It's now months after Hurricane Katrina hit Louisiana. That storm drove hundreds of thousands of people from their homes. Many lost everything, including their work, family heirlooms, beloved pets, and the unaccounted clutter of the history of their lives. Some lost family members as well. By now, many of them should be adjusting to their new homes and new communities. For others, the pain continues and is intense. Some of these people, as well as those hurt by hurricanes Rita and Wilma, will be diagnosed with post-traumatic stress disorder (PTSD). PTSD experts have some recommendations for neurologists and primary care physicians.
PTSD is one of the most serious and longest-lasting of the human responses to trauma. It is diagnosed in individuals who manifest a particular spectrum of behavioral and emotional responses a month or more after experiencing a traumatic event. If PTSD lasts for less than 3 months, it is classified as acute; if it lasts longer than 3 months, it is classified as chronic. If symptoms develop 6 months or more after the traumatic event, the diagnosis is classified as delayed-onset PTSD.
According to psychiatrist and pharmacologist Matthew Friedman, MD, PhD, executive director of the National Center for PTSD at the US Department of Veterans Affairs (VA), at the White River Junction VA Medical Center in New Hampshire, "most people with PTSD will seek primary care rather than mental health care." Thus, a primary care physician--or possibly a neurologist--is likely to be the point of first contact for the patient suffering from this constellation of mental and physical problems. Friedman added, "People with PTSD are much more likely to be high users of medical services than those without."
In a recent review article,1 Ronald Glaser and Janice K. Kiecolt-Glaser of the Institute for Behavioral Medical Research and the Comprehensive Cancer Center of Ohio State University in Columbus noted that stressors affect the hypothalamic-pituitary-adrenal axis, leading to release of glucocorticoid hormones from the adrenal gland. At the same time, the sympathetic-adrenal-medullary axis is stimulated, releasing epinephrine and norepinephrine. Both the hormones and the nervous system connections have direct and indirect effects on immune cells, which, through cytokines, have additional effects on the hypothalamus and pituitary gland. Thus, stress leads to more stress and to immune system dysregulation. This, in part, may help explain the physical manifestations seen in patients with PTSD.
What is trauma?
Psychologist Edna Foa, PhD, a professor at the University of Pennsylvania Department of Psychiatry, defined a traumatic experience: "A traumatic event usually is defined as an event either the person had experienced themselves or had witnessed another person experience. Either he or she or the witness is injured, or dying, or died, or in danger of dying." The person who is experiencing the event is "horrified, terrified, or feeling helpless," she noted.
"The perception of death or danger to one's life is a very important one," Foa said. Among the types of events that may trigger PTSD are shootings, witnessing torture or being tortured, being in a traffic accident, being in a war, being raped, or suffering because of a natural or man-made disaster. Thus, witnessing the devastation of Hurricane Katrina or being near ground zero on September 11, 2001, are the kinds of mass events that can trigger PTSD.
In the normal course of life, people who have been exposed to a traumatic event heal naturally. "Most people are resilient; most people will recover on their own," explained Friedman. "Most people will never progress to full PTSD."
He noted that the classic book on a post-traumatic reaction is the Civil War novel The Red Badge of Courage. This book illustrates, Friedman explained, "an acute post-traumatic reaction . . . , an immediate, intense stress reaction." Recovery from such a reaction occurs in 3 to 4 days. In cases in which a person has been terrified or has witnessed or suffered through a terrifying event, a physician will "want to assume normal recovery," said Friedman. "A significant minority may not recover and may develop acute stress disorder and may go on to PTSD," said Friedman.
Foa and her colleagues reviewed studies on whether immediate psychological debriefing after a traumatic event prevents subsequent PTSD.2 Unfortunately, many of these studies are flawed, and the jury is out on whether such immediate intervention is helpful, ineffective, or even results in more cases of PTSD.
Both Friedman and Foa recommend that primary care physicians screen their patients for PTSD, something they both say is done too infrequently in primary care practices. Such a screening device may identify patients who suffer from the disorder, but who, because of fear of stigma about suffering from a mental health problem, may otherwise be reluctant to seek treatment. Friedman noted that this is especially a problem in the military, because soldiers may believe that admitting to a mental health problem may negatively affect promotion to higher rank.
Foa also recommends that neurologists screen patients who are potentially affected by these latest disasters. "It can be completed in about 10 to 15 minutes in the waiting room," she said.
The 4--or more--questions
Friedman formulated a series of 4 questions for patients (Table). If the patient answers yes to any 3 of the 4 questions, he or she is probably suffering from PTSD. Foa, who is on the committee that defined PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, has developed a more complex screening tool. "It's the only questionnaire that also asks whether you have been traumatized and when did it happen, what is the trauma, what is the trauma that disturbs you the most, what kind of symptoms do you have, and does it interfere with your functioning," she said.
"The symptoms are divided into 3 clusters," Foa explained. "The first one is called the 'reexperiencing' cluster, and that includes recollection of the event." These recollections include nightmares, flashbacks, and emotional reactivity when the person is reminded of the event. The second cluster of symptoms includes avoidance of anything that is likely to remind the person of the trauma, such as attempting to push the event away, avoidance of thinking about the event, or avoiding anything that could be a reminder of the event or that is similar to the event.
