A. Patient Presenting To Mental Health With Suspected PTSD

BACKGROUND

Posttraumatic stress disorder (PTSD) is the development of characteristic and persistent symptoms along with difficulty functioning after exposure to a life-threatening experience or to an event that either involves a threat to life or serious injury. In some cases the symptoms of PTSD disappear with time, whereas in other cases they persist for many years. PTSD often occurs with or precedes other psychiatric illnesses.

The symptoms required for the diagnosis of PTSD may be divided into 3 clusters and should be present for at least 1 month.

• Intrusion or re-experiencing - memories of the trauma or "flashbacks" that occur unexpectedly; these may include nightmares, intrusive mental images or extreme emotional distress and/or physiological reactivity on exposure to reminders of the traumatic event
• Avoidance - avoiding people, places, thoughts, or activities that bring back memories of the trauma; this may involve feeling numb or emotionless, withdrawing from family and friends, or "self-medicating" by abusing alcohol or other drugs
• Hyperarousal - feeling "on guard" or irritable, having sleep problems, having difficulty concentrating, feeling overly alert and being easily startled, having sudden outbursts of anger

PTSD is frequently under-recognized and therefore, often goes untreated. In a general survey in Israel, 9 percent of patients in a primary care setting were found to have PTSD. Only 2 percent of the sample was recognized as having the disorder. Despite this lack of recognition, more than 80 percent of men and 92 percent of women with PTSD in this survey reported significant distress from the disorder. Even individuals with "subthreshold" symptoms who do not meet full diagnostic criteria for the disorder suffer from significant impairment, including increased suicidal ideation.

Patients are most likely to present to primary care with unexplained somatic and/or psychological symptoms, in this case sleep disturbance, night sweats, fatigue, difficulty with memory or concentration, etc. In some cases, PCPs may consider PTSD early and use this guideline first, whereas in others it may be useful to follow the algorithms and recommendation of the DoD/VA guideline for Post Deployment, the VA/DoD guideline for medical unexplained symptoms or the VA/DoD guideline for management of depression in primary care. All this guidelines provide a link to this module when appropriate.

RECOMMENDATIONS

Assessment in Mental Health Specialty

1. Mental health clinicians should obtain a comprehensive diagnostic assessment that includes, but is not limited to, the symptoms that characterize PTSD (see DSM IV, 1994).
2. Routine use of self-administered checklists may ensure systematic, standardized, and efficient review of the patient’s symptoms and history of trauma exposure (see Appendix D [PCL-C]).
3. The assessment should also include review of other salient symptoms (guilt, dissociation, derealization, depersonalization, reduction in awareness of surrounding) that impact on treatment decisions. Structured psychiatric interviews, such as the clinician administered PTSD scale (CAPS), may be considered.

See Module B: Management of ASD & PTSD in Primary Care, Annotation B - Assessment Of Trauma Exposure