Case 25.4 – Post-Traumatic Stress Disorder (PTSD)

Build rapport

Consider if interpreter is needed - CALD background (see question 3 below)

History from Patrick to clarify what happened during the robbery:

• Check in with him that he is feeling able to talk about what happened to him

Physical health review:

• Ask if Patrick was injured in the robbery
• Check in on his current self-care
• Check if he has any medical issues / physical symptoms

Ask about Patrick's functioning:

• Issues at work: How is his job going now, how is his relationship with his employer / co-workers
• Studies: Ask more specifically about his struggles with learning / studying
• Family contact: Is he able to easily speak with them, has he been able to talk to them about what happened
• Social supports in Australia
• Living situation: Does he feel safe at home, if he lives with others then how are they getting along
• Self-care: Is he able to cook / clean for himself?

To clarify a diagnosis for Patrick:

Screen for major depression and psychotic symptoms.

PTSD is a specific diagnosis, and not all responses to trauma are classified as PTSD. Symptoms must last > 1 month. Less than one month = Acute Stress Disorder.

Key Diagnostic Considerations:

Normal Response to Stress:

• Emotional Response (Anxiety or Depressive)
• Defence mechanisms (depersonalisation, derealisation, denial)
• Coping Strategies
• Emotion Reducing Strategies (venting, evaluation & analysis of problem or event)

Adjustment Disorder:

• Symptoms last no longer than 6 months
• The stressor can be of any severity or type
• For Patrick: He has been in Australia for 1 year and symptoms started quickly after the robbery (6 weeks ago) so this timeframe is consistent with adjustment disorder, but need to assess if meets criteria for PTSD

Acute Stress Disorder:

• Refers to initial reaction in first month after a stressor
• Patrick is now 6 weeks post-robbery, so beyond this timeframe

PTSD (\>1 Month after trauma):

Key symptom clusters to assess:

• Hyperarousal: Feeling constantly on edge, exaggerated startle response
• Intrusion / Re-experiencing: Nightmares or flashbacks
• Avoidance: Do you avoid people or going to work?

DSM-5 Diagnostic Criteria - Key Questions to Ask:

A. Exposure to traumatic event:

• Ask Patrick how he felt at the time of the robbery
• Did he fear for his life or think he would be seriously harmed?
• Looking back on the event does he still feel this way?

B. Intrusion symptoms (need one or more):

• Intrusive memories: Does he have thoughts coming into his mind about the robbery, which he can't stop and which make him feel very upset?
• Nightmares: Has he been having nightmares about the robbery or what happened in the aftermath?
• Flashbacks: Has he had "dreams when you're awake" about the robbery, where he feels like it could be happening to him again, and it feels outside of his control?
• Psychological distress: How does Patrick feel if he sees or hears something that reminds him of the robbery? If he thinks about the robbery, how does he feel?
• Physiological reactions: Has Patrick experienced increased heart rate / sweating / shortness of breathing / GI upset when reminded of the event?

C. Avoidance (need one or both):

• Internal avoidance: What does he do when a memory about the robbery comes back to him? Does he immediately try to do something else, to put it out of his mind or use substances so he doesn't have to think about it?
• External avoidance: Has Patrick been able to return to work? How does he feel when he was back at work? Has he changed anything about his work practices as a result of the robbery (e.g., avoiding specific parts of the shop, changed his usual routine)?

D. Negative alterations in cognitions and mood (need two or more):

• Amnesia: Observe whether Patrick is able to remember the details of robbery and whether there are elements that seem to be missing
• Negative beliefs: Ask Patrick how he feels following the event and listen for changes in his world view. Does he now feel it is pointless to be studying? Does he feel his life is ruined? Does Patrick feel that he should never have moved to Australia?
• Persistent negative emotional state: Fear, horror, anger, guilt, or shame
• Diminished interest: In significant activities
• Detachment: Do you feel like you no longer fit in with others, that no one can understand you?
• Inability to experience positive emotions: Inability to experience happiness, satisfaction, or loving feelings

E. Alterations in arousal and reactivity (need two or more):

• Irritable behavior and angry outbursts
• Reckless or self-destructive behaviour: Ask Patrick about driving recklessly, substance use, risky sexual behaviour
• Hypervigilance: Does Patrick feel constantly on edge? How would he respond if he heard a loud noise? Does he worry that all customers coming into the shop could be violent?
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance: Difficulty falling or staying asleep or restless sleep

Risk (and protective) factors are generally divided into pre-traumatic, peri-traumatic, and post-traumatic factors.