An important group of symptoms, said Foa, are the "emotional numbing symptoms." These include detachment from others; loss of interest in once-favored activities; inability to experience the range of emotions one once had; and a feeling of emotional alienation, especially from spouses or children. The final group of symptoms is classified as hyperarousal symptoms: sleep disturbance, hypervigilance, startle responses, exaggerated startle responses, irritability, and outbursts of anger.
Once a patient--such as one who has come through the Hurricane Katrina disaster--has been identified as having experienced a trauma, the next question is what to do about it. Foa used a Katrina victim as an example because more than a month has elapsed since the disaster.
"If a person has very severe symptoms, [he or she] should be treated," she said. "If [patients] have moderate symptoms or mild symptoms, they're likely to improve with time." Those in the latter group, she noted, should be educated so that they will understand that such symptoms "are normal after a traumatic event; they should go away."
For a diagnosis of PTSD, explained Foa, a patient must have at least 1 reexperiencing symptom, 3 avoidance symptoms, and 2 arousal symptoms, along with severe distress, impairment, and dysfunction. Friedman said that a positive response to any 3 of the questions on his screen (Table) means that the patient "ought to receive a more careful assessment because [of] the likelihood [of] PTSD." He said that the VA is now using this 4-question screen annually for all primary care patients.
A patient with these symptoms should be treated with either medication or cognitive-behavioral therapy, according to Foa. She also noted that it's important for therapists to have experience in treating PTSD. Furthermore, it is particularly important to treat patients with PTSD who have experienced the trauma a year or more before presenting for care. Spontaneous recovery after a year is unlikely, she explained.
Joyce Herling, MSW, LCSW, whose psychotherapy practice is in Bronxville and Patterson, NY, receives patient referrals for PTSD treatment from psychiatrists, internists, and neurologists, but the bulk of her referrals come through patient calls to health insurance companies. Insurers, she explained, have social workers and nurses. "If the person calls up [the insurance company] and talks about it, [the screener] would say, 'It sounds to me like you have post-traumatic stress disorder. Here are some professionals in the area,'" said Herling, who once served as an insurance company mental health screener.
Herling uses cognitive-behavioral therapy and sometimes biofeedback to treat these patients. Cognitive-behavioral therapy confronts how the patient is feeling and deals with mechanisms to change these feelings. Techniques may include relaxation exercises or biofeedback.
In biofeedback, the patient is hooked up to a computer that measures breathing and heart rate and teaches the patient methods--the results of which he or she can see on-screen--that will decrease the level of anxiety. Herling said that some of the more advanced biofeedback methods use computer games.
The therapist needs to tailor the treatment to the patient. "Everybody's different," said Herling. "It depends on the person, and it depends on the trauma as well." But, she noted, PTSD does not go on forever in someone receiving treatment. "There's definitely an end point. The dreams get less; they're able to function better; the thoughts aren't as intrusive."
Friedman noted that because so many people who experience PTSD or depression are heavy users of medical care, some medical practices have incorporated primary behavioral health treatment, which tends to yield better results for patients than does treatment at distant mental health centers. Foa said that specialized treatment for trauma is usually available at major medical institutions.
Friedman pointed out, however, that the realities of primary care practice might mean that the primary care physician will treat the patient. He recommended that a patient be given a trial of selective serotonin reuptake inhibitors. If medication is not effective, the patient should be referred to a mental health practitioner.
Foa noted that patients might relapse after medication is discontinued, but relapses do not occur after cognitive behavioral therapy.2 Herling, who works in the mental health practitioner-dense New York City suburban area, said that drugs are a last resort and should be used only when other treatment modalities fail.
Why are some people more vulnerable?
PTSD doesn't develop in everyone who suffers a trauma or witnesses a traumatic event. Some of the latest research on the disorder focuses on identifying high-risk populations. A team of researchers led by Rachel Yehuda, PhD, professor of psychiatry and director of the Traumatic Stress Studies Division at Mount Sinai School of Medicine and Bronx VA Medical Center in New York, noted that the immediate response to the stressor--such as panic--may predict later development of PTSD.3 It's possible that other characteristics, such as lower intelligence, prior trauma, prior psychiatric disorders, lack of a support network, low socioeconomic status, and abnormal physiologic responses, may result in PTSD.2,3
Friedman said that current research is focusing on the social, genetic, and neurohormonal markers that may confer resilience to trauma in some people. He said that researchers are studying several genes to determine the biologic mechanism of resilience. Noted Friedman, "If you understand resilience, you can start talking about prevention; you can start talking about prophylaxis." *
• Foa's Posttraumatic Stress Diagnostic Scales (PDS) is available through Pearson Assessments (www.pearsonassessments.com).
• Joint Veterans Affairs/Department of Defense practice guidelines on PTSD are on the Internet at www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm.
• The National Center for PTSD's Web site (www.ncptsd.va.gov) contains huge amounts of information about the epidemiology, diagnosis, and treatment of the disorder, and information about specific, current disasters that may cause psychological effects in victims.
1. Glaser R, Kiecolt-Glaser JK. Stress-induced immune dysfunction: implications for health. Nat Rev Immunol. 2005;5:243-251.
2. Foa EB, Cahill SP, Boscarino JA, et al. Social, psychological, and psychiatric interventions following terrorist attacks: recommendations for practice and research. Neuropsychopharmacology. 2005;30:1806-1817.
3. Yehuda R, Bryant R, Marmar C, Zohar J. Pathological responses to terrorism. Neuropsychopharmacology. 2005;30:1793-1805.