Andrea Auxier, PhD

1. Session # D3b October 5, 2012 Post-Traumatic Stress Disorder and Medical Comorbidities: Screening and Intervention in Collaborative Care Settings Andrea Auxier, PhD Senior Strategist, Colorado Associated Community Health Information Enterprise/ Colorado Community Managed Care Network Senior Clinical Instructor, Department of Family Medicine University of Colorado Denver School of Medicine Christine Runyan, PhD, ABPP Associate Clinical Professor and Director, Fellowship in Clinical Health Psychology Department of Family Medicine and Community Health University of Massachusetts Medical School Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • List reasons for PTSD screening in primary care • Describe how a screening procedure can be implemented • Discuss how health information technology can be utilized to conduct practice-based assessment • Describe how interventions can be designed in collaborative care settings.

4. PTSD – DSM 5 • Experienced, witnessed an event involving actual or threatened death/ serious injury, or threat to physical integrity of self/ others • Intrusion Symptoms • Persistent Avoidance • Alterations in Cognitions and Mood • Hyperarousal and Reactivity Symptoms • Three new symptoms: • Erroneous self- or other-blame • Negative mood states • Reckless and maladaptive behavior

5. Complex PTSD: • captivity • psychological fragmentation • loss of a sense of safety, trust, self-worth, & coherent sense of self • a tendency to be revictimized • pervasive insecurity • often disorganized-type attachment • poor affect regulation • . . .

6. Basic Facts • Prevalence: 8% Lifetime • Not everyone who experiences a traumatic event will develop PTSD • 8% of men and 20% of women develop PTSD after a trauma 

7. Risk Factors • A previous traumatic event • Psychological difficulties prior to the event • Family hx of of psychological difficulties • Extent to which there was a threat to life • Amount of support following the event • Emotional response during the event • Dissociation • Being a child • Being a woman • Being a recent immigrant from a troubled country

8. Why Primary Care? • It’s the principal point of contact • 12% of pts in community settings have PTSD compared to 8% in general population BUT . . . • Patients don’t come in saying they have PTSD • It’s up to us to identify it

9. Psychiatric Comorbidities 88% of men and 79% of women with PTSD meet criteria for another psychiatric disorder. Men: alcohol abuse/dependence; MDD; conduct disorders; drug abuse/dependence. Women: MDD; simple phobias; social phobias; and alcohol abuse/dependence. U.S. Department of Veteran Affairs, National Center for PTSD

10. Trauma Affects Everything

11. Trauma Affects the Body Increased likelihood of: • poor health functioning (mostly self reported) • morbidity (physical exam/lab tests) HTN Asthma • mortality • cardiovascular reactivity • autonomic hyperarousal • disturbed sleep physiology • chronic pain • adrenergic dysregulation • enhanced thyroid function • altered HPA activity

12. Trauma Affects the Brain

13. HPA Axis Adrenal Cortex Arousal, vigilance, startle, conditioned emotional responses via locus coeruleus (NE) CORTISOL Acute stress Pituitary ACTH Beta Endorphin CRF Hippocampus Mineralcorticoid (MR’s) Glucocorticoid (GR’s) Adrenaline

14. Cortisol in PTSD • Persistently low, with spikes during times of stress • A relatively small stressor to most people will trigger a biochemical cascade in someone with PTSD, manifesting as general hyper-reactivity and avoidant numbing, respectively. • No other emotional condition, including depression, panic attacks, or anxiety disorders will produce this profile.

15. Trauma Affects Language Alexithymia: Inability to verbally describe emotions The “I was so upset I couldn’t think straight” phenomenon, magnified.

