An NP’s Introduction to PTSD, by Dr. Melissa DeCapua
The recent update to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) created a new diagnostic category called trauma-and-stressor-related disorders. This category encompasses the conditions that result from exposure to stressful events including posttraumatic stress disorder (PTSD). Other disorders within this category include acute stress reaction, disinhibited social engagement disorder, reactive attachment disorder, and adjustment disorders.
This article reviews the epidemiology, risk factors, diagnosis, and treatment of PTSD and serves as a quick update for both specialist and non-specialist nurse practitioners.
This information is medical in nature and intended as a primer for nursing professionals and students. Please review this information if you wish, but do not act on it. If you or someone you know is concerned about the possibility of PTSD, please seek professional medical help. Publication Date: August, 2016.
In the United States (U.S.), the lifetime risk of developing PTSD is about 9%. The yearly prevalence among U.S. adults is 3.5%. The rates are higher among veterans, police officers, firefighters, and healthcare workers compared with the general population. The highest rates are found among survivors of rape, military captivity, and ethnically motivated internment or genocide.
Rates are higher among American Indians, U.S. Latinos, and African Americans compared with Caucasians and Asian Americans. Around 30% of veterans who served in the Vietnam War were diagnosed with PTSD compared with 13% of those who served in the recent Iraq and Afghanistan wars. Overall, women are more likely than men to experience PTSD due to their increased risk to be the victim of sexual violence.
The risk factors for developing PTSD are divided into three categories: pretraumatic, peritraumatic, and posttraumatic. They are included in the table below.
|Risk Factors for Developing PTSD|
|Pretraumatic Risk Factors||Peritraumatic Risk Factors||Posttraumatic Risk Factors|
|Prior mental disorder Lower socioeconomic status Lower education Childhood adversity Fatalistic coping strategies Lower intelligence Minority racial/ethnic status Family psychiatric history Female gender Younger age at exposure||Severity of trauma Duration of trauma Trauma perpetrated by caregiver or loved one Being the perpetrator (for military personnel) Dissociation during the trauma||Negative appraisals Inappropriate coping strategies Development of acute stress disorder Subsequent exposure Subsequent adverse life events Financial losses Lack of social support|
|Reference: Diagnostic and Statistical Manual of Mental Disorders (DSM-5)|
Posttraumatic stress disorder occurs in those who have been exposed to an actual or perceived threat of death, serious physical injury, or sexual violence. Often these events can be described as outside the range of normal human experience, including but not limited to combat, natural disasters, terrorist attacks, assault, rape, abuse, torture, and captivity.
This psychiatric illness is diagnosed using the American Psychiatric Association’s diagnostic criteria found in the DSM-5. To be diagnosed with PTSD, an individual must meet the following criteria with symptoms lasting longer than one month and resulting in clinically significant impairment in social and occupational functioning:
- Exposure to actual or perceived threat of death, serious injury or sexual violence.
- Presence of at least one or more intrusion symptoms, which include involuntary memories of the event, distressing dreams of the event, dissociative reactions (e.g. flashbacks), psychological and physiological distress when exposed to cues that resemble the traumatic event.
- Persistent avoidance of anything associated with the traumatic event.
- Negative alterations in cognitions and mood that begin or worsen after the event including feelings of detachment, horror, anger, shame; inability to experience positive emotions; self-blaming and blaming others; or dissociative amnesia.
- Changes in arousal and reactivity including hypervigilance, exaggerated startle response, difficulty concentrating and sleeping, self-destructive behavior, and angry outbursts.
Those with PTSD are 80% more likely than those without PTSD to have another psychiatric disorder, usually either a mood, anxiety, or substance use disorder. In addition, nearly 66% of those with PTSD have two or more other psychiatric conditions. Of U.S. military personnel deployed in recent wars in Afghanistan and Iraq, 48% of those with PTSD also have a traumatic brain injury.
Posttraumatic stress disorder is closely associated with suicidal ideation and an increased risk for suicide attempts. It is also associated with increased levels of social, occupational ,and physical disability and higher rates of healthcare utilization. Furthermore, this psychiatric disorder is associated with poor relationships and high absenteeism from work.
Nurse practitioners should approach patients who experienced trauma with compassion, support, and encouragement. Allow the patient to discuss the event at their own pace. If the patient is reluctant to speak about the trauma, do not press them. This can actually increase the risk of that person developing PTSD. The nurse practitioner should offer the patient and his or her family education in order to destigmatize the symptoms and condition.
Both medication and counseling are used to treat PTSD. Selective serotonin reuptake inhibitors (SSRIs), including sertraline (Zoloft) and paroxetine (Paxil) are first-line treatments for PTSD. Evidence-based psychotherapeutic interventions for PTSD include hypnosis, cognitive therapy, psychodynamic psychotherapy, and behavior therapy. Most psychologists recommend time-limited therapy for victims of trauma because it minimizes the risk of dependence and symptom chronicity.
Here is a list of resources that nurse practitioners can give to their patients regarding PTSD:
Clinical Practice Guidelines
Clinical practice guidelines distill a large amount of research into a short, easy to understand format. Usually, clinical practice guidelines summarize one or more systemic reviews on any given diagnosis or intervention. Nurse practitioners should always check the latest PTSD clinical practice guideline for the most up to date information on PTSD diagnosis and treatment. Listed below are both the international and national clinical practice guidelines published on PTSD.
International Clinical Practice Guidelines:
- World Federation of Biological Psychiatry (WFSBP) guideline on pharmacological treatment of anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder in primary care.
- National Institute for Health and Care Excellence (NICE) guideline on management of PTSD in adults and children in primary and secondary care.
United States Clinical Practice Guidelines
- American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter on assessment and treatment of children and adolescents with posttraumatic stress disorder.
- Institute of Medicine (IOM) report on treatment for posttraumatic stress disorder in military and veteran populations.
- American Psychiatric Association (APA) practice guideline on treatment of patients with acute stress disorder and posttraumatic stress disorder.
- Department of Veterans Affairs/Department of Defense (VA/DoD) guideline on management of posttraumatic stress in veterans.
- American Academy of Pediatrics (AAP) guidance on psychosocial implications of disaster or terrorism on children.
To learn more about posttraumatic stress disorder, check out these excellent textbooks:
Dr. Melissa DeCapua, DNP, PMHNP-BC
Melissa DeCapua is a board-certified psychiatric nurse practitioner who graduated from Vanderbilt University. She has a background in child and adolescent psychiatry as well as psychosomatic medicine. Uniquely, she also possesses a bachelor’s degree in studio arts, which she uses to enhance patient care, promote the nursing profession, and solve complex problems. Melissa currently works as the Healthcare Strategist at a Seattle-based health information technology company where she guides product development by combining her clinical background and creative thinking. She is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Melissa, check out her blog www.melissadecapua.com and follow her on Twitter @melissadecapua.
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