Post-Traumatic Stress Disorder: Diagnosis and Treatment – a Public Health approach

1. Post-Traumatic Stress Disorder:Diagnosis and Treatment – a Public Health approach Physicians for Global Survival Facing off for Justice Conference 26 March 2011 Ottawa, Ontario Canada D. C. Lougheed MD and Dale Dewar MD PTSD - PGS March 2011

2. PTSD – Diagnosis, Treatment and Prevention • History of PTSD • Case Presentation • Diagnosis • Military Context • Civilian Context • Making the Diagnosis • Resources • Challenges to Family Doctors • Prevention • Thanks to Dr Colin Cameron and Dr Chantal Whelan, Ottawa, ON. PTSD - PGS March 2011

3. 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. PTSD - PGS March 2011

4. 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. • Recurrent distressing dreams of the event. • 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). • 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 PTSD - PGS March 2011

5. DSM IV – Post Traumatic Stress Disorder PTSD - PGS March 2011

6. Criterion C: Avoidance/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 • 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) PTSD - PGS March 2011

7. Impact of Events scale PTSD - PGS March 2011

8. 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 PTSD - PGS March 2011

9. Criterion E: DurationCriterion F: Functional Significance • 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 PTSD - PGS March 2011

10. PTSD • What can physicians do? • Public Health Approach: • Primary prevention – prevent the illness – eg vaccination polio • Secondary prevention – diagnose and treat with the goal of full recovery and prevention of serious complications – eg strep throat • Tertiary prevention – treat with the goal of reducing the burden of chronic illness or disability – eg osteoarthritis • What are the implications for prevention of the disease called PTSD? PTSD - PGS March 2011

11. PTSD – Military Populations • Diagnostic issues • Stigma • Acute stress • Concurrent disorders – substance, mood, other • Public Health model • Innocculation – basic training, training in hostage situations • Acute – proximity, immediacy, expectation of return to function • Military resources for treatment • Debriefing • OSI clinics – Ottawa (ROH), Halifax, others • Vets groups – self referral PTSD - PGS March 2011

12. PTSD – Special Civilian Populations • Immigrant and Refugee Populations • Cross-cultural issues • Is it depression, schizophrenia, bipolar illness, substance abuse, dementia • Physical symptoms • Stigma, • Cultural explanations of illness • Challenges for interpretors • Chronic and severe mental illness • Dramatic symptoms of psychosis that are difficult to treat • May end up on ACT teams or with MH case managers • High doses of neuroleptic medications with mood symptoms not treated • Shelter clients – refugees, borderline intellectual abilities, language issues, cultural experience of illness • Consider differential diagnosis including mood disorders PTSD - PGS March 2011

13. PTSD - Conclusions • When the response to treatment is poor, check for history of trauma • Consider the diagnosis of PTSD in unusual presentations of psychosis, especially in refugee populations • Consider the use of a cultural interpreter. • Use a rehabilitation (recovery) model of treatment 1. assess state of change-readiness 2. Help the patient set goals and review personal strengths 3. Emphasise gradual improvement if chronic, rapid return to functioning if acute 4. Importance of return to meaningful social roles PTSD - PGS March 2011

14. With thanks to:Grandchildren of Marvin N. Lougheed MD FRCPC PTSD - PGS March 2011