16. Trauma Affects Memory • Amygdala: Implicit Memory • Skills & habits • Emotional responses • Classically conditioned responses • Reflexive actions • Hippocampus: Explicit Memory • Categorizes & stores temporal & spatial elements of incoming stimuli • Shuts off HPA response to stress • Develops 18-36 months after the amygdala

17. Early Memory • Somatic • Visual • Out of context • Blurred around the edges • Emotional • Non-verbal • Intense

18. Trauma Affects Personality • Difficulty trusting • Irregular moods • Persistent sense of shame • Unstable relationships • Prefrontal cortex damage: • impulsivity, poor planning and judgment Borderline Personality Disorder

19. Trauma Affects Perception • Hostile Attribution Bias: overattributing of hostile intent to others • Correlated with anger & defensive aggression

21. Aggression Offensive: predatory attack, no attempt to escape, anger-motivated (left-brain) • Involves prefrontal cortex, amygdala, lateral hypothalamus Defensive: attack only when escape seems impossible, fear-motivated (right-brain). • Involves amygdala, medial hypothalamus Almost without exception: aggressive behavior is preceded by the perception of some kind of physical or psychological threat

22. Trauma Breeds More Trauma • People who experience a trauma are more likely to experience another one than those who have not. • Physiological contributors: neuroendocrine dysregulation, neuroanatomical damage • Psychological contributors: depression, hostility, poor coping • Behavioral contributors: impulsivity, alcohol/substance use

23. Trauma Costs Money • High rates of healthcare services utilization 2) Difficulty in provider-patient communication leads to: • reduction in active collaboration in evaluation and treatment • increase in the likelihood of somatization • reduction in adherence to medical regimens

24. It’s OK to Ask“But … I’m not sure I want to know the answer.” Patients want you to ask Focus on current symptoms and circumstances, not detailed information about the traumatic event (s) Don’t Reflexively Say “I’m Sorry” Let the patient know that you recognize how difficult it may be for him or her to answer questions If he/she begins to get upset and wants to stop, ask them to let you know. Give them choices and control

25. PC-PTSD Screening • Brief, 4 item Screen for Primary Care • Does not ask patient the traumatic event • Asks Y/N symptoms in the past month • nightmares, intrusive thoughts, on guard or easily startled, feeling detached • Cut off score of 3 recommended • Sensitivity • Women: .70, Men: .94 • Specificity • Women: .84, Men: .92 Prins, et al. (2003). The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9-14

26. Using EHRs for Practice-Based Research • Challenges: • Implementation • Data Entry • Data Extraction • Registries

27. 1 Year of Salud Screenings 2607 patients screened with PC-PTSD • 1884 English-Speaking • 662 Spanish Speaking • 1143 Non-Hispanic White • 1203 Hispanic 311 positive screens = 12% • 229 Diabetes (11.9% positive) • 397 HTN (13.1% positive)

28. When a Patient Discloses Trauma Relax Appreciate she trusted you enough to disclose emotionally painful material Provide psycho-education materials Encourage self-soothing activities – meditation, yoga, vigorous exercise, writing Promote mastery and self-help Write down any medical instructions – assume that under stress people aren’t taking in all the information they need

29. In 15 Minutes?! …Key Principles of Trauma Informed Care Adopted from Weinreb, L. NIAAA Manual Recognize trauma’s central role in health and illness Validate patient’s experience Link symptoms to past experiences of trauma Meet patient where they are Encourage patient to play an active role in goal setting Build trust in relationship Facilitate choice whenever / as much as possible May get worse before it gets better Talk less … Listen more Healing is Possible – Evidence Based Treatments

30. Intervention Goals • Break silence about trauma and abuse • Shift blame from survivor • If relevant, establish short term safety plan • Give the patient control and choice • Contextualize and normalize the experience • Validate coping strategies • Integrate trauma factors in how you conceptualize and address problems • Maintain positive relationship • Offer referrals for services

31. Healing is PossibleEvidence Supported Treatments (A Level Recommendation*) Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007 Narration (oral, written, past tense, imaginal) * Cognitive Therapy, Cognitive Processing Therapy (CPT) * Exposure Therapy * Stress Inoculation Training (SIT) * Psychoeducation * Eye Movement Desensitization and Reprocessing DBT Strategies Mindfulness Based Strategies Complementary and Integrative Modalities (Yoga, Meditation, Acupuncture) Pharmacotherapy (SSRI, SNRI) *

32. Conclusions • Many of our patients are suffering from unrecognized trauma • They most likely will not tell us unless we ask the right questions, at the right time, in the right way • If they don’t have the words to tell us, we have to help them find the words • When they are ready to tell us their stories, we have to be willing to hear them

33. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!