Post-traumatic stress disorder (PTSD) is a medical condition that primary care providers often manage in the outpatient health care atmosphere. Ferri (2018) defines PTSD as a condition that develops in some people after witnessing or experiencing a traumatic event that involves actual or threatened injury to self or others. The distressing occurrence leaves the person feeling fearful, worried, and helpless; the traumatic incident is often replayed over in the person’s mind, and they are likely to experience nightmares, flashbacks, sleep disturbances and intrusive thoughts surrounding the event (Dunphy et al., 2015; Ferri, 2018). Post-traumatic stress disorders are found among people who have endured overwhelming situations such as war/military combat, rape/abuse, torture, natural disasters, and life-threatening accidents (Dunphy et al., 2015). This condition leaves individuals trying to escape their thought lives and can produce a sense of numbness combined with a physiological status of hyperarousal (Dunphy et al., 2015). Often patients become very detached from their social lives as they are unable to progress beyond their traumatic experiences (Collins-Bride, Saxe, Duderstadt, & Kaplan, 2017).
Bailey, Cordell, Sobin & Neumeister (2013) state, “PTSD presents a significant burden not only to individuals but society at-large. The majority of people with PTSD meet the diagnostic criteria for other psychiatric disorders, including major depression and anxiety disorders. Individuals with a PTSD diagnosis are more likely than the general population to use drugs and experience impairments in psychosocial functioning and to engage in suicidal behaviors”.
Going through trauma is not rare; 60% of men and 50% of women will experience at least one trauma in their lives. While fewer than 10% of individuals who have experienced a traumatic event, Veterans carry a disproportionate amount of this burden. The U.S. Department of Veterans Affairs states, when you are in the military, you may see combat. You may have been on missions that exposed you to horrible and life-threatening experiences. These types of events can lead to PTSD. The number of Veterans with PTSD varies by service era:
- Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF): 11-20% in a given year
- Gulf War (Desert Storm): 12% in a given year
- Vietnam War: 15-30% in their lifetime (2016).
Another source of PTSD in the military is related to Military Sexual Trauma (MST); 23% of women reported sexual assault when in the military and 55% of women and 38% of men in the military have experienced sexual harassment.
Traumatic experiences are often accompanied by intense fear, horror, and helplessness. The pathophysiology of PTSD is constantly researched and ever evolving. Once thought to be a normal response to a traumatic event, it is now believed that the response of an individual to trauma depends not only on stressor characteristics, but also on factors specific to the individual. For most of the population, the psychological trauma from the experience is acute and limited. Though transient, such reactions can be quite unpleasant and are typically characterized by phenomena that can be grouped for the most part into three primary domains: reminders of the exposure (flashbacks, intrusive thoughts, nightmares), activation (hyperarousal, insomnia, agitation, irritability, impulsivity and anger) and deactivation (numbing, avoidance, withdrawal, confusion, derealization, dissociation, and depression) (Sherin & Nemeroff, 2011). PTSD is characterized by the presence of signs and symptoms in the three primary domains described above for a period extending beyond 1 month.
No two traumas are the same and therefore, PTSD presentation is very individualized. In order for PTSD to be diagnosed, symptoms must have persisted for longer than one month. Ferri states that key PTSD symptoms include: Distressing memories or dreams of the event; in children, this may be manifested in repetitive play, flashbacks, intense distress, avoidance, negative emotions, detachment, aggressive or reckless behavior, hypervigilance, trouble concentrating and depersonalization (2018).
PTSD treatment is just as highly individualized as the diagnosis. The VA states “evidence-based psychotherapy is the most-highly recommended treatment for post-traumatic stress disorder (PTSD) and is one of many effective treatments for PTSD. Each VA medical center offers one or more specific evidence-based psychotherapies for PTSD (2016). Cognitive behavior therapy should be outlined with sensitivity to the patient, working at their pace. Ferri (2018) denies a cure for PTSD; however combinations of medications can be used for management including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, antidepressants, alpha-adrenergic receptor blockers, antipsychotics, ketamine (Ferri, 2018). Supportive therapies include coping skills which can decrease symptom intensity and frequency. Group therapy and couples therapy. A very popular coping mechanism used by veterans, is therapy or emotional support dogs.
