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www.tnpj.com The Nurse Practitioner • November 2010 41

pproximately 20% to 29% of Americans have ex-perienced at least one traumatic event, and PTSD affects 5 million people each year. Lifetime preva-

lence of PTSD is estimated at 24% among trauma victims and 27% among women, and up to 58% of at-risk indi-viduals (combat veterans, volcano eruption survivors, or victims of criminal violence) have PTSD.1,3 About a third of these have chronic PTSD. Those involved in certain occupa-

tions, such as fi refi ghting, law enforcement, or emergency medical services, may have an increased risk of PTSD.

PTSD consists of persistent hyperarousal with intrusive thoughts about the trauma and a compelling need to avoid situations related or similar to the trauma. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV) defi nes trauma as an event outside the range of normal human experience that would distress

By Sharon M. Valente, PhD, RN, CS, FAAN

A

Evaluating and Managing Adult

in Primary Care

Abstract: Posttraumatic stress disorder (PTSD) is an anxiety disorder with a

sustained and dysfunctional emotional reaction to a traumatic event, threat

of injury or death, and pain.1,2

Key words: anxiety, evaluation and treatment, posttraumatic stress disorder

PTSD

Illus

tratio

n by

Alb

erto

Rug

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

42 The Nurse Practitioner • Vol. 35, No. 11 www.tnpj.com

Evaluating and managing adult PTSD in primary care

almost anyone, and also takes into account the objective characteristics of the stressor and the victim’s subjective experiences.4 Examples of a traumatic event that might trigger PTSD might be robbery, armed conflict, rape, a natural disaster, or a terrorist attack. These patients con-tinue to experience the trauma repeatedly after the event is over and may have painful memories of the event if they are exposed to or hear about an event similar to that which

they have experienced. These symptoms may interrupt education or job success, fi nancial independence, and rela-tionships, and precipitate mood disorders, substance abuse, and suicide.

Without treatment, patients with PTSD risk complica-tions and may encounter problems with quality of life, social interactions, daily functioning, and psychological issues. PTSD leads to sick days, poor job performance, costly medical and emergency care visits, mental health visits, and greater reliance on disability or welfare. Some patients may contemplate suicide. Diagnosis requires that the symptoms of reexperiencing, avoidance, and arousal occur for at least 1 month. Routine use of screening instru-ments and careful assessment are the keys to evaluation.

■ Pathophysiology

Stress activates the hypothalamic-pituitary-adrenal (HPA) axis and the arousal/sympathetic system. It activates the corticotropin-releasing hormone, arginine vasopres-sin, the pro-opiomelanocortin-derived peptides alpha-melanocyte-stimulating hormone and beta-endorphin, the glucocorticoids, and the catecholamines norepinephrine and epinephrine. The stress system is necessary for well-being, functioning, and social interactions. It may also hinder growth and development and lead to endocrine, metabolic, autoimmune, and psychiatric disorders. The severity of these disorders may reflect the individual’s genetic vulnerability, environmental stressors, and timing of the stressful event(s).

■ Screening for PTSD

Routine use of PTSD screening inventories help providers detect the risk for PTSD and associated mental health dis-orders such as depression and suicide risk, and identify those who may need further evaluation. These instruments doc-

ument symptoms and can improve diagnostic accuracy. They also track treatment outcomes to provide evidence to third-party payors, policymakers, and research-funding agencies and show which treatments work effectively for specifi c patients.5

One screening tool is the PTSD Checklist (PCL), which is a 17-item, self-assessment based on DSM-IV symptoms, and it takes about 5 minutes to complete. The Primary Care

PTSD Screen (PC-PTSD) comprises four questions and has both civilian and military screens. Answering yes to three of the four questions indicates a need for further evaluation.6,7 The Im-pact of Events Scale–Revised (IES-R) is another screening tool with 22 self-assessment questions. It has a sensitiv-

ity of 0.89, positive predictive power of 0.89, and overall effi ciency of 0.89.8 Another instrument, the Posttraumatic Diagnostic Scale (PDS), is a 49-item, self-report tool that measures the severity of PTSD, as well as the effects on the patient’s current quality of life.

