In primary care settings, clients may seek help for a range of problems, including low mood, anger, relationship problems, sleep difficulties, sexual dysfunction and physical health complaints. Due to a lack of awareness of the implications of psychological symptoms, a fear of stigma or a need to avoid talking about the trauma (a hallmark symptom of PTSD), clients often seek treatment for physical health problems (National Institute of Clinical Excellence [NICE], 2005). In addition, one of the most common complaints of people with PTSD is poor sleep, including difficulty falling and staying sleep and early morning awakenings.
One of the most prominent symptoms presented at primary care settings is the avoidance of trauma-related situations and cues. Since clients may not voluntarily discuss a traumatic event or posttraumatic symptoms, primary care practitioners should consider asking clients whether they have experienced a traumatic event. This is particularly recommended for clients with repeated, non-specific physical health problems (ACPMH, 2007; NICE, 2005).
If there is evidence of a traumatic event, the client should be assessed for posttraumatic symptoms. The DSM-IV-TR criteria for PTSD (APA, 2000) are (** Proposed revisions to the diagnostic criteria of PTSD in the DSM-5 can be found here **).
- Criterion A:
- (1) An individual experienced, witnessed or was confronted with a traumatic event(s) that involved actual death, threatened death, serious injury, or a threat to the physical integrity of self or others, and
- (2) responded with intense fear, helplessness, or horror
- Criterion B: The traumatic event is persistently re-experienced in one or more of the following ways:
- recurrent intrusive thoughts, images or perceptions of the event
- recurrent nightmares of the event
- acting or feeling as if the event were recurring
- intense psychological distress upon exposure to internal or external cues that symbolize or resemble an aspect of the trauma
- physiological distress upon exposure to cues
- Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by at least three of the following:
- efforts to avoid thoughts, feelings or conversations about the trauma
- efforts to avoid activities, places or people that arouse recollections of the trauma
- inability to recall an important aspect of the trauma
- feeling of detachment or estrangement from others
- restricted range of affect
- sense of a foreshortened future
- Criterion D: Persistent symptoms of arousal symptoms as indicated by at least two of the following:
- difficulties falling or staying asleep
- irritability or outbursts of anger
- concentration difficulties
- exaggerated startle response.
- Criterion E: Duration of the symptoms in Criterion B, C and D is greater than a month
- Criterion F: The symptoms cause significant distress or impairment in social, occupational or other important areas of functioning. Specifiers:
- acute—symptoms less than three months
- chronic—symptoms more than three months
- with delayed onset—six months between traumatic event and symptom onset.
Screening and Assessment
Structured interviews can aid in the screening and assessment of PTSD. Here are some examples:
- The PTSD Symptom Scale Interview (Foa et al., 1993)
- The Structured Interview for PTSD (SIP) (Davidson et al., 1997)
- The Clinician Administered PTSD Scale (Blake et al., 1995)
- The Structured Clinical Interview for DSM-IV Axis I Disorders .
While self-report measures are easily implemented, they are not appropriate as a primary diagnostic tool due to the high potential of symptom exaggeration and lack of diagnostic specificity with regards to symptoms. Self-report measures are better suited as a supplement to structured interviews or as a measure of symptom change over the course of treatment. These widely used self-report measures are good screening tools that can be easily implemented and scored in primary care settings:
- Impact of Event Scale–Revised (Sundin & Horowitz, 2002)
- PTSD Checklist–Civilian Version (Walker et al., 2002)
- Short Form of the PTSD Checklist–Civilian Version (Lang & Stein, 2005)
- PTSD Checklist Stressor Specific Version (Weathers et al., 1991)
- Short Screening Scale for DSM-IV PTSD (Breslau et al., 1999).
Financial compensation is more often a consideration with PTSD than with other physical and mental health problems (ACPMH, 2007); therefore, symptom exaggeration and malingering should be assessed. As with all assessments, simple yes or no responses do not suffice. More details should always be requested (e.g., if someone endorses flashbacks, ask about the content of the flashbacks, how often they occur and what the experience is like).
In particular, be attuned to inconsistencies in reported symptoms (e.g., a client endorses a strong startle response yet does not flinch at a loud bang outside the office door). Familiarize yourself with the details of malingering, which can be found in the "Other Conditions That May Be a Focus of Clinical Attention" chapter of the DSM-IV-TR (APA, 2000).