Clinical diagnosis of PTSD primarily rests upon assessing patients for the inclusion criteria of this condition as listed by the Diagnostic and Statistical Manual of Mental Disorders-Five (DSM-V). The DSM-V requires that at patient have experienced a stressful event with the above stated clinical symptoms that have lasted more than one month (Ferri, 2018). Collins-Bride et al. (2017) suggested in their literary work that medical providers utilized an evidence-based assessment tool, such as the Generalized Anxiety Disorder scale, to screen for the hidden symptoms related to the patient’s trauma and anxiety. The authors also recommended for clinicians to use the DREAMS mnemonic when interviewing patients who may be dealing with this health concerns; The DREAMS mnemonic is outlined as follows:
- Detachment of social life (Collins-Bride et al., 2017).
- Reliving the event (Collins-Bride et al., 2017).
- Event creates emotional distress (Collins-Bride et al., 2017).
- Avoidance of situations, people, and place that trigger flashbacks (Collins-Bride et al., 2017).
- Month or longer of symptoms (Collins-Bride et al., 2017).
- Sympathetic hyperactivity of physiological symptoms (Collins-Bride et al., 2017).
When a patient has been diagnosed with PTSD, education is important. The patient, as well as their family, should be educated to the symptoms of PTSD, causes, risk factors and triggers, complications, prevention and treatment options. The patient should be included in developing their plan of care and again, it is important to work at the patients’ pace. One of the most important aspects of the care of a patient with PTSD is having an honest conversation with their provider. The patient must understand that life with PTSD is manageable, as they are often burdened with a stigmatism that PTSD is a sign of weakness. Patients should seek care with a provider they feel they can be transparent and honest with, as these patients have a high propensity for suicidal ideation and attempts and is associated with aggressive behaviors (U.S. Department of Veterans Affairs, 2016). When patients feel safe in their care, they seek help before they reach extremes. Finally, patients and their families should be educated related to emergency contacts and emergency access to facilities when patients have acute episodes.
During follow-up care, patients should remember to be patient with themselves. They must allow themselves to realize this is a difficult time in their lives. They should not distance themselves for worry of bringing others down, but should surround themselves with quality family and friends who are empathetic to their needs. Eating healthy, getting exercise, practicing relaxation and avoiding negative surroundings is important. The patient should stay in close contact with their provider as their therapeutic medication dosing is perfected. Patients generally begin with several appointments per week during the first couple of weeks and as the patient is stabilized can be less frequent until they are seen on an as needed basis. As providers, it is important to have open relationships with patients, so they are never afraid to turn to you when they are in need.
References:
Bailey, C. R., Cordell, E., Sobin, S. M., & Neumeister, A. (2013). Recent Progress in Understanding the Pathophysiology of Post-Traumatic Stress Disorder: Implications for Targeted Pharmacological Treatment. CNS Drugs, 27(3), 221–232. http://doi.org/10.1007/s40263-013-0051-4
Collins-Bride, G. M., Saxe, J. M., Duderstadt, K. G., & Kaplan, R. (2017). Clinical guidelines for advanced practice nursing (3rd ed.). Burlington, MA: Jones & Barlett Learning.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis Company.
Ferri, F. F. (2018). 2018 Ferri’s Clinical Advisor. Philadelphia, PA: Elsevier.
Sherin, J. E., & Nemeroff, C. B. (2011). Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues in Clinical Neuroscience, 13(3), 263–278.
U.S. Department of Veterans Affairs. (2016). PTSD: National Center for PTSD. Retrieved from https://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp
