of Traumatic Stress in Medical Settings
On Tuesday, September 11th, 2001, the nation was rocked by the single largest terrorist attack ever experienced by this country. From this tragedy thousands are dead or missing, tens of thousands know someone who was killed or injured, and hundreds of millions have directly witnessed the destruction through media sources and other mediums.
A series of subsequent anthrax deaths and the continued threats of biological and nuclear terrorist attacks have only further heightened anxiety. In light of these events, some national mental health professionals have predicted an epidemic of stress-related disorders in the coming months.
Consequently, medical practitioners will likely see a significant increase in traumatized individuals presenting in their offices. Many of these patients will complain of physical rather than mental or emotional symptoms. This wave of complaints will range from ulcers, hypertension, and irritable bowel syndrome to anxiety and depression. In many cases, the physical and psychological responses are inextricably tied together. It is a well-documented fact that nearly half of all patient visits for mental health concerns are to medical practitioners and of those visits, 90% are to primary care providers.
Despite its prevalence, traumatic stress reactions such as Post-Traumatic Stress Disorder (PTSD) are likely to remain largely unrecognized and untreated in medical settings. This is particularly concerning as PTSD is most effectively treated in the first few months after onset. Left untreated, these disturbing symptoms and associated psychological problems frequently become fixed, and in a chronic stage, much more resistant to amelioration.
It is recommended that primary care providers better educate themselves about the signs and effects of traumatic stress on individuals and routinely screen for trauma in their offices, particularly after major disasters. Failure to properly diagnose and treat psychological trauma has adverse effects on physical and mental health, often leading to PTSD and other more permanent impairment.
One of the first things physicians can do in assessing for trauma-related problems is to be alert to those triggers that can precipitate such conditions in their patients. Natural and man-made disasters, rape, domestic and other violence, war, torture, plane and automobile accidents should all be considered as possible precipitants (Herman, 1992). In addition to disasters and other traumatic events, life-threatening medical conditions such as severe burns, cancer, myocardial infarctions and serious injuries can also cause PTSD.
It should be noted that in assessing traumatic stress, professionals also have to consider those with secondary exposure as potentially affected. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders now defines the stressor event to include learning of a trauma occurring to a loved one. For example, parents who are traumatized when they learn of their child's trauma are classified as having PTSD or Secondary Traumatic Stress Disorder (STSD). Besides family members, this variant is often observed in first responders to disasters such as police, fire, and medical personnel. In some severe cases a serious disaster can affect the entire community,
Which patients are least and most likely to react negatively to stressful and traumatic events? How is it that some patients seem to be immune to significant life stress? Research indicates that there are "bullet proof" or resilient individuals who are less prone to experience stress-related symptomatology, even when exposed to the most trying of life circumstances.
These psychologically hardy individuals respond to severe stress with what researchers refer to as "self-righting behaviors," sharing three traits that provide extra protection from the ravages of stress. They have solid social support networks, maintain an internal belief of control over their lives or what we commonly refer to as "optimism," and have more active coping styles. These reliant individuals are better able to bounce back then their less hardy counterparts.
In contrast, certain patients are much more vulnerable to the effects of stress and change. Physicians need to be particularly alert to this group of individuals. These patients, besides lacking the protective traits of their hardier counterparts, tend to fall into two groups:
Patients who are already experiencing serious or life-threatening health conditions such as myocardial infarction, cancer, severe burns or injuries will likely be more affected by stress and trauma. In fact, these conditions alone can often cause or exacerbate PTSD.
Patients who are already experiencing stressful life events, such as divorce, family problems, health crises, or the loss of a loved one, are already emotionally weakened and will likely have more difficulty managing the additional stresses of a traumatic event than their more stable counterparts. The same holds true for those patients who are already experiencing or being treated for psychiatric conditions such as depression, anxiety, substance abuse or personality disorders.
A second group of patients who are more susceptible to traumatic events are those with some prior history of trauma. Individuals who have been engaged in war, torture, domestic or other violence, serious automobile accidents, abuse, rape, natural or man-made disasters all share a heightened susceptibility to stress disorders.
