Post Traumatic Stress Disorder for the Primary

Care and Emerg PARon Andersen CCPA

Disclosures I am employed by the CF, currently. I have no financial disclosures or sponsorships

to disclose. I am NOT a psychiatrist.

Objectives

Review the Diagnostic Criteria as per DSM – IV and preview the DSM-5 (released March 2013)

ID someone in crisis Where to turn for more information…(the

second most important section)

What does PTSD look like?? Can anyone easily identify someone with

PTSD?? Can you quickly see who is at risk??

What does PTSD look like…

What does PTSD look like…

What does PTSD look like…

What does PTSD look like…

What does PTSD look like…

Who is vulnerable???

DSM – IV - TR Criteria Diagnostic criteria for PTSD include a history

of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning

DSM – IV – TR Criteria Cont. Criterion A: stressor The person has been exposed to a traumatic event in

which both of the following have been present: The person has experienced, witnessed, or been

confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behaviour.

DSM – IV – TR Criteria Criterion B Criterion B: intrusive recollection The traumatic event is persistently re-experienced in at

least one of the following ways: Recurrent and intrusive distressing recollections of

the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content

DSM – IV – TR Criteria Criterion B Acting or feeling as if the traumatic event were

recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.

Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

DSM – IV – TR Criterion C Criterion C: avoidant/numbing Persistent avoidance of stimuli associated with

the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

Efforts to avoid activities, places, or people that arouse recollections of the trauma

DSM – IV – TR Criterion C Inability to recall an important aspect of the trauma Markedly diminished interest or participation in

significant activities Feeling of detachment or estrangement from others Restricted range of affect (e.g., unable to have loving

feelings) Sense of foreshortened future (e.g., does not expect to

have a career, marriage, children, or a normal life span)

DSM – IV – TR Criterion D Criterion D: hyper-arousal Persistent symptoms of increasing arousal (not present

before the trauma), indicated by at least two of the following:

Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hyper-vigilance Exaggerated startle response

DSM – IV – TR Criteria Cont. Criterion E: duration Duration of the disturbance (symptoms in B, C, and D) is more

than one month. Criterion F: functional significance The disturbance causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning.

Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more Specify if: With or Without delay onset: Onset of symptoms at least six

months after the stressor

DSM-5 (not released) May 2013(ish)

A. Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways: directly experiencing the traumatic event(s)   witnessing, in person, the traumatic event(s) as

they occurred to others

DSM-5 (not released) May 2013(ish)Criterion A cont’d

learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental

experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

DSM-5 (not released) B. Presence of one or more of the following intrusion

symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: spontaneous or cued recurrent, involuntary, and intrusive

distressing memories of the traumatic event(s) (Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.)

recurrent distressing dreams in which the content or affect of the dream is related to the event(s) (Note: In children, there may be frightening dreams without recognizable content. )

DSM-5 (not released)Criterion B cont’d

dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. (Note: In children, trauma-specific reenactment may occur in play.)

intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

marked physiological reactions to reminders of the traumatic event(s)

DSM-5 (not released) C. Persistent avoidance of stimuli associated with the

traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by avoidance or efforts to avoid one or more of the following: distressing memories, thoughts, or feelings about or closely

associated with the traumatic event(s) external reminders (i.e., people, places, conversations,

activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s)

DSM-5 (not released) D. Negative alterations in cognitions and mood

associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following: inability to remember an important aspect of the traumatic

event(s) (typically due to dissociative amnesia that is not due to head injury, alcohol, or drugs)

persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous").  (Alternatively, this might be expressed as, e.g., “I’ve lost my soul forever,” or “My whole nervous system is permanently ruined”). 