Although all patients can be at risk for PTSD, veterans are more likely than civilians to have PTSD. When assessing veterans, be careful to note the patient’s age (50 to 64); if they ever served in a war zone; poor functioning score on the Short Form (36) Health Survey (SF-36), which assesses physical and mental well-being; or if they are experiencing musculoskeletal pain, a greater percentage of persistent reexperiencing or avoidance/numbing symptoms, and a previously diagnosed substance use disorder.9

■ Assessment

A focused history and physical examination can elicit re-ports of trauma and possible relationship between symp-tom onset and duration. Symptoms of PTSD usually occur within 3 months of the trauma and include fl ashbacks of the event; shame or guilt; upsetting dreams or nightmares about the event; avoiding thoughts of the event; feeling numb, irritable, or angry; self-destructive behavior; sleep and appetite disturbances; memory problems; poor con-centration; being easily startled; and a lack of pleasure re-garding activities once previously enjoyed. History should include questions about symptom onset, duration, fre-quency, and associated symptoms. There may also be trau-ma associated with symptom onset. Sleep disturbances affect approximately 70% of patients with PTSD.

Psychosocial and emotional factors such as hopeless-ness, anxiety, and depression should be assessed. Mood disorders and substance use can increase the perception of symptoms and can hinder recovery. A complete neurobe-havioral mental status examination can help determine

Without treatment, patients with PTSD risk

complications and may encounter problems

with quality of life and psychological issues.




whether emotional symptoms are comorbid or consequenc-es of the trauma and establish a baseline for treatment. For a complete neurobehavioral examination, cognitive and memory tests such as the Folstein Mini-Mental State Ex-amination may be necessary.10

Patients should also be assessed for nonspecifi c symp-toms of stress, such as gastric distress, headaches, pelvic pain, and insomnia. The clinician should ask about the severity of reaction to the trauma, any prior psychiatric conditions, family history of psychiatric illness, and whether previous psychosocial support was attained.

People with PTSD report diverse symptoms. In one study of 120 hospitalized injury survivors, trauma survivors expressed concerns regarding physical health (68%), work and fi nance (59%), social issues (44%), psychological issues (25%), medical issues (8%), and legal issues (5%). Those with three severe concerns immediately after the trauma had higher PTSD symptom levels over the course of the year. Greater initial concern severity independently predicted persistent PTSD symptoms 12 months after the injury.11,12 Aggression and irritability are common, and posttraumatic symptoms can contribute to aggressive behaviors in the elderly, medically ill, and cognitively impaired patients. Others with PTSD have described feeling so tense that anger

exploded over insignifi cant situations. In a study of 32 elderly men with PTSD, long-term care patients reported feeling angry and irritable (47%), and these feelings sig-nifi cantly correlated with observed aggressive behaviors.13 Observed aggressive behaviors were signifi cantly more fre-quent among those reporting past traumatic stressors, and the behavior was signifi cant enough that it frightened others. These symptoms interfered with their activities, relationships, and quality of life.

If a patient discloses experiencing a traumatic incident, the clinician should use an empathetic approach when speaking, reassuring the patient that the emotions and accompanying symptoms the patient is now feeling are common and normal reactions from dealing with such an experience. Patients need to understand that feeling angry, embarrassed, or fearful is not uncommon.

■ Diagnosis

For a patient to be diagnosed with PTSD, he must have ex-perienced or witnessed an event involving actual or threat-ened bodily injury or death or threat to physical integrity, and must have felt helpless, horrifi ed, or terrifi ed during the experience (see Diagnostic criteria).4 Examples can include war, disaster, accidents, and domestic violence. Diagnosis

