Ron 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 DSM5 released March 2013 ID: 918581
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Slide1
Post Traumatic Stress Disorder for the Primary Care and Emerg PA
Ron Andersen CCPA
Slide2Disclosures
I am employed by the CF, currently.
I have no financial disclosures or sponsorships to disclose.
I am
NOT
a psychiatrist.
Slide3Objectives
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)
Slide4What does PTSD look like??
Can anyone easily identify someone with PTSD??
Can you quickly see who is at risk??
Slide5What does PTSD look like…
Slide6What does PTSD look like…
Slide7What does PTSD look like…
Slide8What does PTSD look like…
Slide9What does PTSD look like…
Slide10Who is vulnerable???
Slide11DSM – 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
Slide12DSM – 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.
Slide13DSM – 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
Slide14DSM – 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
Slide15DSM – 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
Slide16DSM – 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)
Slide17DSM – 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
Slide18DSM – 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
Slide19DSM-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
Slide20DSM-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.
Slide21DSM-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. )
Slide22DSM-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)
Slide23DSM-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)
Slide24DSM-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”).
Slide25DSM-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)
Slide26DSM-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)
Slide27DSM-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).
Slide28DSM-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
Slide29DSM-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.
Slide30DSM-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
Slide31DSM-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
Slide32The 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….
Slide33The 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’….
Slide34The 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?
Slide35Treatment 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)
Slide36Treatment Modalities
Psychotherapy which can include;
Cognitive Behavioral Therapy
Re-exposure therapy
EMDR (Eye movement desensitization and reprocessing)
Trauma focused
Coping mechanism optimization
Psychodynamic
Eclectic
Slide37Questions?? Comments?
Okay the good stuff is next…..
Slide38Resources
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.
Slide39Resources
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
Slide40Resources
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