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

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

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

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

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

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

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

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

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

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

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

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

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

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