Diagnostic criteria

Major criteria Evidence

Stressor: Person has experienced or

witnessed an unusual traumatic event

that has these two elements

• The event involved actual or threatened death or serious physical injury to

the person or to others

• The patient felt intense fear, horror, or helplessness

Intrusive recollection: Patient

repeatedly relives the event in at

least one of the following ways

• Intrusive, distressing thoughts or images

• Repeated, distressing dreams

• Flashbacks, illusions, or hallucinations

• Marked mental distress in responding to cues that evoke the event

• Physical reactions (increased vital signs) to these cues

Avoidance/numbing: Repeated

avoidance of trauma-related stimuli

and numbing

• Tries to avoid thoughts, feelings, and conversations about the event

• Tries to avoid activities, people, or places that recall the event

• Cannot recall an important feature of the event

• Feels detached or isolated from others

• Is restricted in ability to love or feel strong emotions

• Feels life will be brief or unfulfi lled

Hyperarousal: Has at least two of the

following symptoms of hyperarousal

(not previously present)

• Insomnia

• Irritability

• Poor concentration

• Hypervigilance

• Increased startle response

Symptoms: • Acute: Symptoms have lasted longer than 1month but less than 3 months

• Chronic: Symptoms have lasted for more than 3 months

Functional signifi cance: • Symptoms cause distress or impair functioning

Source: United States Department for Veterans Affairs, National Center for PTSD. Advancing science and promoting understanding of traumatic stress. http://www.ncptsd.va.gov/ncmain/information/treatmt/tre_type.jsp.




rests on identifying the major symptoms of PTSD, such as hyperarousal and numbing/avoidance behaviors. This di-agnosis may lurk behind nonspecific symptoms such as headaches, insomnia, and stomachaches. Patients often have diffi culty describing the problems. Patients can be reluctant to talk about their traumatic events, “battle fatigue,” and nightmares of war, and may be unable to describe symptoms.

General medical conditions, such as head trauma or burns, may occur as a result of the trauma and require evaluation. Differential diagnosis includes mood disorders, agoraphobia, obsessive-compulsive disorder (OCD), social phobia, specifi c phobia, major depressive disorder, somati-zation disorder, and substance abuse and substance abuse–related disorders.

Misdiagnosis of PTSD is common. Presenting symp-toms may include heart palpitations, shortness of breath, and chest pain that mimics cardiac conditions. When no medical cause is found, clinicians often refer patients to an internist or cardiac specialist, but they should also con-sider trauma and psychiatric causes. Symptoms of numbing, avoidance, and hyperarousal present before exposure to the stressor might be caused by a brief psychotic disorder, con-version disorder, or major depressive disorder. Acute stress disorder (ASD) symptoms occur within 4 weeks of the traumatic event and resolve in 4 weeks. OCD includes recur-rent intrusive thoughts unrelated to the traumatic event. Flashbacks in PTSD need to be differentiated from psy-chotic symptoms, delirium, substance abuse, and psychot-ic disorders due to a general medical condition. In some instances, malingering will require consideration if the disorder offers financial gain or benefits. Practitioners should also understand that an adjustment disorder may create a similar pattern of symptoms caused by a less extreme stress-or, such as a divorce or losing a job.

■ Psychopharmacology and cognitive-

behavioral therapy

Effective treatment strategies include a combination of psychotherapy, such as cognitive-behavioral therapy (CBT), and psychosocial and medication treatments. Other therapies, including prolonged ex-posure (PE), cognitive processing therapy (CPT), and skills training, are used for many patients with PTSD (see Common alternative therapies for PTSD ).3,4 How-ever, the Institute of Medicine reports that evidence is inadequate to support the efficacy of PE, CPT, and eye movement desensitization and further research is

needed.14 Medication is usually recommended for psychi-atric comorbidities, suicidal ideation, severe and continued symptoms, continued diffi culty functioning, and if psy-chotherapy is ineffective. Pharmacotherapy includes anti-depressants and newer antianxiety or mood-stabilizing medications.

Among veterans with PTSD, 80% were prescribed some type of psychotropic medication; 89% were prescribed an-tidepressants, 61% received anxiolytics/sedative-hypnotics, and 34% received antipsychotics. Medications were likely to be prescribed for those with greater mental health service use and comorbid psychiatric disorders. Comorbidities effec-tively predicted use of each of the three medication subclasses (depressive disorders were associated with antidepressant use, anxiety disorders with anxiolytic/sedative-hypnotic use, and psychotic disorders with antipsychotic use), and were tar-geted at specifi c symptoms, such as insomnia, anxiety, night-mares, and fl ashbacks. Use of anxiolytics/sedative-hypnotics and antipsychotics in the absence of a clearly indicated diag-nosis was substantial.

