Why should primary health care providers be knowledgeable about
traumatic stress?
The primary care practitioner is likely to
see an increase in traumatized individuals after a disaster or
national terroristic event. Many of these patients will present
with physical rather than mental or emotional symptoms. It is
recommended that primary care providers educate themselves about
the effects of trauma and routinely screen individuals for trauma after major
disasters.
Having knowledge about traumatic stress is important
because:
Trauma often leads to PTSD and other impairment
In addition to disasters and other traumatic life events,
life-threatening medical conditions such as myocardial
infarction, severe burns, severe injuries, and cancer can cause
or exacerbate PTSD.
Patients with PTSD experience a significant degree of
functional impairment similar to that observed in patients
suffering from major depression.
Patients with untreated anxiety report levels of functioning
within the range expected for patients with chronic physical
diseases such as diabetes and congestive heart failure.
PTSD is associated with significant problems in living,
including alcohol abuse, marital problems, unemployment, and
suicidal ideation. PTSD is also associated with high levels of
use of medical services.
Traumatic experiences and traumatic stress bring about
hormonal, neurochemical, immune functioning, and autonomic
nervous system changes which can affect physical health.
PTSD often presents to primary care providers, but goes
unrecognized
In the private sector, nearly half of all visits instigated
by a mental-health disorder are to a medical clinic or provider.
Of those visits, 90% are to primary care providers.
Despite its prevalence, PTSD is likely to remain unrecognized
and untreated in primary care patients. Few medical clinics
systematically identify trauma survivors who have related
mental-health problems.
Failure to identify and treat PTSD has adverse effects on the
patient's physical and mental health
Traumatic stress is associated with increased health
complaints, health services utilization, morbidity, and
mortality.
Untreated PTSD can impair recovery from medical
conditions.
In failing to address the impact of traumatic stress on health,
patients and doctors become less likely to achieve desired
outcomes.
Screening and Referral Procedure Overview
A. Screen administration
A practitioner can distribute a
traumatic stress self-report screening instrument prior to a
medical appointment. Completed screens are collected and reviewed
by the physician, nurse, physician's assistant, or a mental-health
consultant to identify patients who are likely to be experiencing
distressing posttrauma reactions. Screening items can also be added
to the standard medical history forms that patients complete at
first visits.
B. Discussion and referral
After a review of the screen
results and a discussion with the patient, the provider can decide
whether the patient may benefit from further specialized
mental-health evaluations. Patients with positive screens may be
referred, depending on availability, to specialized PTSD treatment,
behavioral medicine, or more general mental-health services for
further evaluation and possible treatment.
It is important to understand the reason for screening
instruments. Some patients who screen "positive" will not actually
be diagnosed with PTSD after a detailed clinical evaluation by a
mental-health professional. However, screening instruments increase
a primary care provider's ability to detect PTSD and to initiate
appropriate referral. Patients who screen positive for PTSD should
be explicitly screened for suicidal ideation as well.
C. Educational materials
Patients who screen positive for
PTSD (and their families) may also benefit from educational
materials about trauma and PTSD, such as those in the National
Center for PTSD website Fact Sheets.
D. Follow-up
At the patient's next visit, it is important
to ask whether he or she followed through with the referral for
mental-health evaluation or care. If the patient did follow
through, the practitioner can ask if the referral was perceived as
helpful. If the patient did not follow through with the referral
and is still in need of care, the provider can try to learn what
the obstacles to obtaining care were.
If the Patient Refuses Referral to Mental-Health Care
Many patients are reluctant to participate in mental-health
treatment. Common reasons include discomfort with the idea of
seeing a psychologist or psychiatrist, a perceived stigma
associated with treatment, previous negative experiences with
mental-health providers, negative attitudes towards healthcare
agencies, a lack of confidence in the helpfulness of counseling,
or a reluctance to open up old emotional wounds. Faced with this
situation, the primary practitioner can do several things to
raise the likelihood of acceptance of a referral:
Suggest an evaluation rather than treatment. Sometimes, it is useful to suggest that the patient meet
with a mental-health professional so that he or she can learn
more about posttraumatic stress, ask questions, and consider
with the mental-health provider whether more contacts will be
useful.
Normalize the idea of treatment. Explain that treatment involves common sense activities
that include learning more about PTSD, finding and practicing
ways of coping with trauma-related symptoms and problems,
taking steps to improve relationships with family and friends,
and making contact with other patients who experience similar
problems.
Give the patient educational materials that describe PTSD and its common co-morbid conditions
(depression, substance abuse), treatment for PTSD, and coping
with PTSD. Sometimes he or she will read the materials at a
later time and begin to think more carefully about
participation in treatment.
Give information about different ways the patient can
seek assistance. Avenues for assistance include local
mental-health services; online resources; and local community,
spiritual, and mental-health resources.
Consider involving the patient's spouse or partner in the
discussion if it seems appropriate and the patient gives his or her
permission. This may help clarify for the patient the impact of
PTSD on others in his or her life and increase his or her
motivation to seek help.
Make sure to follow up on the issue in the next
appointment and keep track of the patient's progress with respect to
PTSD.
The Use of a Primary Care Screen
The table below shows the Primary Care PTSD Screen (PC-PTSD)
that has been designed for use in primary care and other medical
settings. The PC-PTSD is brief and problem-focused. The screen does
not include a list of potentially traumatic events. There
are two reasons for this:
Studies on trauma and health in both male and female patients
suggest that the active mechanism linking trauma and physical
health is the diagnosis of PTSD. In other words, the relationship
between trauma and health appears to be mediated through a
current PTSD diagnosis.
A symptom-driven screen, rather than a trauma-focused screen,
is attractive to primary care staff who may not be able to
address a patient's entire trauma history during their visit with
the patient. Such a trauma inquiry might be especially
problematic with a VA population where the average number of
traumatic events meeting criterion A for PTSD is over 4.
