Download Post-Traumatic Stress Disorder - Physicians for Global Survival

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
1
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
2
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
3
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 anPTSD
aspect
the2011
traumatic event
- PGSof
March
4
DSM IV – Post Traumatic Stress Disorder
PTSD - PGS March 2011
5
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
6
Impact of Events scale
PTSD - PGS March 2011
7
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
8
Criterion E: Duration
Criterion 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
9
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
10
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
11
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
12
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
13
With thanks to:
Grandchildren of Marvin N. Lougheed MD FRCPC
PTSD - PGS March 2011
14