One treatment explored the effect of childhood threat on treatment outcome in a three-stage psychodynamically ori-ented inpatient treatment program (PITT). The study fol-lowed a 6-week treatment group of 84 inpatients compared with controls. The experimental group reported an improve-ment in depression, anxiety, somatization, and self-soothing compared to the control group.15 Other researchers have ex-plored early trauma-focused cognitive-behavioral therapy (TFCBT) as a preventive intervention for people at risk for developing chronic PTSD. Evidence suggests that TFCBT is effective in preventing chronic PTSD in patients with

Common alternative therapies for PTSD

Therapy Description

Exposure therapy Exposure therapy aims to reduce fear through

reminders of a past traumatic event. Patients

carefully and gradually face their anxieties in a safe

and controlled environment.

CPT CPT was designed specifi cally for patients with PTSD

caused by sexual assault. In 12 sessions, this therapy

combines cognitive therapy and exposure therapy.

The patient explores pretrauma beliefs about the self

and the world, and writes about the experience and

reads it out loud. The therapist will help identify

where the patient has issues and needs clarity in her

thinking process.

Eye movement

desensitization

and reprocessing

(EMDR)

This relatively new therapy helps change how

patients react to memories of trauma. While

discussing the trauma patients learn to focus on eye

movements or sound taps to help unfreeze the

brain’s information processing system (research

shows that this may minimize PTSD symptoms).




an initial ASD diagnosis.16 Other psychological treatments have been used, including hypnosis for insomnia and eye movement desensitization.17

■ Cognitive-behavioral therapy

Practice guidelines recommend CBT and selective serotonin reuptake inhibitors as primary treatments for PTSD.18 CBT is an effective, directive, time-limited approach used to change irrational thoughts, assumptions, and beliefs. Cogni-tive therapy emphasizes being present in the moment, problem solving, and rational thinking. It targets negative viewpoints and automatic and negative-thinking patterns such as the future is bleak, the world is barren, and the self is worthless. Patients need to discuss negative or irrational thoughts that infl uence relationships, intimacy, reality per-ception, survivor guilt, and sexual behavior.

Cognitive techniques include questioning idiosyncratic meanings, reevaluating automatic conclusions, examining options and alternatives, and reattributing responsibility for things beyond the patient’s control. It also explains how irrational and negative-thinking patterns, such as irrational fears about death, being unloved, or survivor guilt, may cause needless distress and interfere with treatment itself as well as quality of life. This cognitive reframing helps the patient identify and reexamine automatic thoughts and learn to reverse these thoughts by distraction, discussion, positive self-talk, or relaxation.

According to one study, effective treatments focus on the patient’s memory for the trauma and its meaning.19,20 Cognitive distortions often keep people from disclosing a psychiatric disorder. Patients can learn to correct overgen-eralizations or catastrophic expectations. Women veterans who received prolonged CBT were more likely than the control group to eliminate PTSD symptoms.9

■ Conclusion

Patients need to understand that PTSD is an anxiety disor-der that responds to treatment with therapy and medications for anxiety and depression. Patients need to be active in the treatment process, learning strategies for calming and reduc-ing anxieties such as meditation, yoga, self-hypnosis, and visualization strategies. Encourage good sleep hygiene, rou-tine exercise, and a healthy diet. Support group that focuses on anxiety and anger management may also be useful.

Those with PTSD present to primary care for various symptoms. When a clinician asks whether the symptoms began after any type of trauma and uses a screening inven-tory, diagnostic accuracy improves. Treatment should be symptom specifi c, such as targeting mood disorders, insom-nia, and headaches. Patients with PTSD should maintain regular follow-up visits with their healthcare provider. Refer-

ral to a psychiatrist is recommended for patients with treatment resistant disorders such as major depression or suicidal ideation. In many cases, it is helpful for NPs to co-manage patients with PTSD with a mental health spe-cialist and arrange schedules so both providers can see the patient on the same day.