Risk Factors Present for Patrick:

• Lack of social support prior to event – struggled to make friends in Australia
• Minority racial/ethnic status – from Rwanda
• Young age
• Perceived threat to life – threatened with a knife
• Negative appraisals, exposure to reminders, loss of ability
• Exposure to reminders – quickly returned to work
• Potential losses if he cannot study in Australia
• Lack of social support – family likely overseas

Cultural Factors to Consider:

For Patrick consider the context of the 1994 Rwandan genocide and the potential for intergenerational trauma – although he was not yet born it is likely some of his relatives were affected. Research has demonstrated long-lasting and intergenerational effects of mass violence on individuals, families and communities.

Culture-Related Diagnostic Issues (from DSM-5):

The risk of onset and severity of PTSD may differ across cultural groups as a result of variation in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after a mass killing), the ongoing sociocultural context (e.g., residing among unpunished perpetrators in post conflict settings), and other cultural factors (e.g., acculturative stress in immigrants). The relative risk for PTSD of particular exposures (e.g., religious persecution) may vary across cultural groups.

Other Risk Factors for PTSD (from DSM-5):

Pre-traumatic factors:

• Temperamental: Childhood emotional problems by age 6 years (prior traumatic exposure, externalizing or anxiety problems); prior mental disorders (panic disorder, depressive disorder, PTSD, or OCD)
• Environmental: Lower socioeconomic status; lower education; exposure to prior trauma (especially during childhood); childhood adversity (economic deprivation, family dysfunction, parental separation or death); cultural characteristics (fatalistic or self-blaming coping strategies); lower intelligence; minority racial/ethnic status; family psychiatric history. Social support prior to event exposure is protective
• Genetic and physiological: Female gender, younger age at time of trauma exposure (for adults); certain genotypes may be protective or increase risk

Peri-traumatic factors:

• Environmental: Severity (dose) of trauma; perceived life threat; personal injury; interpersonal violence; dissociation that occurs during the trauma and persists afterward

Post-traumatic factors:

• Temperamental: Negative appraisals, inappropriate coping strategies, and development of acute stress disorder
• Environmental: Subsequent exposure to repeated upsetting reminders, subsequent adverse life events, and financial or other trauma-related losses. Social support (including family stability) is a protective factor that moderates outcome after trauma

Background:

In most Australian States, there are legislative and policy requirements to ensure that people from culturally and linguistically diverse backgrounds are not prevented by barriers of communication or culture from making optimal use of health services. Health services staff should inform clients of their rights of access to interpreting services.

For Patrick:

The need for an interpreter should be assessed at the initial contact with Patrick and reviewed at key points in the service delivery process. Using incidental interpreters (e.g., children, relatives, cleaners…) is fraught with dangers and can lead to serious errors or ethical breaches.

Communication in any clinical relationship is of paramount importance. Inadequate communication with people who have limited English proficiency limits their ability to access services, and has a profound impact on the quality of treatment they receive.

Working with interpreters:

Preparation:

• Ensure that you know which language (and dialect) Patrick speaks
• Check whether there may be an ethno-political divide between consumer and interpreter, which could be relevant as Patrick is from Rwanda
• Ask Patrick if the gender of the interpreter is important to the interview
• Brief the interpreter. It is advisable that clinicians confer with the interpreter prior to the meeting in order to provide information about the purposes of the consultation and to establish the mode of interpreting (i.e. consecutive or simultaneous interpreting)

Technical language:

• Interpreting consists of interpreting meaning as well as possible—some words or phrases often have no direct translation in another language—and the interpreter is not specially trained or educated in health issues or terminology
• Use clear and simple language to explain mental health terms and processes
• Avoid acronyms and jargon
• Check for understanding

Confidentiality:

It is important to stress to the patient (and interpreter) that all information is confidential. Although interpreters are bound by a Code of Ethics to ensure that they maintain confidentiality in their work, many service-users are unaware of this. Concern about what happens to information divulged in the presence of an interpreter may be based on past experience of, for example, stigma, or interpreting by unqualified staff. Failure to maintain confidentiality is a serious breach of ethics.

• When briefing the interpreter, reiterate the expectation of confidentiality
• When introducing the interpreter to the patient explain that everything discussed in the meeting is considered confidential (subject to the requirements of law) and that the interpreter, as well as staff, are bound to observe confidentiality

Psychological Intervention:

Psychoeducation:

• Provide psychoeducation to Patrick about PTSD
• Explain that the course of PTSD varies enormously from person to person; it can be delayed, intermittent, and chronic
• Address stigma concerns - normalize his experience and emphasize that PTSD is a recognized medical condition, not "being crazy"

Mindfulness:

• Mindfulness can be helpful

Referral for Specialized Therapy:

Patrick will need to be referred for appropriate therapy as soon as possible (referred for treatment with a psychologist or psychiatrist who has specific experience with trauma-focused interventions).

