Session # D3b
October 5, 2012
Post-Traumatic Stress Disorder and Medical Comorbidities:
Screening and Intervention in Collaborative Care Settings
Andrea Auxier, PhD
Senior Strategist, Colorado Associated Community Health Information Enterprise/
Colorado Community Managed Care Network
Senior Clinical Instructor, Department of Family Medicine
University of Colorado Denver School of Medicine
Christine Runyan, PhD, ABPP
Associate Clinical Professor and Director, Fellowship in Clinical Health Psychology
Department of Family Medicine and Community Health
University of Massachusetts Medical School
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
• List reasons for PTSD screening in
primary care
• Describe how a screening procedure can
be implemented
• Discuss how health information technology
can be utilized to conduct practice-based
assessment
• Describe how interventions can be
designed in collaborative care settings.
PTSD – DSM 5
Experienced, witnessed an event involving actual or threatened
death/ serious injury, or threat to physical integrity of self/ others
 Intrusion Symptoms
Persistent Avoidance
 Alterations in Cognitions and Mood
 Hyperarousal and Reactivity Symptoms
Three new symptoms:
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Erroneous self- or other-blame
Negative mood states
 Reckless and maladaptive behavior
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Complex PTSD:
– captivity
– psychological fragmentation
– loss of a sense of safety, trust, self-worth, &
coherent sense of self
– a tendency to be revictimized
– pervasive insecurity
– often disorganized-type attachment
– poor affect regulation
– ...
Basic Facts
• Prevalence: 8% Lifetime
• Not everyone who experiences a traumatic
event will develop PTSD
– 8% of men and 20% of women develop
PTSD after a trauma
Risk Factors
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A previous traumatic event
Psychological difficulties prior to the event
Family hx of of psychological difficulties
Extent to which there was a threat to life
Amount of support following the event
Emotional response during the event
Dissociation
Being a child
Being a woman
Being a recent immigrant from a troubled country
Why Primary Care?
• It’s the principal point of contact
• 12% of pts in community settings have PTSD
compared to 8% in general population
BUT . . .
• Patients don’t come in saying they have PTSD
• It’s up to us to identify it
Psychiatric Comorbidities
88% of men and 79% of women with PTSD meet
criteria for another psychiatric disorder.
Men: alcohol abuse/dependence; MDD; conduct
disorders; drug abuse/dependence.
Women: MDD; simple phobias; social phobias;
and alcohol abuse/dependence.
U.S. Department of Veteran Affairs, National Center for
PTSD
Trauma Affects Everything
Trauma Affects the Body
Increased likelihood of:
1) poor health functioning (mostly self reported)
2) morbidity (physical exam/lab tests)
HTN
Asthma
3) mortality
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cardiovascular reactivity
autonomic hyperarousal
disturbed sleep physiology
chronic pain
adrenergic dysregulation
enhanced thyroid function
altered HPA activity
Trauma Affects the Brain
HPA Axis
Adrenal
Cortex
Arousal, vigilance, startle,
conditioned emotional responses
via locus coeruleus (NE)
Acute stress
CRF
Pituitary
Hypothalamus
(lateral)
CORTISOL
ACTH
Beta Endorphin
Amygdala
(central nucleus)
Hippocampus
Mineralcorticoid
(MR’s)
Medulla
Adrenaline
Glucocorticoid
(GR’s)
Cortisol in PTSD
• Persistently low, with spikes during times of
stress
• A relatively small stressor to most people will
trigger a biochemical cascade in someone with
PTSD, manifesting as general hyper-reactivity
and avoidant numbing, respectively.
• No other emotional condition, including
depression, panic attacks, or anxiety disorders
will produce this profile.
Trauma Affects Language
Alexithymia: Inability to verbally describe
emotions
The “I was so upset I couldn’t think straight”
phenomenon, magnified.
Trauma Affects Memory
• Amygdala: Implicit Memory
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Skills & habits
Emotional responses
Classically conditioned responses
Reflexive actions
• Hippocampus: Explicit Memory
– Categorizes & stores temporal & spatial elements of
incoming stimuli
– Shuts off HPA response to stress
– Develops 18-36 months after the amygdala
Early Memory
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Somatic
Visual
Out of context
Blurred around the edges
Emotional
Non-verbal
Intense
Trauma Affects Personality
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Difficulty trusting
Irregular moods
Persistent sense of shame
Unstable relationships
Prefrontal cortex damage:
– impulsivity, poor planning and judgment
Borderline Personality Disorder
Trauma Affects Perception
• Hostile Attribution Bias: overattributing of
hostile intent to others
• Correlated with anger & defensive
aggression
Aggression
Offensive: predatory attack, no attempt to escape, angermotivated (left-brain)
– Involves prefrontal cortex, amygdala, lateral
hypothalamus
Defensive: attack only when escape seems impossible,
fear-motivated (right-brain).
