L. Treatment in Primary Care

BACKGROUND

Primary care providers often treat patients with mental health disorders. Many options are available to primary care providers to treat stress-related disorders and to relieve the burden of suffering for ASD/PTSD patients, including pharmacotherapy, supportive counseling, hypnosis, and referral resources.

Since people who develop ASD are at greater risk of developing PTSD, they should be identified and offered treatment as soon as possible. Research suggests that relatively brief but specialized interventions may effectively prevent PTSD in some subgroups of trauma patients.

RECOMMENDATIONS

ALL PATIENTS with Stress Related Disorders

1. A supportive and collaborative treatment relationship or therapeutic alliance should be developed and maintained with patients with ASD/PTSD inclusive of their input in treatment planning.
2. Primary care providers should routinely provide the following services for all patients with stress related disorders, especially those who are reluctant to seek specialty mental health care:
   • Supportive counseling
   • PTSD-related education
   • Regular follow-up and monitoring of symptoms
   • Early recognition of PTSD
3. Primary care providers should consider consultation with mental health providers for patients with ASD/PTSD, who warrant a mental health referral but may be reluctant or refuse it.
4. Primary care providers should take leadership in convening a collaborative team for patients with PTSD. Team members may include the primary care providers, mental health specialists, chaplains, pastors, social worker, occupational or recreational therapists, Vet Centers, Family Support Centers, Exceptional Family Member Programs, VA Benefit Counselors, peer-support groups, and others.

ASD

5. Because ASD does not occur in all people who later develop PTSD, consider treatment for acutely traumatized people with ASD, with severe PTSD symptoms as well as for those who are incapacitated by acute psychological or physical symptoms.
6. Patients with ASD should be monitored for development of PTSD. The use of validated PTSD symptom measure such as the PTSD Checklist should be considered (see Appendix D).
7. Primary care providers should consider pharmacologic management of disruptive symptoms (e.g., sleep) (see Interventions: Pharmacotherapy for ASD).
8. Brief (4 to 5 sessions) of cognitive behavioral therapy (CBT) is an effective early intervention for patients with ASD. In addition to targeted brief interventions, some trauma survivors may benefit from follow-up provision of ongoing counseling or treatment.

PTSD

9. All patients with PTSD should have a specific primary care provider assigned to coordinate their overall healthcare.
10. Pharmacologic management of PTSD or related symptoms may be initiated based on a presumptive diagnosis of PTSD. Long-term pharmacotherapy will be coordinated with other intervention once the patient has been referred to the mental health clinic (see Interventions: Pharmacotherapy for PTSD).
11. Primary care providers should perform a brief PTSD symptom assessment at each visit. The use of a validated PTSD symptom measure, such as the PTSD Checklist, should be considered (see Appendix D).
12. Primary care providers should assess patients with PTSD for associated high-risk behaviors (e.g., smoking, alcohol/drug abuse, HIV and hepatitis risks) and comorbid medical and psychiatric illnesses.

DISCUSSION

Establishing Therapeutic Alliance

Many people with PTSD find that their relationships with others have changed as a result of exposure to trauma. They often report that they have difficulty trusting others, are suspicious of authority, dislike even minor annoyances, and generally want to be left alone. Since the doctor-patient relationship draws heavily on trust, respect, and openness, and since the relationship often has to be formed in a bureaucratic setting, the doctor may find the PTSD patient to be withholding, negativistic, or even hostile at the initial meeting. He or she may seem to have “an attitude.” Over the years, many combat veterans have been misunderstood and misdiagnosed by otherwise competent professionals over exactly this dynamic. In transference terms, it's as if the patient brings to the initial meeting the full force of the traumatic experience. He may take on the persona of the combat soldier, the rape victim, or the assault or accident victim. If a therapeutic relationship is to have any opportunity to develop, the treatment provider often must make an internal shift from being a medical or psychiatric detective to being open, available and honest on a personal level. Some providers naturally relate in this way, but others have found that they are most useful when they “put on the white coat” and withdraw into ‘professional' role. Medical schools and graduate schools often teach this role however, with the combat veteran, the truly professional stance is the one of caring and concerned involvement on a personal level. The provider who relates from a stilted defensive role will meet a veteran who does the same. If the provider wants to assist the patient in finding and re-developing trust in a core identity that has been shifted by combat or sexual assault, the provider must relate from his/her own core identity. In short, the clinician who can realte honestly and openly is more likely to have a patient who is willing to relate to him/her as a fellow human being and an effective partner in treatment.

