PTSD Defined: Why discuss PTSD and pain? Alicia Harding, RN-C, FNP-C Gretchen Noble, PsyD

Transcription

1 Alicia Harding, RN-C, FNP-C Gretchen Noble, PsyD Why discuss PTSD and pain? The symptoms reported by your patients may represent an undiagnosed disorder. Mental health impairment may complicate physical symptoms and may impair a patient s ability to cope with and/or selfmanage their pain or illness. PTSD requires psychological intervention and/or psychotropic medication. Without appropriate treatment, PTSD will likely cause notable impairment in an individual s day-to-day functioning. PTSD and pain have a reciprocal, negative affect on each other. PTSD Defined: Post-traumatic stress disorder (PTSD) is a debilitating illness characterized by symptoms of re-experiencing, avoidance, emotional numbing and hyperarousal resulting from an emotionally traumatic event with actual or perceived threat. (American Psychiatric Association, 2000) 1

2 Diagnostic Criteria: PTSD A. Stressor B. Intrusive Recollection C. Avoidant / Numbing D. Hyperarousal E. Duration F. Impaired Functioning Stressor Criterion: 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. Children may present with disorganized or agitated behavior. Traumatic Events: Combat or military exposure Child sexual or physical abuse Terrorist attacks Sexual or physical assault Serious accidents, such as a car wreck. Natural disasters, such as a fire, tornado, hurricane, flood or earthquake. 2

3 Intrusive Recollection Criteria: The traumatic event is persistently re-experienced in at least one of the following ways: Recurrent and intrusive distressing recollections 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 Physiologic reactivity upon exposure to internal or external cues Avoidant / Numbing Criteria: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least 3 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 Sense of foreshortened future Hyperarousal: Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least 2 of the following: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilence Feeling tense or on edge Exaggerated startle response 3

4 Reactions in Children: Young children: Repetitive play may occur in which themes or aspects of the trauma are expressed Frightening dreams without recognizable content New-onset bedwetting Forgetting how or being unable to speak Excessive clinginess to parents or other adults Older children / Adolescents: More like adult reactions May become disruptive, disrespectful or destructive Greater feelings of guilt (Hamblen, 2006) What patients say when they present for treatment: I have PTSD. Primary complaints upon presentation for treatment: Insomnia Nightmares Social withdrawal / Isolation Family / marital dysfunction Hazardous driving, Speeding tickets, Accidents Work problems Aggression / Anger Anxiety symptoms / Panic Suicidality Somatic symptoms Substance abuse Depression Poorly treated pain Headaches / Chest pain 4

5 Primary Care PTSD Screen (PC-PTSD) Scale\Instructions: In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: Have had nightmares about it or thought about it when you did not want to? YES / NO Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO Were constantly on guard, watchful, or easily startled? YES / NO Felt numb or detached from others, activities, or your surroundings? YES / NO Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. PTSD Symptom Checklist: Self-report measure Takes approximately 5-10 minutes to complete a PCL The PCL has 3 different versions: Military, Civilian, Specific A diagnosis can be made by: 1.) Calculating the total symptom severity score (range = 17-85) by summing the scores from each of the 17 items (Each item is given a value of 1-5 with 5 being extremely distressing) 2.) Determine whether an individual meets DSM-IV symptom criteria by looking for symptoms rates as Moderately or above (Response 3-5) 1 B item (questions 1-5) 3 C items (questions 6-12) 2 D items (questions 13-17) Comorbid Pain & PTSD: Symptom Overlap Anxiety Hyperarousal Avoidant behaviors Emotional lability Elevated somatic focus Hypervigilance Dysregulated startle response Dysregulated pain modulation (Asmundson & Coons, 2002) 5

6 Helpful Responses: Ensure privacy, speak privately with the patient Provide education: trauma can lead to emotional AND physical symptoms Avoid assumptions about how a specific trauma affected your patient Acknowledge distress and provide an empathetic response ( I m sorry that you have had such terrible nightmares ) Show interest and concern Unless you have appropriate mental health training and will be the person to evaluate or treat the patient, it is not advisable to elicit a detailed account of the trauma or to challenge the patient's report in any way. PTSD Prevalence: Adults The National Comorbidity Survey Replication PTSD was assessed among 5,692 participants using DSM-IV criteria. Lifetime prevalence of PTSD among adult Americans: 6.8% Current past year PTSD prevalence: 3.5% The lifetime prevalence of PTSD among men: 3.6% The lifetime prevalence of PTSD among women: 9.7% PTSD Prevalence: Children Studies indicate that 15-43% of girls and 14-43% of boys experience at least one traumatic event during their childhood. Of those children and adolescents who have experienced a trauma, 3-15% of girls and 1-6% of boys develop PTSD. High prevalence of PTSD in at-risk samples: ~100% of children who witness a parental homicide or sexual assault develop PTSD. ~90% of sexually abused children ~77% of children exposed to a school shooting ~35% of urban youth exposed to community violence (National Center for PTSD) 6