A positive response to the screen does not necessarily indicate
that a patient has Posttraumatic Stress Disorder. However, a
positive response does indicate that a patient
may have PTSD or trauma-related problems and further
investigation of trauma symptoms by a mental-health professional
may be warranted.
Current research suggests that the results of the PC-PTSD should
be considered "positive" if a patient answers "yes" to any three
items.
Discussing Screening Results with Patients
Provide an appropriate context for the discussion
Ensure privacy by closing the door and keeping family members
out of the room.
Inform patients that traumatic events and the distress they
create can have important effects on the body and on health as
well as on the patient's psychological functioning.
Explain that you are opening this discussion as part of an
effort to provide more comprehensive health care and that a
greater understanding and recognition of symptoms of
posttraumatic stress may be of benefit, both psychologically and
physically.
Ask about traumatic events
Make no assumptions about the meaning or impact of traumatic
events for an individual; your assumptions may be inconsistent
with the patient's feelings and experience.
As the patient is responding to your questions:
Acknowledge any reported distress (e.g., "I'm sorry you have
had such terrible nightmares").
Show interest and concern, and tell the patient that you are
glad that he or she has told you about the symptoms.
Offer empathic support.
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.
The practitioner may say:
"At some point in their lives, many people have experienced
extremely distressing events such as combat, physical or sexual
assault, or a bad accident. Have you ever had any experiences
like that?"
If the PC-PTSD screening instrument is utilized, clarify
responses to determine:
a. Whether the patient has had a traumatic experience
"I notice from your answers to our questionnaire that you
experience some symptoms of stress. At some point in their lives,
many people have experienced extremely distressing events such as
combat, physical or sexual assault, or a bad accident, and
sometimes those events lead to the kinds of symptoms you have.
Have you ever had any experiences like that?"
b. Whether endorsed screen items are really trauma-related
symptoms
"I see that you have said you have nightmares about or have
thought about an upsetting experience when you did not want to.
Can you give me an example of a nightmare or thinking about an
upsetting experience when you didn't want to?"
If a patient gives an example of a symptom that does not appear
to be in response to a traumatic event (e.g., a response to a
divorce rather than to a traumatic event), it may be that he or she
is ruminating about a negative life event rather experiencing
intrusive thoughts about a traumatic stressor.
c. Whether endorsed screen items are disruptive to the patient's
life
"How have these thoughts, memories, or feelings affected your
life? Have they interfered with your relationships? Your work?
How about with recreation or your enjoyment of activities?"
Positive responses to these questions in addition to endorsement
of trauma symptom items on the PC-PTSD Screen indicate an increased
likelihood that the patient has PTSD and needs further
evaluation.
Discern whether traumatic events are ongoing in a patient's
life
If ongoing traumatic events are a part of the patient's life, it
is critical that the primary care practitioner discern whether the
patient needs an immediate referral for social work or
mental-health services. The practitioner might ask:
"Are any of these dangerous or life-threatening experiences
still continuing in your life now?"
If ongoing family violence is suspected, it is imperative that
the patient be told the limits of confidentiality for medical
professionals, who are mandated to report suspected ongoing abuse
of children and dependent adults. Discussion of possible abuse should take place in the absence of
the suspected perpetrator; if the abuser is present, victims may
deny abuse for fear of retaliation.
If ongoing threats to safety are present:
Acknowledge the difficulty in seeking help when the trauma
has not stopped.
Determine if reporting is legally mandated. If it is, develop
a plan with the patient to file the report in a way that
increases rather than decreases the safety of the patient and his
or her loved ones.
If reporting is not appropriate, provide written information (or
oral if written might stimulate violent behavior in the
perpetrator) about local resources that might help the situation.
Establish a plan that the patient will agree to in order to move
toward increased safety. The National Domestic Violence Hotline is
available to guide callers to local resources: 1-800-799-SAFE or
TTY: 1-800-787-3224.
Make a recommendation for further evaluation and provide a
referral.
If it appears that a patient does have active PTSD symptoms:
Explain why the screen results lead you to recommend that he
or she seek further evaluation and/or treatment.
Encourage the patient to voice any reservations or concerns
he or she might have about seeking treatment. You may be able to
facilitate pursuit of treatment by listening to these concerns,
acknowledging their validity, and addressing some of the
patient's questions about what to expect during mental-health
evaluation and treatment.
Make sure the patient understands that he or she is not
crazy.
Explain to patients that although a wish to avoid reminders
of the trauma is natural and common, this avoidance may actually
interfere with recovery. This avoidance may prohibit helpful
processes that can result from talking through the experience,
receiving social support, or receiving specialized
treatment.
After discussion with the patient, if possible, invite family
members to participate in a brief discussion and enlist their
support for a mental-health evaluation by a specialist.
Provide the patient with a written referral to a
mental-health professional.
Provide information to the mental-health professional
Provide the mental-health professional with:
A copy of the PC-PTSD results
Any relevant information about health events or injuries that
might have been traumatic
Information about any suspected negative impact of the
patient's posttraumatic symptoms on health or medical
compliance
Schedule a follow-up
Consider scheduling in-person or telephone follow-ups and/or
relatively frequent brief office visits. Regular check-ins with
patients about their current functioning and follow-ups with
referrals is crucial for keeping patients involved in their own
recovery process.
Reference
Prins, A., Kimerling, R., Cameron, R., Oumiette, P.C., Shaw, J.,
Thrailkill, A., Sheikh, J. & Gusman, F. (1999). The Primary
Care PTSD Screen (PC-PTSD). Paper presented at the 15th annual
meeting of the International Society for Traumatic Stress Studies,
Miami, FL.