A general understanding of what has happened to the veteran is critical in this process of developing a therapeutic relationship. Every provider working with combat veterans should be advised to read some basic material on the experience of combat and watch videotape of the same. Unsettling though it may be, the provider must understand the feelings of profound rage and grief that are involved in traumatic experiences. These feelings will be present in the interview setting and must be met with respect at a minimum.. Another useful way to think about the combat veteran is that the individual has been subjected to an experience that has moved them away from their center and at the same time has developed a persona with PTSD diagnostic characteristics. At first, it may seem that this person has no real center in much the same way that a person with borderline personality disorder seems to lack a center. Their identity seems to have been redefined by their traumatic experience, and the provider is not accustomed to dealing with the features of this apparent new identity. The requirement is simply to first understand this aspect of the veteran's persona, and then to accept it, empathize with it, get curious about it, and welcome it home. The veteran himself is struggling with exactly the same tasks.

ASD Treatment

The relationship between ASD and PTSD was examined in three prospective studies. Classen and colleagues (1998) studied the acute stress reactions of bystanders to a mass shooting in an office building. They assessed 36 employees (bystanders) 8 days after the shooting. Between 7 and 10 months later, they reassessed 32 employees for posttraumatic stress symptoms and found that 33 percent of them met criteria for ASD and that meeting criteria for ASD was a strong predictor of PTSD (accounting for 19 percent of the variance),as well as intrusion (accounting for 53 percent of the variance) and avoidance (accounting for 45 percent of the variance).

In another prospective study, Harvey and Bryant (1998a) examined the relationship between ASD and PTSD in 92 motor vehicle accident survivors. From the twelve participants (13 percent) who met criteria for ASD within 2 to 26 days of the accident, 78 percent met criteria for PTSD 6 months later. Nineteen participants (21 percent) met some but not all of the criteria for ASD; of the 15 individuals available for follow-up, 9 (60 percent) met criteria for PTSD. From the 61 participants who did not meet the criteria for ASD; only 2 met criteria for PTSD. This study provides strong evidence of ASD being a predictor of PTSD. Nevertheless, Harvey and Bryant concluded that the current criteria for ASD might be too stringent for ASD to be used to predict the risk for PTSD. Bryant and Harvey (1998b) also examined the relationship between ASD and PTSD for a subset (n=79) of the motor vehicle accident survivors who suffered mild traumatic brain injury as a result of the accident. They were particularly interested in the utility of ASD as a predictor of PTSD in individuals with postconcussive symptoms that could overlap with ASD symptoms. Their results were similar to previously reported findings: 14 percent met criteria for ASD; 6 months after the event, 82 percent of those with ASD also met criteria for PTSD.

In another prospective study, Brewin and colleagues (1999) evaluated the use of ASD to predict PTSD in 157 survivors of violent assault. Participants were assessed for several ASD symptoms using items from the Posttraumatic Stress Disorder Symptoms Scale (Foe et al. 1993); additional items were generated to determine whether the event met the ASD criterion. Nineteen percent of participants met criteria for ASD and 20 percent met criteria for PTSD at 6-month follow-up. They found that meeting full criteria for ASD was a better predictor of PTSD than any of the symptom clusters. Eighty three percent of participants who met criteria for ASD were diagnosed with PTSD six months later.

Research suggests that relatively brief but specialized interventions may effectively prevent PTSD in some subgroups of trauma patients. Several controlled trials have suggested that brief (i.e., 4 to 5 sessions) cognitive-behavioral treatments, comprised of education, breathing training/relaxation, imaginal and in vivo exposure, and cognitive restructuring, delivered within weeks of the traumatic event, can often prevent PTSD in survivors of sexual and non-sexual assault (Foa et al., 1995) and MVAs and industrial accidents (Bryant et al., 1998a , 1999). Brief intervention with patients hospitalized for injury has been found to reduce alcohol consumption in those with existing alcohol problems (Gentilello et al., 1999). Controlled trials of brief early intervention services targeted at other important trauma sequelae (e.g., problems returning to work, depression, family problems, trauma recidivism, and bereavement-related problems) remain to be conducted, but it is likely that targeted interventions may be effective in these arenas for at least some survivors.