7 PTSD Prevalence: Veterans The RAND Corporation, Center for Military Health Policy Research, published a population-based study in Examined the prevalence of PTSD among previously deployed Operation Enduring Freedom and Operation Iraqi Freedom service members PTSD was assessed using the PCL in 1,938 participants. The prevalence of current PTSD was 13.8%. Risk Factors: Risk factors for PTSD include: Having a history of mental illness Living through dangerous events and traumas Getting hurt Seeing people hurt or killed Feeling horror, helplessness or extreme fear Having little or no social support after the event Dealing with extra stress after the event, such as loss of a loved one, pain and injury or loss of a job or home (Brewin, Andrews & Valentine, 2000) Factors Promoting Resilience: Resilience factors for PTSD include: Finding a support group after a traumatic event Seeking out support from other people, such as friends and family Feeling good about one s own actions in the face of danger Having effective/healthy coping strategies Being able to act and respond effectively despite feeling fear (Charney, 2004) 7

8 Chronic Pain in Patients with PTSD: 20% of military veterans with PTSD developed chronic pain >50% of firefighters with PTSD reported significant musculoskeletal pain 21% in those without comorbid PTSD 20-30% of community mental health patients with PTSD reported a persistent pain syndrome (Asmundson, 2002) PTSD in Patients with Chronic Pain: Studies find 10-50% of those receiving care in pain management clinics meet criteria for PTSD National Comorbidity Study indicates that patient with musculoskeletal pain are 4x more likely to develop PTSD MVA Survivors 39:% Assault Victims 39% Homicide Survivors 7% Rape Survivors 64% Vietnam Veterans 15.2% of males; 8.5% of females (National Center for PTSD) Possible Linking Mechanisms: 1) They co-occur, but are unrelated. 2) Once condition causes the other. 3) Some third factor causes both: Shared Vulnerability 4) Each influences the other: Mutual Maintenance 8

9 Shared Vulnerability: Individual factors predispose certain individuals to develop both chronic pain and PTSD symptoms when exposed to certain life events: *Anxiety Sensitivity: Dispositional tendency to become fearful; more specifically refers to the fear of anxiety symptoms based on the belief that the symptoms will cause harmful consequences Trait Negative Affectivity Harm Avoidance Genetic Predisposition: Serotonergic Dysregulation (Asmundson & Coons, 2002) Mutual Maintenance: (Sharp & Harvery, 2001) Neurobiology: 9

10 Potential Negative Outcomes: Sleep Disturbance Stress Related Illness Complicated Pain Disability Biological Psychological Substance Abuse Addiction Psychiatric Illness Suicide Family Discord Abuse Employability Workplace Productivity Cost to Society Social Case Example: 17-year old male Symptoms of Acute Stress Insomnia; purposeful avoidance of sleep due to nightmares Hypervigilence Intrusive images and thoughts Re-experiencing of trauma / flashbacks Avoidance Emotionally detached / flat affect Irritable / tense / on edge Angry outbursts / poor frustration tolerance Pain Complaints Onset: 17 days ago following MVA Duration: Constant Location: left shoulder and neck with radiation to left hand Character: burning/shooting Aggravating factors: movement, light touch, stress Alleviating factors: Nothing Associated symptoms include: allodynia, numbness to left 4 th and 5 th digits, anxiety, sleep disturbance, nightmares Treatment of Pain: Prior to pain consultation: Norco 10/325mg PO Q4hr scheduled Morphine 7.13mg IV Q2hr PRN pain x2 doses Morphine 6.04mg IV Q2hr PRN pain x6 doses Tizanidine 10mg PO BID Following pain consultation: Gabapentin 100mg PO TID (Titrated to 1200mg/day) Ketorolac 30mg IV Q6hr ATC Methocarbamol 1,000mg PO Q6hr ATC Oxycontin 40mg PO Q12hr ATC Lidocaine Patch applied daily Bowel regimen: Senna/Docusate and Miralax Massage therapy Intensive PT twice daily Intensive OT twice daily Child life involvement for goal setting / scheduling Patient / family education and empowerment 10

11 Treatment of PTSD: Identification of ongoing trauma exposure Abusive relationship Witnessing domestic violence or parental drug use Identification of mental health comorbidities Depression Panic Disorder Substance abuse Suicidality Psychotherapy Individual or group Cognitive-behavioral therapy (CBT) Pharmacological intervention Cognitive-Behavioral Therapy: Exposure therapy Helps patient to face and control fear Exposes to previous trauma in a safe environment Assists patient in coping with the feelings brought about by the trauma Cognitive restructuring Helps to make sense of negative memory Looking at event in a more realistic manner Stress-inoculation training Symptom reduction via skill-building for anxiety reduction Trauma-focused CBT Skills training Exposure therapy Comments & Questions 11

12 References: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, Asmundson, G., Coons, M. (2002). PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Canadian Journal of Psychiatry, 47(10) Brewin, C., Andrews, B., Valentine, J. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting Clinical Psychology, 68(5) Charney, D. Psychobiological mechanisms of resilience and vulnerability: Implications for successful adaptation to extreme stress. American Journal of Psychiatry, 161(2) Child Welfare Information Gateway. (2009). Understanding the Effects of Maltreatment on Brain Development. Available from Hamblen, J. PTSD in children and adolescents: A National Center for PTSD Fact Sheet. Accessed August 8, National Institute of Mental Health (NIMH). Sharp, T., Harvey, A. (2001). Chronic pain and posttraumatic stress disorder: mutual maintenance. Clinical psychology review. 21(6)