Definition. Objectives. PTSD: The Unrecognized Symptom Jorge I. Ramirez, MD, FAAHPM Caroline Schauer, RN, BSN, CHPN

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Objectives Describe Post Traumatic Stress Disorder (PTSD) and the population affected by this

suffering from PTSD Definition An anxiety disorder that can develop when a person has

1 PTSD: The Unrecognized Symptom Jorge I. Ramirez, MD, FAAHPM Caroline Schauer, RN, BSN, CHPN VISN 23 Hospice and Palliative Care Objectives Describe Post Traumatic Stress Disorder (PTSD) and the population affected by this disorder Identify team specific interventions that can be offered to those identified to be suffering from PTSD Definition An anxiety disorder that can develop when a person has experienced, witnessed, or was confronted with an event(s) that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

2 Characteristics of PTSD History of trauma Re-experiencing Avoidance/numbing Heightened physiological arousal (sleep disturbance, irritability, hypervigilance) Common traumatic events Child abuse (physical, psychological, or sexual) Physical assault: sexual, domestic violence, elder abuse/neglect Traumatic experiences: war combat, survivors of catastrophic events (9/11, World Trade Center bombing, holocaust) Major medical illness trauma (survivors of cancer, HIV, etc) High Risk Populations Veterans Veterans who were POWs Refugees from war-torn countries Americans living in urban, inner city, poor neighborhoods Patients admitted to surgical trauma wards Victims of disasters, traffic accidents and interpersonal violence

3 Prevalence 7.8% of Americans Women twice at risk as men Lower socioeconomic status, lower educational levels and poor social support increase risk Cumulative trauma and peri-traumatic dissociation increases risk Combat veterans have 60% prevalence Additional considerations Patients with PTSD may not remember the traumatic event, especially if a long time has elapsed, or if the patient has repressed the traumatic event Patients with dementia can experience PTSD even though, cognitively, the memory of the event may be absent Depression, substance abuse and other mental illnesses are often co-morbid with PTSD Additional Considerations Major life changes, including retirement, terminal illness, grief and bereavement can exacerbate PTSD The patient may not have a recognized or diagnosed PTSD PTSD could have been well managed up until this point PTSD can complicate the dying process if key memories are trauma related

4 PTSD and the Dying Process PTSD symptoms can occur for the first time or recur at the end-of-life Protective mechanisms like denial and repression, which helped cope with PTSD, may crumble as terminal illness progresses PTSD may amplify existing symptoms such as pain, which can become refractory PTSD and the Dying Process Opioid-induced altered levels of consciousness can precipitate or exacerbate PTSD symptoms. Thus, PTSD patients may refuse opioids and tolerate pain to avoid the psychological distress of PTSD breakthrough High risk for agitation at the end of life 3 Symptom Types Repetitive or Re-experienced Disturbing memories Nightmares Flashbacks (may include the physical symptoms such as a racing heart or sweating Avoidance Behavioral, cognitive or emotional avoidance Attempt to prevent reminders of the trauma

5 3 Symptom Types Hyperarousal Hypervigilance Mood swings/irritability Anger Exaggerated startle response Insomnia Management of PTSD Non-pharmacological interventions: -Counseling -Cognitive behavioral therapy -Psychotherapy -Massage, music and relaxation therapies -Guided imagery Manage co-morbid illnesses: depression, drug-seeking behavior due to past history of substance abuse Management of PTSD Pharmacological: -Treatment may be defined by prognosis -For those with at least one month of life expectancy Antidepressants SSRIs Tricyclic antidepressants

6 Management of PTSD For those with days or weeks to live Focus should be rapid alleviation of distress and enhanced comfort Short acting benzodiazepines or neuroleptics Management of PTSD Pharmacological (cont.): - Antidepressants: SSRI s (preferably non-activating) mirtazapine (also treats anorexia) venlafaxine -Sympathetic blockade: prazocin, clonidine, propranolol -Anxiolytics: benzodiazepines -Mood stabilizers: gabapentin, lamotrigine -Anti-psychotics: useful in severe agitation -Consider palliative sedation Management as an Interdisciplinary Team Utilize the strengths of all Interdisciplinary Team members: Physician, NP, PA Nurse Nursing Assistant Psychologist Social Worker Chaplain Volunteer who is also a veteran John s story

