Day # 106: Clinical Pearls for PTSD

Up to this point we have covered core features of PTSD, diagnostic criteria, epidemiology, risk factors, and pathogenesis. Today we are going to have a discussion on clinical pearls for PTSD which will include tips on the clinical interview, validated questionnaires, differential diagnosis, and comorbidities. Let's get started.


Today's Content Level: Beginner; Intermediate



REMINDER 1


Before we start our discussion it will be helpful to review the symptom criteria for post-traumatic stress disorder (PTSD). See full criteria on day # 103: Intro to PTSD.

  • TRAUMA mnemonic

  • Traumatic event -> Exposure to actual or threatened death, serious injury, or sexual violence. Exposure may occur through direct experience or witnessing the trauma.

  • Re-experience -> Intrusive symptoms (memories, nightmares, flashbacks, distress).

  • Avoidance -> Avoids reminders of the trauma.

  • Unable to function -> Mood/Cognitive alterations. May include amnesia, negative beliefs about self/world, distorted self-blame, persistent negative emotion, isolation, inability to feel positive emotion, etc.

  • Month or more of symptoms -> Trauma occurred at any time in the past. Symptoms last > 1 month.

  • Arousal increased -> May include hyper-vigilance, irritability, insomnia, etc.

  • Specifiers

  • With dissociative symptoms (depersonalization or derealization)

  • With delayed expression (full criteria not met until >6 months after the event)


•Keep in mind that the symptoms of PTSD can vary person to person. Some may have a pronounced fear response with significant hyperarousal such as anger/irritability, startle response, hyper-vigilance, and frequent flashbacks and psychological distress. Many individuals may appear more isolative, avoidant, anxious, anhedonic, and sometimes believe they are protecting their family by doing so. This is one reason why PTSD used to be included in the anxiety disorder section in DSM-3 and DSM-4.


•Patients with PTSD may initially seek help due to urging from family members or friends. They may also first see primary care and other non-psychiatric providers for physical consequences of PTSD such as insomnia, chronic pain, or GI distress.


Potential limitations of interviewing these patients include minimization of symptoms, avoidance behaviors, memory deficits, or exaggeration for secondary gain. It is also invaluable to appreciate if there are any culture-bound experiences of stress. Examples include ataque de nervios in certain hispanic cultures and taijin kyofusho in japanese culture.



CLINICAL INTERVIEW


Here are some sample questions to give you an idea for how you can screen for PTSD symptoms:

  • Do you have a trauma history? Have you or someone you know experienced an event in which you feared for your life?

  • Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. Examples include a physical or sexual assault, abuse, a serious accident, a war, or seeing someone seriously killed or injured. Have you experienced this kind of event? (PC-PTSD-5)

  • In the past month how often have you had repeated, disturbing, and unwanted memories of the stressful experience? (PCL-5 #1)

  • How much effort have you made to avoid thinking or talking about the event, or doing things which remind you of what happened? (SPRINT #2)

  • To what extent have you lost enjoyment for things, kept your distance from people, or found it difficult to experience feelings? (SPRINT #3)

  • Do you ever blame yourself for the event? Are you depressed?

  • In the past month have you been constantly on guard, watchful, or easily started? (PC-PTSD-5)


Overview of the clinical interview:

  • Clarify whether the stressful event meets "criterion A". Trauma = Exposure to actual or threatened death, serious injury, or sexual violence. Exposure may occur through direct experience or witnessing the trauma. (What is trauma, anyway?)

  • Clarify onset/duration of symptoms with patient and family. Document when symptoms first occurred after the trauma (acute or delayed) and if they have had any symptom free periods after first experiencing symptoms.

  • Screen for other traumatic events that may have occurred during childhood or earlier in life.

  • Remember to ask about each symptom cluster (intrusive symptoms; avoidance behaviors; mood/cognitive alterations; hyperarousal; dissociative symptoms)

  • Screen for how their symptoms are affecting their function to include school/work/social/relationship difficulties, avoidance behaviors, concentration, insomnia/nightmares, etc.

  • Psychiatric review of systems - particular attention to anxiety disorders, depressive disorders, substance use disorders, sleep disorders, traumatic brain injury, and personality disorders.

  • Substance use - determine if comorbid substance abuse, particularly alcohol.

  • Medical history, past treatment history, and relevant family history.