DSM-5 (not released)Criterion D cont’d

persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s)

persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)

markedly diminished interest or participation in significant activities

feelings of detachment or estrangement from others persistent inability to experience positive emotions (e.g.,

unable to have loving feelings, psychic numbing)

DSM-5 (not released) E. Marked alterations in arousal and reactivity

associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: irritable or aggressive behavior reckless or self-destructive behavior hypervigilance exaggerated startle response problems with concentration sleep disturbance (e.g., difficulty falling or staying asleep

or restless sleep)

DSM-5 (not released) F. Duration of the disturbance (Criteria B, C,

D, and E) is more than 1 month. G. The disturbance causes clinically

significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributed to the direct physiological effects of a substance (e.g., medication, drugs, or alcohol) or another medical condition (e.g. traumatic brain injury).

DSM-5 (not released) Rationale of changes; Revision of Criterion A1 – to remove

ambiguities and tighten the definition of “traumatic event”

Deletion of Criterion A2 – because it has no utilitity

Slight revision to Criterion B

DSM-5 (not released) Rationale of Changes cont’d

B1 clarified to define “intrusive recollection” and eliminate depressive rumination

B2  slight changes make the criterion more applicable across cultures

B3 clarified to indicate that flashbacks are dissociative symptoms that occur on a continuum

Dividing DSM-IV Criterion C into two separate clusters (e.g., DSM-5 Criteria C and D) Thereby resulting in four, rather than three distinct diagnostic clusters.

DSM-5 (not released) Revising and adding diagnostic symptoms for

Criterion D (Negative Cognitions and Mood) D2 (DSM-IV “foreshortened future”) clarified &

expanded to encompass exaggerated negative beliefs and expectations about the future

D3 (new symptom) –persistent distorted blame of self or others

D4 (new symptom) – persistent negative emotional state

DSM-5 (not released) Rationale of Changes cont’d

Revising and adding diagnostic symptoms for Criterion E (“Alterations in Arousal and Reactivity”)

E1 – clarifying that this pertains to behaviour (“irritable or aggressive”)

E2  (new symptom) = reckless or self-destructive behaviour

Eliminating the Acute vs. Chronic specifier Addition of a Preschool Subtype Addition of a Dissociative Subtype

The ID of someone in crisis There is no doubt most of you working in

primary care knows how to ID someone in a mental health crisis….but….

The ID of someone in crisis …the difficulty ID’ing a member of the EMS,

Police, Fire, military member or Primary Care worker in crisis lies with their years of training.

Whether it be the way they are dressed, appearance or attitude…they often just don’t fit the crisis ‘mold’….

The ID of someone in crisis ….so what does that mean…doesn’t fit the

mold? Well ultimately it may rest upon you to dig

that little bit deeper, and to prod your SP just that little bit extra…after all wouldn’t you rather be the PA that gets someone a little mad about asking all those dumb questions?

Treatment Modalities There are several types of treatment for PTSD;

Pharmacological, including SSRIs SNRIs Atypical anti-psychotics (not supported in some trials) Benzodiazipines Alpha-adrenergic receptor blockers (prazosin) Combinations of many of these….(this often leads to

the patient feeling like a guinea pig, or an experiment)

Treatment Modalities Psychotherapy which can include;

Cognitive Behavioral Therapy Re-exposure therapy EMDR (Eye movement desensitization and

reprocessing) Trauma focused Coping mechanism optimization

Psychodynamic Eclectic

Questions?? Comments?

Okay the good stuff is next…..

Resources Veterans Affairs Canada

http://www.veterans.gc.ca/eng/crisis-help-line This will give you a crisis line number for your patient

to call to be in contact with any number of resources. National Center for PTSD (US Dept of

Veterans) http://www.ptsd.va.gov/index.asp

This website is incredible, it will overwhelm at first but take the time to see all that it has.

Resources PTSD Association

http://ptsdassociation.com/index.php A Canadian take on PTSD and help available.

Tema Conter Memorial Trust http://www.tema.ca/

Another great site for EMS, Police, Fire and Military personnel.

DSM-IV- TR http://dsm.psychiatryonline.org/book.aspx?

bookid=22

Resources DSM-5

http://www.dsm5.org/Pages/Default.aspx Centre for Addictions and Mental Health

CAMH http://www.camh.ca/en/hospital/Pages/home.aspx