1. Post-Traumatic Stress Disorder: Diagnosis and Treatment – a Public Health approach
Physicians for Global Survival
Facing off for Justice Conference
26 March 2011
Ottawa, Ontario
Canada
D. C. Lougheed MD and Dale Dewar MD
PTSD - PGS March 2011

2. PTSD – Diagnosis, Treatment and Prevention
History of PTSD
Case Presentation
Diagnosis
Military Context
Civilian Context
Making the Diagnosis
Resources
Challenges to Family Doctors
Prevention
Thanks to Dr Colin Cameron and Dr Chantal Whelan, Ottawa, ON.
History –American Civil war – alcohol an opiate abuse in male soldiers and female civilians; battle fatigue WW1, concentration camp survivors, WW2, civilians after Hiroshima , Cocoanut Grove fire in 1941, Canadian Dr Divic 1962 Montreal article gas explosion
PTSD - PGS March 2011

3. Criterion A : Stressor
The person has been exposed to a traumatic event in which both of the following have been present:
The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
The person's response involved intense fear, helplessness, or horror.
PTSD - PGS March 2011

4. Criterion B: Intrusive Recollection
The traumatic event is persistently re-experienced in at least one of the following ways:
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
Recurrent distressing dreams of the event.
Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated).
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
PTSD - PGS March 2011

5. DSM IV – Post Traumatic Stress Disorder
PTSD - PGS March 2011

6. Criterion C: Avoidance/numbing
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect (e.g., unable to have loving feelings)
Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Emphasise functional impairment
3 symptoms at least
PTSD - PGS March 2011

7. Impact of Events scale PTSD - PGS March 2011
Horowitz, Wilner and Alvarez, 1979
Intrusive and avoidant symptoms
PTSD - PGS March 2011

8. Criterion D: Hyper arousal
Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hyper-vigilance
Differential diagnosis – anxiety, sleep disorder, depression, bipolar illness, acute stress response, etc
R/O general medical condition causing anxiety, depressiin, psychosis
PTSD - PGS March 2011

9. Criterion E: Duration Criterion F: Functional Significance
Duration of the disturbance (symptoms in B, C, and D) is more than one month.
Criterion F: functional significance
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than three months
Chronic: if duration of symptoms is three months or more
With or Without delay onset: Onset of symptoms at least six months after the stressor
PTSD - PGS March 2011

10. PTSD What can physicians do? Public Health Approach:
Primary prevention – prevent the illness – eg vaccination polio
Secondary prevention – diagnose and treat with the goal of full recovery and prevention of serious complications – eg strep throat
Tertiary prevention – treat with the goal of reducing the burden of chronic illness or disability – eg osteoarthritis
What are the implications for prevention of the disease called PTSD?
Rehabilitation model of care
Why do some people not get it? – socia/peer support, innoculation,
Who is at risk –
Pretrauma variable (personal susceptibility), trauma characteristics (magnitude of stress event); post-trauma variables
PTSD - PGS March 2011

11. PTSD – Military Populations
Diagnostic issues
Stigma
Acute stress
Concurrent disorders – substance, mood, other
Public Health model
Innocculation – basic training, training in hostage situations
Acute – proximity, immediacy, expectation of return to function
Military resources for treatment
Debriefing
OSI clinics – Ottawa (ROH), Halifax, others
Vets groups – self referral
Education, recognition of stressors, ventilation,
Battle fatigue
Issue Halifax- homelessness in vets with PTSD
PTSD - PGS March 2011

12. PTSD – Special Civilian Populations
Immigrant and Refugee Populations
Cross-cultural issues
Is it depression, schizophrenia, bipolar illness, substance abuse, dementia
Physical symptoms
Stigma,
Cultural explanations of illness
Challenges for interpretors
Chronic and severe mental illness
Dramatic symptoms of psychosis that are difficult to treat
May end up on ACT teams or with MH case managers
High doses of neuroleptic medications with mood symptoms not treated
Shelter clients – refugees, borderline intellectual abilities, language issues, cultural experience of illness
Consider differential diagnosis including mood disorders
DALE
Dale
Education, recognition of stressors, ventilation,
Battle fatigue
PTSD - PGS March 2011

13. PTSD - Conclusions
When the response to treatment is poor, check for history of trauma
Consider the diagnosis of PTSD in unusual presentations of psychosis, especially in refugee populations
Consider the use of a cultural interpreter.
Use a rehabilitation (recovery) model of treatment
1. assess state of change-readiness
2. Help the patient set goals and review personal strengths
3. Emphasise gradual improvement if chronic, rapid return to functioning if acute
4. Importance of return to meaningful social roles
Change readiness – precontemplation, contemplation, change, relapse prevention
Discuss ‘chronic’ = longer course
PTSD - PGS March 2011

14. With thanks to: Grandchildren of Marvin N. Lougheed MD FRCPC
PTSD - PGS March 2011