In both cases, the symptom picture is much the same in the immediate aftermath of a trauma or disaster. The majority of survivors will experience normal, acute stress reactions with the concomitant agitation, insomnia, intrusive thoughts or images of the traumatic event, nightmares, hypervigilence, change in eating habits, trembling, withdrawal, emotional numbing, impaired concentration and depression.
When there is an established relationship over time, the doctor will pick up these signs by the patient's presentation or by asking some open-ended questions. How is the patient sleeping? Are their physical symptoms, such as gastrointestinal problems, worse since the traumatic event? Have they experienced difficulties at work or home? These symptoms may yield an opportunity to begin a conversation about how they are functioning since the traumatic situation.
Patients may also screen for traumatic stress by using simple self-report instruments completed prior to a medical appointment. These screening questions can also be added to standard medical history forms that patients complete at first visits. Screening instruments or questions increase a physician's ability to detect PTSD and to initiate appropriate referral for specialty care.
One instrument, the Primary Care PTSD Screen, was designed specifically for use in primary care or medical settings (Prins, Kimerling, Cameron, et al, 1999). The PC-PTSD is brief, problem-focused, and easily implemented in a busy office practice.
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
Current research findings indicate the results of the PC-PTSD should be considered "positive" if the patient answers "yes" to any two items or to the single item three, measuring hyperarousal. One study of victims of the 1993 World Trade Center bombings in New York (Difede et al.1995) indicated that avoidance and numbing symptoms may be the best predictors of those at risk for psychiatric casualty, both PTSD and other disorders. For those physicians who suspect traumatic stress but who do not wish to administer a written instrument, these questions can be administered verbally during a standard examination.
A positive response to the screen does not necessarily indicate that a patient has PTSD, but it does suggest that the patient may have PTSD or trauma-related problems and that further evaluation, either by the treating doctor or a mental health professional, may be warranted. Also patients who screen positive should be explicitly asked about suicidal ideation and substance abuse as well.
When a mental health referral is indicated, there are several things the doctor can do to raise the likelihood of the patient following through on such a recommendation. Many patients are hesitant to accept such referrals due to the perceived stigma associated with such treatment, a reluctance to open up "old wounds," or the discomfort with the idea of seeing a psychiatrist or psychologist.
Several studies have pointed out that following a terrorist event such as the Oklahoma City bombing, many of those in close proximity to the disaster do not believe they need help, and will not seek out services, despite reporting significant emotional distress (Meyer, 1991: Sprang, 2000). Of those individuals studied who were directly exposed to the Oklahoma City bomb blast, nearly half had an active post-disaster psychiatric disorder, with PTSD being diagnosed in one-third of respondents (North et al., 1999). Major depression was the most common associated disorder.
This lack of help seeking is critical for providers to address. Regardless of the cause of their hesitation, the doctor can often facilitate these referrals by first listening to their concerns, suggesting a consultation rather than treatment, and giving the patient educational materials. The physician may also consider involving a spouse or partner in the discussion, stressing the advantages of learning to cope with their trauma, and making sure to follow-up on the issue in the next medical appointment.
In addition to the referral, the treating provider can help by reassuring the patient they are not crazy and that their symptoms are normal reactions to horrible events. Most survivors benefit from a frank discussion that their need to avoid any reminders of the trauma is natural, but that this avoidance may at times actually interfere with their recovery.
These individuals need to understand that recovery from trauma is best facilitated by talking through the experience and allowing outside social support. If after a few months their symptoms are not better, they need to be willing to seek out some form of specialized treatment. After this discussion with the patient, it may be possible to invite family members in to enlist the patient's cooperation in a mental health referral.
Fortunately many people who experience acute stress reactions find their symptoms remit over a relatively brief of period of time. For those 8% of people who develop more serious PTSD conditions, there are several effective mental health interventions for both the acute and chronic stages of the disorders.