REFERENCES 1. Charatan F. One in fi ve US soldiers have depression or post-traumatic stress

disorder, study fi nds. BMJ. 2008;336(7650):913.

2. Leibowitz RQ, Jeffreys MD, Copeland LA, Noel PH. Veterans’ disclosure of trauma to healthcare providers. Gen Hosp Psychiatry. 2008;30(2):100-103.

3. United States Department of Veteran Affairs. National Center for PTSD. What is PTSD? http://www.ptsd.va.gov/public/pages/what-is-ptsd.asp.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.

5. Valente SM, Saunders JM. Screening for depression and suicide: self-report instruments that work. J Psychosoc Nurs Ment Health Serv. 2005;43(11):22-31.

6. Weathers FW, Huska JA, Keane TM. PTSD Checklist Stressor Specifi c Version (PCL-S). Boston, MA: National Center for PTSD, Behavioral Science Divi-sion; 1991. http://www.northeastcenter.com/PTSD_checklist_stressor_spe-cifi c_version%20_PCL_S.htm.

7. Bliese PD, Wright KM, Adler AB, Cabrera O, Castero CA, Hoge CW. Validat-ing the primary care posttraumatic stress disorder screen and the posttrau-matic stress disorder checklist with soldiers returning from combat. J Consult Clin Psychol. 2008;76(2):272-281.

8. Brewin CG. Systematic review of screening instruments for adults at risk of PTSD. J Trauma Stress. 2005;18(1):53-62.

9. Magruder KM, Yeager DE. Patient factors relating to detection of posttrau-matic stress disorder in Department of Veterans Affairs primary care settings. J Rehabil Res Dev. 2008;45(3):371-382.

10. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical meth-od for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.

11. Zatzick DF, Russo J, Rejotte E, et al. Strengthening the patient-provider rela-tionship in the aftermath of physical trauma through an understanding of the nature and severity of posttraumatic concerns. Psychiatry. 2007;70(3):260-273.

12. Zatzick DF, et al., J Consult Clini Psychol. 2008;76(2):272-281.

13. Carlson EB, Lauderdale S, Hawkins J, Sheikh JI. Posttraumatic stress and aggression among veterans in long-term care. J Geriatr Psychiatry Neurol. 2008;21(1):61-71.

14. Institute of Medicine and the National Academies. Treatment of Post Trauma Stress Disorder (PTSD). National Academies Press; 2007.

15. Lampe A, Mitmansgruber H, Gast U, Schussler G, Reddemann L. Treatment outcome of psychodynamic trauma in an inpatient setting. Neuropsychiatr. 2008;22(3):189-197.

16. Kornør H, Winje D, Eckeberg Ø, et al. Early trauma-focused cognitive-behavioural therapy to prevent chronic post-traumatic stress disorder and related symptoms: a systematic review and meta-analysis. BMC Psychiatry. 2008;19(8):81.

17. Abramowitz EG, Barak Y, Ben-Avi I, Knobler HY. Hypnotherapy in the treatment of chronic combat-related PTSD patients suffering from insom-nia: a randomized, zolpidem-controlled clinical trial. Int J Clin Exp Hypn. 2008;56(3):270-280.

18. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.

19. Ehlers A, Clark DM, Hackmann A, McManus F, Fenell M. Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behav Res Ther. 2005;43(4):413-431.

20. Ehlers A, Clark DM. Post-traumatic stress disorder: the development of ef-fective psychological treatments. Nord J Psychiatry. 2008;62(suppl 47):11-18.

Sharon M. Valente is an associate chief nurse of research and education at the University of Southern California, Los Angeles, Calif.

This material is the result of work supported with the resources and use of the fa-cilities at Department of Veterans Affairs Greater Los Angeles Healthcare System.

DOI-10.1097/01.NPR.0000388940.54617.99


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