Two well-designed studies offer evidence that brief treatment interventions utilizing a combination of cognitive behavioral techniques may be effective in preventing PTSD in a significant percentage of subjects. In a study of a brief treatment program for recent sexual and nonsexual assault victims who all met criteria for PTSD, Foa at al., (1995) compared repeated assessments vs. a Brief Prevention Program (BPP) (four sessions of trauma education, relaxation training, imaginal exposure, in vivo exposure, and cognitive restructuring). Two months posttrauma, only 10 percent of the BPP group met criteria for PTSD, whereas 70 percent of the repeated assessments group met criteria for PTSD. In a study of motor vehicle and industrial accident victims who met criteria for ASD, Bryant et al., (1998a) compared five sessions of nondirective supportive counseling (support, education, and problem-solving skills) vs. a brief cognitive-behavioral treatment (trauma education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in vivo exposure to avoided situations). Immediately post-treatment, 8 percent in the CBT group met criteria for PTSD, versus 83 percent in the supportive counseling group. Six Months Post-Trauma, 17 percent in CBT met criteria for PTSD, versus 67 percent in supportive counseling. One important caveat to these interventions is that dropout rate was high, and the authors concluded that those with more severe symptoms may need supportive counseling prior to more intensive cognitive behavioral interventions.

In addition to targeted brief interventions, some trauma survivors may benefit from follow-up provision of ongoing counseling or treatment. Candidates for such treatment would include survivors with a history of previous traumatization (e.g., survivors of the current trauma who have a history of childhood physical or sexual abuse) or preexisting mental health problems.

PTSD Treatment

Pharmacologic management of PTSD and related symptoms
It is usually feasible, depending on the provider’s confidence and motivation in treating PTSD, to consider offering pharmacological therapies within the primary care setting.

• The symptom relief that medication provides allows most patients to participate more effectively in psychotherapy when their condition may otherwise prohibit it.
• Acute (emergency room) administration of propranolol in the immediate aftermath of a traumatic event appeared to prevent the later development of physiological hyperreactivity but neither reduced ASD nor prevented subsequent PTSD.
• Antidepressant medications may be particularly helpful in treating the core symptoms of PTSD—especially intrusive symptoms.

Refer to the evidence-based pharmacologic strategies for ASD and PTSD, summarized in the section on Pharmacotherapy Intervention of this guideline. The section also includes medication tables that summarize indications/benefits, contraindications/adverse effects, and usual dosages.

Supportive Counseling
Primary care-based supportive counseling for PTSD has received little study to date and cannot be endorsed as an evidence-based psychotherapeutic strategy. However, it may be the sole psychotherapeutic option available for the patient with PTSD who is reluctant to seek specialty mental health care. Elements for primary care-based supportive counseling for PTSD include helping patients brainstorm and solve problems of everyday living and problems presented by PTSD symptoms and sequelae (e.g., agoraphobia or other phobic avoidance), provision of PTSD-related psychoeducation, assisting patients in recognizing early signs and symptoms of PTSD relapse, and encouraging initiation of active coping strategies such as physical activity, relaxation strategies, and social and recreational activities.

Regular follow-up and monitoring
Regular follow-up with monitoring and documentation of symptom status should be part of primary care treatment of any chronic disease. Primary care providers should perform a brief PTSD symptom assessment at each visit (no more than quarter-annually is usually needed for the patient with apparently stable PTSD symptoms). The mnemonic “DREAMS” is an effective way for some primary care providers to remember cardinal PTSD symptom domains (Lange, 2000):

• Detachment
• Reexperiencing the event
• Event had emotional effects
• Avoidance
• Month in duration (symptoms for >1 month)
• Sympathetic hyperactivity or Hypervigilance

The use of a pencil-paper measure of PTSD symptom severity such as the PTSD Checklist (see appendix D PCL) should be considered. Scores on the PCL may be plotted serially over time to create a longitudinal record of symptom severity and may be helpful for recognizing environmental (e.g., renewed proximity to a previously abusive parent) or seasonal (e.g., anniversary of a traumatic war event) precipitants of PTSD symptoms.

Early recognition of a psychosocial crisis and referral to specialists
Primary care providers may be the first to recognize that a patient with PTSD is entering a related psychosocial crisis. Depending on the severity and disability associated with the crisis and the potential for harm to the patient or others, the primary care provider may be obliged to obtain specialty mental health services, even if that patient is reluctant to seek those services.

Coordination of general health care
The traditional role of the primary care provider as the coordinator of various disciplines and consultants involved in the treatment of any single patient is especially relevant for the patient with PTSD. Particularly in patients with chronic PTSD, medically unexplained symptoms or problems with substance use (including smoking) may lead to the need for a wide range of specialists. Coordination of these services is important to avoid confusion and unnecessary health care use.