The treatment of choice for traumatic conditions is
cognitive-behavior therapy. Numerous studies have shown
the effectiveness of brief cognitive-behavioral therapy for
PTSD and related conditions (Byrant, Harvey, Dang et al. 1998).
Additionally, psychotropic medications have also
proven highly beneficial. Comorbid disorders such as
depression, anxiety, and substance abuse also respond to
effective treatment. Existential therapy approaches can also
be helpful in the later stages of treatment to assist the patient
to
find meaning in their tragedy (Buffone, 2001).
For many individuals suffering symptoms of acute and chronic stress, experience indicates few of these survivors make use of available mental health services. This places physicians and other health professionals on the front lines of early diagnosis and treatment. As mentioned, doctors can play a key role in the early detection and treatment of these disorders.
In many cases the physician is the only professional who ever sees survivors of traumatic stress. Once detected, there are several things the treating doctor can do to aid these patients.
For example, patients who test positive on screens may also benefit from educational handouts and materials about trauma and PTSD such as those available from the National Center for PTSD Website at http://www.ncptsd.org. These educational materials help normalize common reactions to trauma, facilitate recognition of significant problems, and increase knowledge of and acceptance of outside services. As discussed earlier, reassurance that the patient's experiences are normal reactions to extraordinary events is also comforting.
Patients should also be encouraged to exercise, decrease caffeine and other stimulant use, and maintain their normal routines. It is critically important that family and significant others be mobilized to provide social support to the victim, whenever possible. It is important that the physician avoids pushing people to talk about their experience before they are ready. Those patients who have a good support system and the opportunity to process these images and feelings at their own pace are likely to do well. Over time, most people do recover.
In some cases psychotropic medications may be needed when the patient shows signs of significant distress or has not recovered after a few months. After trauma, some survivors experience extreme and persistent arousal in the form of anxiety, irritability, hypervigilence, panic and insomnia. Empirical research has shown that hyperarousal during the first few weeks following trauma is a risk factor for the development of PTSD. Although alternate psychological and social techniques exist to treat this trauma-related arousal, the primary care doctor is most likely to rely on pharmacotherapy.
Pharmacologic agents for treatment of this form of hyperarousal includes benzodiazepines and antiadrenergic agents such as clonidine, guanfacine and propranolol. Benzodiazepines are useful because they are fast acting, effective and quickly reduce anxiety and improve sleep. However, prolonged use is not generally indicated. One study found that the early and more prolonged use of these medications was actually associated with a higher rate of PTSD (Gelpin et al. 1996). Studies suggest that benzodiazepines are best used to treat extreme arousal, insomnia, and anxiety acutely but that their use be time-limited because of the risk of substance abuse problems.
Recent trauma survivors may often suffer from debilitating symptoms of depression. Because depressive symptoms originating soon after trauma may predict PTSD, it is suggested antidepressant medications, particularly the SSRI's be considered as part of the treatment regimen. Sertraline is the only FDA approved medication for treatment of PTSD. In addition, SSRI's may be useful to control the anxiety and irritability often seen in depressions and traumatic stress conditions. For patients with significant sleep problems, low dose trazadone, nefazodone and amitriptyline are possible choices.
Finally it is essential that treaters educate patients about potential medication side effects, interactions with alcohol, other medications, and remain in close touch after initiating these agents. This will allow the physician to gauge the seriousness of any side effects, encourage compliance, and respond to any negative reactions of these medications. In addition, the added therapeutic support can help to relieve the psychological burden in persons suffering from traumatic distress. For a more comprehensive review of medications used in the treatment of PTSD, refer to the Expert Consensus Guideline Series Treatment of Posttraumatic Stress Disorder at http://www.psychguides.com/ptsdgl.pdf.
Medical practitioners can serve a vital role in the proper identification and treatment of traumatic stress. Tools are available for rapid assessment and treatment of these acute stress conditions.
Effectively applied, physicians can often prevent the development of more chronic and disabling problems such as PTSD, depression, substance abuse, and social and vocational dysfunction seen in trauma survivors.