Posttraumatic stress disorder: Often missed in primary care

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Behavioral Health

Posttraumatic stress disorder: Often missed in primary care

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

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References

1. Bobo WV, Warner CH, Warner CM. The management of post traumatic stress disorder (PTSD) in the primary care setting. South Med J. 2007;100:797-802.

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

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

4. Gerson R, Rappaport N. Traumatic stress and posttraumatic stress disorder in youth: recent research findings on clinical impact, assessment, and treatment. J Adolesc Health. 2013;52:137-143.

5. Zohar J, Juven-Wetzler A, Myers V, et al. Post-traumatic stress disorder: facts and fiction. Curr Opin Psychiatry. 2008;21:74-77.

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

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

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

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

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

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

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

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

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

15. Forneris CA, Gartlehner G, Brownley KA, et al. Interventions to prevent post-traumatic stress disorder: a systematic review. Am J Prev Med. 2013;44:635-650.

16. Trivedi RB, Post EP, Sun H, et al. Prevalence, comorbidity, and prognosis of mental health among US veterans. Am J Public Health. 2015;105:2564-2569.

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

18. United States Census Bureau. U.S. and World Population Clock. Available at: https://www.census.gov/popclock/. Accessed August 16, 2017.

19. American Psychiatric Association. Guidelines and implementation. In: Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd ed. Arlington, Va: American Psychiatric Association; 2015:9-45.

20. Williams AA, Williams M. A guide to performing pelvic speculum exams: a patient-centered approach to reducing iatrogenic effects. Teach Learn Med. 2013;25:383-391.

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

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

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

24. Gallagher MW, Thompson-Hollands J, Bourgeois ML, et al. Cognitive behavioral treatments for adult posttraumatic stress disorder: current status and future directions. J Contemp Psychother. 2015;45:235-243.

25. Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat. 2011;7:167-181.

26. Cusack K, Jonas DE, Forneris CA, et al. Psychological treatments for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Clin Psychol Rev. 2016;43:128-141.

27. Thompson BL, Luoma JB, LeJeune JT. Using acceptance and commitment therapy to guide exposure-based interventions for posttraumatic stress disorder. J Contemp Psychother. 2013;43:133-140.

28. Lohr JM, Hooke W, Gist R, et al. Novel and controversial treatments for trauma-related stress disorders. In: Lilienfeld SO, Lynn SJ, Lohr JM, eds. Science and Pseudoscience in Clinical Psychology. New York, NY: Guilford Press; 2003:243-272.

29. Sikes C, Sikes V. EMDR: Why the controversy? Traumatol. 2003;9:169-182.

30. Davidson PR, Parker KCH. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. J Consult Clin Psychol. 2001;69:305-316.

31. Devilly GJ. Power therapies and possible threats to the science of psychology and psychiatry. Aust N Z J Psychiatry. 2005;39:437-445.

INTEGRATING EXPOSURE AND COGNITIVE THERAPIES IS KEY

Offer any patient who meets criteria for PTSD a referral for exposure therapy and trauma-focused cognitive behavioral therapy (TF-CBT), the first-line treatments for PTSD.^1,4,8,24,25

Exposure therapies for PTSD are supported by strong evidence and help patients to become desensitized to distressful memories through gradual, repeated exposures in a relaxed or safe space.^8,26

Cognitive methods, such as cognitive processing therapy, cognitive behavioral therapy, and cognitive reprocessing have moderate strength of evidence, and may be combined with exposure therapy.²⁶ Cognitive therapies help patients change thoughts, beliefs, and behaviors that contribute to PTSD symptoms.^8,26

Exposure and TF-CBT have the most empirical evidence for child, adolescent, and adult PTSD, and are effective for the range of PTSD symptoms,^4,8,25 including avoidance—a fundamental component of PTSD that drives other PTSD symptoms²⁷—comorbid depression, and other emotions associated with trauma (eg, shame, guilt, and anger).^8,25 Family involvement is recommended for children and adolescents.⁴

Screen for a history of trauma in any patient who has depressive symptoms.

For patients with comorbid substance abuse, offer integrated PTSD/substance abuse treatment, which is more effective than isolated treatment of each.⁴ Relaxation training can be helpful as an adjunct to TF-CBT, but is not sufficient as a stand-alone treatment.¹³ Other psychotherapies, such as supportive, psychodynamic, systemic, and hypnotherapy, have not proved effective.¹⁴

Eye Movement Desensitization and Reprocessing (EMDR), a much publicized but controversial treatment, integrates components of exposure and cognitive therapies with therapist-directed eye movements.^28-30 Patients imagine their trauma while the therapist directs their eye movements, which is thought to provide exposure to trauma images and memories, thereby reducing symptoms. EMDR has been found to reduce PTSD symptoms with a low to moderate strength-of-evidence rating.²⁶ However, it has not proved more effective than other exposure and cognitive therapies, and its unique component (eg, eye movements) has not added any effect to outcomes.^28-31

Other newer therapies, such as Acceptance and Commitment Therapy^7,24,27 and online and computer-assisted treatments, are being evaluated.¹⁴

Medications take on an adjunct role to therapy

Drug treatment of PTSD has not been effective in children or adolescents.^4,8 In adults, medications have helped relieve some symptoms of PTSD. However, given their low effect sizes, medications are not recommended as first-line treatments over exposure and TF-CBT. Their usefulness lies chiefly in an adjunct role to exposure and cognitive therapies or for patients who refuse psychotherapy.^4,8,25

Selective serotonin reuptake inhibitors such as fluoxetine, paroxetine, and sertraline, have been effective for such PTSD symptoms as intrusive thoughts, negative or irritable mood, anxiety, restlessness, attention difficulties, and hyperarousal.^1,8

While benzodiazepines have been used to control anxiety, hyperarousal, and insomnia, they have not been effective for most other PTSD symptoms, including avoidance, re-experiencing, and cognitive symptoms. Furthermore, they are not recommended given their augmentative effect on other related symptoms and associated conditions (eg, dissociation, disinhibition, substance abuse) and possible interference with desensitization that occurs in exposure therapy.^1,5

While PTSD is detected more often among veterans, due to regular screening through the VA system, most cases are related to civilian traumas, such as sexual assault.

If a patient has significant insomnia and PTSD-related nightmares, consider starting prazosin at 1 mg/d and titrating up to an effective dose, which typically ranges from 5 to 20 mg per day.^1,5Additionally, trazodone or antihistamines may be used to enhance sleep.¹