  • Risk assessment for suicide and aggression - risk/safety assessments covered in full here and here. Remember that PTSD independently increases the risk for suicidal ideations and suicide attempts. 2

  • Rating scales: The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is a long structured clinical interview and is the gold standard for diagnosis of PTSD. Helpful screeners include the Primary Care PTSD Screen (PC-PTSD-5) or the Trauma Screening Questionnaire (TSQ). The PTSD Checklist for DSM-5 (PCL-5) is often used to measure PTSD severity and is used in the initial treatment planning and to monitor treatment progress.


COMORBIDITIES 3, 4


Post-traumatic stress disorder (PTSD) is highly co-morbid with other psychiatric disorders as well as general medical conditions. Individuals with PTSD are 80% more likely than those without PTSD to meet criteria for at least one other mental disorder. There are multiple reasons for this including shared genetic and environmental vulnerabilities, potential causal relationships, and consequences of treatment.

  • Anxiety disorders (~50-80%) are common (generalized anxiety disorder; panic disorder; social anxiety disorder; separation anxiety disorder)

  • Depressive disorders (~40-60%) (major depressive disorder; persistent depressive disorder)

  • Substance use disorder, commonly alcohol (~8-14%)

  • Personality disorders, specifically there can be overlap with borderline personality disorder or antisocial personality disorder. Sometimes called "complex PTSD".

  • Traumatic brain injury (TBI). Mild TBI cases are estimated to be seen in ~50% of U.S. military personnel / combat veterans deployed to recent wars in Afghanistan/Iraq who have a diagnosis of PTSD.

  • Common somatic features OR medical comorbidities -> hypertension, tachycardia, angina, stomach ulcer, chronic pain, and insomnia.



DIFFERENTIAL DIAGNOSIS 5


•Before making any psychiatric diagnosis it is important to consider other related disorders and appropriately determine the best fit according to the patients symptoms, biological, psychological, and social factors.


Differential diagnosis:

  • Acute stress disorder: As discussed in an earlier post, acute stress disorder both involve exposure to a traumatic event and the symptom criteria are nearly identical. The difference lies in the timing of symptoms. Acute stress disorder = trauma occurred < 1 month ago. Symptoms last > 3 days and < 1 month.

  • Adjustment disorder: Development of behavioral/emotional symptoms after an identifiable stressful event. Either the stressor does not meet "criterion A" of a traumatic event OR if it does the patient is not experiencing the rest of the PTSD symptom criteria.

  • Anxiety disorders: PTSD and anxiety disorders share common features to include anxiety, irritability, avoidance, difficulty concentrating, insomnia, panic/hyperarousal, etc. To diagnose PTSD these symptoms not to be associated with a specific traumatic event.

  • Depressive disorders: PTSD and depressive disorders share common features, particularly the negative alterations in cognition and mood. Depression may precede the traumatic event or occur after.

  • Psychotic disorders: Distinguish the flashbacks seen in PTSD from perceptual disturbances seen in psychotic disorders (hallucinations, illusions). When you see perceptual disturbances, particularly in children, make sure to screen for PTSD.

  • Dissociative disorders: Dissociative symptoms can co-occur with PTSD and the specifier of PTSD with dissociative symptoms should be used. If the patient experiences dissociative symptoms without meeting other criteria for PTSD then consider other dissociative disorders (dissociative amnesia, depersonalization disorder, derealization disorder).

  • Personality disorders: Maladaptive patterns of behavior and interpersonal difficulties are core features of personality disorders, however if these started or were significantly worsened after exposure to a traumatic event it may be an indication of PTSD rather than a personality disorder. The relationship of borderline personality disorder and PTSD is an area of lively discussion and this is sometimes called"complex PTSD".

  • Traumatic brain injury (TBI): Brain injury may occur in the context of certain traumatic events (motor vehicle accidents, physical assault, combat, bomb blasts, etc.). Symptoms of PTSD and TBI can overlap such as irritability, concentration deficits, and changes in mood. Screen for symptoms more specific to PTSD such as re-experiencing/intrusive symptoms and avoidance behaviors.



CONCLUSION


I hope you enjoyed these clinical pearls. Today's lesson was geared towards a beginner/intermediate audience, but I hope all of the readers got something out of today's topic.


Resources for today's post include: Kaplan and Sadock's Comprehensive Psychiatry, DSM-5, First Aid for the Psychiatry Clerkship, and Pocket Psychiatry.













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