Post-Traumatic Stress Disorder_

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					    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

    D. C. Lougheed MD and Dale Dewar MD

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    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.

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                     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

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                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
                           PTSD - PGS March traumatic event
  symbolize or resemble an aspect of the2011                             4
DSM IV – Post Traumatic Stress Disorder

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                 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)

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Impact of Events scale

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                   Criterion D: Hyper arousal

• Persistent symptoms of increasing arousal (not present
  before the trauma), indicated by at least two of the

•   Difficulty falling or staying asleep
•   Irritability or outbursts of anger
•   Difficulty concentrating
•   Hyper-vigilance

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                    Criterion E: Duration
            Criterion F: Functional Significance

• Criterion E: duration
• 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

• Specify if:
• With or Without delay onset: Onset of symptoms at least six months
  after the stressor
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• 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?

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                    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

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               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

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                          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
    4. Importance of return to meaningful social roles

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With thanks to:   Grandchildren of Marvin N. Lougheed MD FRCPC

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