7 Physician, Nurse Practitioners, Physician Assistants Assess for symptoms of PTSD Consider PTSD as an option when assessing for delirium or anxiety Consider management options in light of prognosis and life expectancy Teach the patient and family what you know about PTSD and appropriate management Nursing Ask patients about: Their veteran status Whether or not they saw combat If they feel they have PTSD Approach sleeping PTSD patients cautiously! Assess for symptoms of distress or anxiety Explore both pharmacologic and nonpharmacologic approaches Offer support to the caregiver and teach effective management strategies Nursing Assistants Explain all cares and ask for permission to do cares Watch for triggers Avoid startling or surprising the patient Wake sleeping patient carefully!

8 Social Work Assess veteran and combat status Assess level of anxiety and distress Assess current coping strategies and support systems Caregivers may also be experiencing PTSD which may surface during or after the patient s illness and death Patient may experience intense anxiety, sadness, guilt or anger Psychosocial support is essential Chaplaincy Goal is to alleviate distress and enhance comfort Needs may be spiritual as well as cognitive and emotional Both the patient and the family may experience spiritual distress May experience survivors guilt, fear of retribution, a sense of failure, a belief they deserve punishment May be terrified of dying Spiritual support is essential Chaplaincy Spiritual Concerns at the End of Life (Gallop, 1997) Not being forgiven by God (56%) Not reconciling with others (56%) Dying when feeling removed or cut off from God or a Higher Power (51%) The possibility of continued emotional-spiritual suffering (51%)

9 Psychology Experts in the field Cognitive Behavioral Therapy is the treatment of choice for chronic PTSD but may not be appropriate for the dying patient Disease process may affect treatment plan Psychology The uncontrollable emotional and physiological responses activate the amygdala, the locus of fear-driven learning Medication may be limited in controlling these symptoms because they cannot affect this learned response to the same extent they do in disorders of emotionality such as depression or anxiety Goals of care will be determined by the patient and their physical/emotional/spiritual status PTSD Plan of Care Assess symptoms Assist the patient and family in creating a safe and peaceful atmosphere Explore the patient s coping mechanisms and support systems

10 PTSD Plan of Care Develop a disease appropriate approach to recurring symptoms with the patient and family May require a combination of pharmacologic and nonpharmacologic interventions Continue to reassess effectiveness of plan Honoring our Veterans at the End of Life Military recognition ceremoniespresentation of medals, awards, certificates to the veteran and family Flag ceremonies at the time of death Processional as the veteran leaves the unit/ward Memorial services Hospice Veteran Partnerships Mission: Establish an enduring network of hospices and VA professionals [and] veterans... working together to provide quality services through the end of life for veterans and their families.

11 Thank you for caring for our Veterans! Resources Block, S.D. ( 2006) Psychological Issues in End-of-Life Care, Journal of Palliative Medicine, Vol. 9 No. 3 p Feldman, D.B., Periyakoil, V.J. (2006) Posttraumatic Stress Disorder at the End of Life, Journal of Palliative Medicine, Vol. 9 No.1 p Firth, P. (2008) Spiritual Distress, Walsh: Palliative Medicine 1 st ed. Retrieved from Holland, J.C., Greenberg, D.B., Hughes, M.K. (2006), Quick Reference for Oncology Clinicians, American Psychosocial Oncology Society, Charlottesville, VA. Periyakoil, VJ,(2009), Palliative Patients with Past Traumatic Life Events: A Skill-Based Approach for Multidisciplinary Clinicians, AAHPM Conference Post-traumatic Stress Disorder(2007),Rackel: Textbook of Family Medicine, 7 th ed. Retrieved from Raymer, M., Holland, E. (2003) Exploring the Role of Psychosocial and Spiritual Care in Pain Management, NHPCO Audioconference. Shalev,A.Y. (2009) Posttraumatic Stress Disorder and Stress-Related Disorders, Psychiatric Clinician of North America, 32 p VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress (2004), Department of Veterans Affairs, Department of Defense, Version 1.0, Washington. D.C.

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