Kessler et al. (1995) found that for most clients, PTSD symptoms decrease substantially in the first year after the trauma without treatment. However, for those whose symptoms do not abate with time, there are a variety of empirically supported treatment approaches:
- Trauma-focused Cognitive-behavioural therapy
- Trauma-focused CBT is a short-term, structured and empirically supported treatment method. It focuses on the relationship between emotions, thoughts and behaviours around the traumatic event, and how this relationship maintains anxiety and other PTSD symptoms. The therapy involves psychoeducation, arousal management strategies (e.g., relaxation or breathing training), cognitive restructuring, in vivo (i.e., live) exposures and imagined exposures.
- Prolonged exposure is one of the central tenets of trauma-focused CBT. It involves confronting the feared objects, activities, places, people or memories with the expectation that anxiety will lessen within and between exposures.
- Eye movement desensitization and reprocessing
- EMDR is based on the assumption that during the traumatic event, emotions are stored in a manner that is disconnected from existing memory networks (ACPMH, 2007). During treatment, clients are asked to focus on the memory of the trauma while moving their eyes back and forth. Over the years, EMDR has incorporated key components of CBT, such as in vivo exposure and cognitive restructuring. There is increasing evidence that the eye movements are unlikely to be beneficial; rather it is the cognitive-behavioural therapy components that are effective (Foley & Spates, 1995; Renfrey & Spates, 1994). Therefore, the important focal point is the reprocessing of the traumatic event.
Therapy typically involoves eight to 12 weekly sessions that are 60 to 90 minutes in length for clients experiencing PTSD from a single traumatic event. Depending on the severity of the trauma and the client's ability to work outside the treatment session, treatment can be extended. The number of sessions is often increased when there are multiple traumas, comorbid disorders, traumatic bereavement or chronic disability resulting from the trauma. Trauma-focused treatment should be undertaken by psychologists or other mental health practitioners who are specifically trained in the treatment of PTSD (ACPMH, 2007).
- Pharmacological interventions should not:
- be used as routine first-line treatment in preference to trauma-focused therapy (ACPMH, 2007; NICE, 2005)
- be used as a preventive intervention following trauma, or
- be used within four weeks of the appearance of symptoms unless the client's distress cannot be managed by psychological treatment alone (ACPMH, 2007).
- Despite the limited evidence base for pharmacological treatment, medications should be considered when clients are:
- unwilling to engage in trauma-focused psychological treatment
- not stable enough to begin psychological treatment (e.g., they are actively suicidal, or are experiencing severe and ongoing life stress such as domestic violence)
- not benefitting from psychological treatment
- experiencing significant dissociative symptoms
- having symptoms so severe they require medication in conjunction with trauma-focused therapy.
- Selective serotonin reuptake inhibitors (SSRIs)
- SSRIs are recommended as first-line, short-term and long-term treatment of PTSD (ACPMH, 2007; NICE, 2005) in the situations described above. The advantages of SSRIs include broad-spectrum properties to reduce PTSD symptoms, as well as the ability to treat comorbid disorders and sleep disturbances (a common complaint in PTSD).
- Dosing recommendations for SSRIs are similar to those for treating depressive disorders: trial for six to 12 weeks and maintenance for six to 12 months (Antai-Otong, 2007). If clients respond to drug treatment, it should be continued for at least 12 months before gradual withdrawal (ACPMH, 2007). Davis et al. (2006) recommend a minimum of 12 to 24 months of treatment for chronic PTSD.
- In the initial stages of SSRI treatment, signs of akathisia (restless leg syndrome), suicidal ideation and increased anxiety and agitation should be noted and monitored. Adults with PTSD who start antidepressants and have an increased suicide risk should be seen one week after initiation of medication (NICE, 2005).
- Serotonin and norepinephrine reuptake inhibitors (SNRIs)
- These are considered second-line medications for PTSD (ACPMH, 2007; Antai-Otong, 2007; NICE, 2005). Dosing recommendations are similar to those for SSRIs.
- Examples include: venlafaxine and bupropion
Assessing Treatment Response
When assessing a client's response to treatment, many primary care practitioners rely on the client's subjective response. This may include the number of re-experiencing symptoms, the level of social or occupational impairment or the activities, people or places the client is avoiding (ACPMH, 2007). In addition, a number of self-report tools, such as the Beck Depression Inventory or the Hamilton Rating Scale for Depression, can provide practitioners with a sense of the client's overall level of distress and impairment. More specific PTSD instruments, such as the ones mentioned earlier in this chapter, are also useful when assessing a client's progress.
**Please note that this information is based on the DSM-IV criteria and changes may have occured in the more recent DSM-5**