In practice, most treatment plans seek to:

• Dampen emotional arousal
• Deal with the meaning of the trauma
• Use exposure techniques to desensitize the patient from the disturbing memories

Evidence-Based Psychological Treatments:

• Trauma focused cognitive behavioural therapy (CBT)
• Prolonged Exposure (PE)
• Cognitive Processing Therapy (CPT)
• Eye movement desensitization and reprocessing (EMDR)

Evidence:

Cochrane Systematic Review - Psychological treatment of post-traumatic stress disorder (PTSD):
There was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly.

Watkins et al. Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions 2018:
In 2017 Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) each published treatment guidelines for PTSD. Both guidelines strongly recommended use of Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT).

Social Interventions:

• Support for return to work – consider other financial supports available in the short term if unable to continue work at present
• Promote social skills
• Promote exercise for recovery
• Consider contact with trauma support groups
• Multicultural mental health support – e.g. Embrace
• Contact with family
• Secure living situation
• Support from university for Patrick for his studies – special consideration may be needed to ensure he does not fail, extra support, reduce course load etc.
• Consider any legal or compensation issues

Biological/Pharmacological Management:

Medications are second line treatment for PTSD

SSRIs are widely used to reduce arousal and distress and to treat comorbid conditions.

Cochrane review - Pharmacotherapy for PTSD:
Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of SSRIs as first line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment.

For Patrick specifically:

• Respect his preference not to take medication initially
• Start with psychological interventions
• Medication can be reconsidered if:
  • Psychological therapy is insufficient
  • Comorbid conditions develop (depression, anxiety)
  • Patrick changes his mind about medication

Treat any comorbid conditions:

• Monitor for development of depression, substance use, physical health problems
• Address these if they arise

Context:

Trauma—and its consequences—is one of the most common mental health problems. For example, in Australia, half of the adult population has been exposed at some stage to a serious traumatic experience. Traumatic events are part and parcel of the work of some professions (e.g., military, police, and rescue services). Trauma in childhood is very prevalent (e.g., child abuse) and plays an etiological role in the development of almost all psychiatric disorders.

Evidence on Prevention:

There is little evidence showing which interventions actually reduce PTSD and which do not.

Psychological Debriefing:

Debriefing has become very popular when seeking to prevent or reduce PTSD among people exposed to traumatic events, natural or manmade. However, there is no evidence that single-session individual psychological debriefing is a useful treatment for the prevention of PTSD after traumatic incidents. A more appropriate response could involve a 'screen and treat' model.

What Could Have Been Done Differently for Patrick:

Immediate Post-Incident Support:

• Employer could have provided more support - not requiring Patrick to clean up the damage alone
• Encouraged (or required) Patrick to take time off work, even if paid leave was needed
• Provided access to Employee Assistance Program or counseling services
• Offered workplace modifications (not working alone at night, security measures)

Early Screening and Monitoring:

• Screen and treat model - early identification of those developing symptoms
• Follow-up contact from GP or mental health services in the weeks following the trauma
• Monitoring for development of acute stress disorder symptoms

Social Support:

• Activation of social support networks
• Connection with cultural community supports
• University support services engagement
• Facilitation of contact with family

Practical Support:

• Financial assistance to allow time off work
• Help with practical matters (police statements, victim support services)
• Not requiring immediate return to the scene of trauma

Would This Have Prevented PTSD?

It is difficult to say definitively whether these interventions would have prevented Patrick from developing PTSD:

• PTSD development is multifactorial - many risk factors were present for Patrick that could not be changed (young age, minority status, lack of social support, cultural factors)
• Some people will develop PTSD despite optimal post-incident care
• However, addressing modifiable risk factors (especially rapid return to work, lack of support, ongoing exposure to reminders) may have reduced his risk
• Early identification and treatment of acute stress symptoms is the most evidence-based approach to reducing PTSD development
• The absence of social support in the immediate aftermath was a significant missed opportunity

Key Learning Points:

• Single-session debriefing is not effective for PTSD prevention
• "Screen and treat" model is more appropriate than universal debriefing
• Social support is one of the most important protective factors
• Avoiding rapid return to trauma reminders may be helpful
• Early identification and treatment of acute stress symptoms is important