posttraumatic stress disorder in children. Retrieved from http://emedicine.medscape.com
Lynn SJ, Malakataris A, Condon L, Maxwell R, Cleere C. (2012). Post-traumatic stress disorder: cognitive hypnotherapy, mindfulness, and acceptance-based treatment approaches. Am J Clin Hypn, 54(4), 311–30. Retrieved from http://www.ncbi.nlm.nih.gov
Mayo Clinic. (2014). Post-traumatic stress disorder (PTSD): coping and support. Retrieved from http://www.mayoclinic.org
Meffert SM, Henn-Haase C, Metzler TJ, Qian M, Best S, Hirschfeld A, McCaslin S, et al. (2014). Prospective study of police spouse/partners: a new pathway to secondary trauma and relationship violence? PLoS One, 9(7), e100663. Doi: 10.1371/journal.pone.0100663. eCollection 2014. Retrieved from http://www.ncbi.nlm.nih.gov
Miller K. (2014). Off-label drug use: what you need to know. Retrieved from http://www.webmd.com
Murrough JW, Czermak D, Henry S, Nabulsi N, Gallezot JD, Gueorguieva R, Planeta-Wilson B, et al. (2011). The effect of early trauma exposure on serotonin type 1B receptor expression revealed by reduced selective radioligand binding. Arch Gen Psychiatry, 68(9), 892–900. Retrieved from http://archpsyc.jamanetwork.com
NANDA International, Inc. (2014). Nursing diagnoses: definitions and classification, 2015-17. Philadelphia: Wiley Blackwell.
National Center for PTSD (NCPTSD). (2011a). Treatment for PTSD. Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD). (2013b). Suicide and PTSD. Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD). (2014c). PTSD in children and teens. Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD). (2014d). How common is PTSD? Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD), (2014e). Co-occurring conditions. Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD). (2014f). Understanding PTSD treatment. Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD). (2014g). Prolonged exposure therapy. Retrieved from http://www.ptsd.va.gov
National Center for PTSD (NCPTSD). (2014h). PTSD in children and adolescents. Retrieved from http://www.ptsd.va.gov
National Health Service (NHS). (2013). Causes of post-traumatic stress disorder. Retrieved from http://www.nhs.uk
National Registry of Evidence-based Programs and Practices (NREPP). (2014). Prolonged exposure therapy for posttraumatic stress disorders. Retrieved from http://www.nrepp.samhsa.gov
Neumeister A, Normandin MD, Pietrzak RH, Piomelli D, Zheng MQ, Gujarro-Anton A, Potenza MN, et al. (2013). Elevated brain cannabinoid CB1 receptor availability in post-traumatic stress disorder: a positron emission tomography study. Molecular Psychiatry, 18(9), 1034–40. Retrieved from http://www.ncbi.nlm.nih.gov
Renshaw KD, Allen ES, Rhoades GK, Blais RK, Markman HJ & Stanley SM. (2011). Distress in spouses of service members with symptoms of combat-related PTSD: secondary traumatic stress or general psychological distress? J Fam Psychol, 25(4), 461–9. Doi: 10.1037/a0023994.
Roesler R & Schwartsmann G. (2012). Gastrin-releasing peptide receptors in the central nervous system: role in brain function and as a drug target. Front. Endocrin, 3, 159.Doi: 10.3389/fendo.2012.00159. Retrieved from http://journal.frontiersin.org
Schnurr PP. (2012). PTSD: principles of diagnosis and treatment: comorbidities and consequences. Retrieved from http://www.medscape.org
Selye H. (1991). The stress of life (rev. ed.). New York: McGraw-Hill.
Staggs S. (2013). Psychotherapy treatment for PTSD. Psych Central. Retrieved from http://psychcentral.com
Trafton A. (2013). McGovern neuroscientists discover new role for “hunger hormone.” Retrieved from http://mcgovern.mit.edu
Trimble MR. (1981). Posttraumatic neurosis, from railway spine to the whiplash. Chichester: John Wiley.
Tull M. (2014a). PTSD and suicide. Retrieved from http://ptsd.about.com
Tull M. (2014b). Medications for PTSD. Retrieved from http://effectivehealthcare.ahrq.gov
U.S. Department of Health and Human Services (USDHHS). (2013). Executive summary: interventions for the prevention of posttraumatic stress disorder (PTSD) in adults after exposure to psychological trauma. Retrieved from http://effectivehealthcare.ahrq.gov
Varcarolis EM. (2013). Essentials of psychiatric mental health nursing (2nd ed.). St. Louis: Saunders.
Veith C. (1965). Hysteria: the history of a disease. Chicago: University of Chicago Press.
Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. (2013a). The clinician-administered PTSD scale for DSM-5 (CAPS-5). Retrieved from http://www.ptsd.va.gov
Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. (2013b). The PTSD checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at http://www.ptsd.va.gov
Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. (2013c). The life events checklist for DSM-5 (LEC-5). Retrieved from http://www.ptsd.va.gov
Whitman JB, North CS, Downs DL, Spitznagel EL. (2013). A prospective study of the onset of PTSD symptoms in the first month after trauma exposure. Annals of Clinical Psychiatry, 25(2), E8–17.
Willard HS, Boyt Schell BA. (2014). Willard & Spackman’s occupational therapy (12th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.