– Involves amygdala, medial hypothalamus
Almost without exception: aggressive behavior is preceded by the
perception of some kind of physical or psychological threat
Trauma Breeds More Trauma
• People who experience a trauma are more
likely to experience another one than
those who have not.
– Physiological contributors: neuroendocrine
dysregulation, neuroanatomical damage
– Psychological contributors: depression,
hostility, poor coping
– Behavioral contributors: impulsivity,
alcohol/substance use
Trauma Costs Money
1) High rates of healthcare services utilization
2) Difficulty in provider-patient communication
leads to:
 reduction in active collaboration in evaluation and treatment
 increase in the likelihood of somatization
 reduction in adherence to medical regimens
It’s OK to Ask
“But … I’m not sure I want to
know the answer.”
• Patients want you to ask
• Focus on current symptoms and circumstances, not
detailed information about the traumatic event (s)
• Don’t Reflexively Say “I’m Sorry”
• Let the patient know that you recognize how difficult
it may be for him or her to answer questions
• If he/she begins to get upset and wants to stop, ask
them to let you know. Give them choices and control
PC-PTSD Screening
Brief, 4 item Screen for Primary Care
 Does not ask patient the traumatic event
 Asks Y/N symptoms in the past month
 nightmares, intrusive thoughts, on guard or
easily startled, feeling detached
 Cut off score of 3 recommended
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Sensitivity
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Women: .70, Men: .94
Specificity
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Women: .84, Men: .92
Prins, et al. (2003). The primary care PTSD screen (PC-PTSD): development
and operating characteristics. Primary Care Psychiatry, 9, 9-14
Using EHRs for Practice-Based Research
• Challenges:
Implementation
Data Entry
• Data Extraction
• Registries
1 Year of Salud Screenings
2607 patients screened with PC-PTSD
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1884 English-Speaking
662 Spanish Speaking
1143 Non-Hispanic White
1203 Hispanic
311 positive screens = 12%
• 229 Diabetes (11.9% positive)
• 397 HTN (13.1% positive)
When a Patient Discloses Trauma
• Relax
• Appreciate she trusted you enough to disclose emotionally
painful material
• Provide psycho-education materials
• Encourage self-soothing activities – meditation, yoga,
vigorous exercise, writing
• Promote mastery and self-help
• Write down any medical instructions – assume that under
stress people aren’t taking in all the information they need
In 15 Minutes?! …
Key Principles of Trauma Informed Care
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Recognize trauma’s central role in health and illness
Validate patient’s experience
Link symptoms to past experiences of trauma
Meet patient where they are
Encourage patient to play an active role in goal setting
Build trust in relationship
Facilitate choice whenever / as much as possible
May get worse before it gets better
Talk less … Listen more
Healing is Possible – Evidence Based Treatments
Adopted from Weinreb, L. NIAAA Manual
Intervention Goals
• Break silence about trauma and abuse
• Shift blame from survivor
• If relevant, establish short term safety plan
– Give the patient control and choice
• Contextualize and normalize the experience
• Validate coping strategies
• Integrate trauma factors in how you conceptualize and
address problems
• Maintain positive relationship
• Offer referrals for services
Healing is Possible
Evidence Supported Treatments (A Level Recommendation*)
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Narration (oral, written, past tense, imaginal) *
Cognitive Therapy, Cognitive Processing Therapy (CPT) *
Exposure Therapy *
Stress Inoculation Training (SIT) *
Psychoeducation *
Eye Movement Desensitization and Reprocessing
DBT Strategies
Mindfulness Based Strategies
Complementary and Integrative Modalities (Yoga,
Meditation, Acupuncture)
• Pharmacotherapy (SSRI, SNRI) *
Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder
(PTSD). Cochrane Database of Systematic Reviews 2007
Conclusions
• Many of our patients are suffering from
unrecognized trauma
• They most likely will not tell us unless we
ask the right questions, at the right time, in
the right way
• If they don’t have the words to tell us, we
have to help them find the words
• When they are ready to tell us their
stories, we have to be willing to hear them
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
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PTSD in Primary Care Settings - Collaborative Family Healthcare