CHAPTER 38 Approach to the Patient Following a Traumatic Event RAPHAEL ORNSTEIN 1. Trauma A. Definition 1. According to DSM-IV, a traumatic event involves “actual or threatened death or seri- ous injury or a threat to the physical integrity of self or other.” Examples of trauma include the following: 1. Exposure to military combat, violent assault (including rape and robbery), domestic vio- ence, automobile accidents, childhood physical and sexual abuse or neglect, natural disasters, and sudden catastrophic medical illnesses , Witnessing a traumatic event c. Being told about a trauma experienced by a loved one 2. Traumatic events are associated with experiences of overwhelming fear and helplessness, Because of the intensity of feelings associated with a traumatic event, perception of the event may be distorted; it may be experienced as fragments of sensations, time may be slowed or accelerated, feelings may be dissociated from the events as they are occurring, and there can be varying degrees of amnesia for all or part of the traumatic event. Il. Responses to Traumatic Stress ‘A. Acute and Iong-term responses to traumatic events are varied and multideter- mined. Neatly every person can be expected to have some disruption in their mental functioning following a significantly traumatic event (i., a “normal” stress response). On average, most people are able to adapt following a traumatic event and return to their previous level of functioning, with or without some chronic symptoms. When the symp- toms following a trauma impair functioning they often appear as syndromes, labeled in the DSM-IV as acute stress disorder and posttraumatic stress disorder. Chronic expo- sure to trauma or trauma occurring in childhood can produce long-lasting personality dis- turbances. It is also common for traumatic events to cause psychiatric morbidity without meeting criteria for these syndromes; following a traumatic event individuals are at higher risk for depression, anxiety, somatoform disorders, and substance abuse. 1. The psychological disruption following a traumatic event takes the form of alternat- ing states of mind; the person is overwhelmed with thoughts, feelings, or images of the trauma, along with states of numbness, denial, and avoidance. a. Trauma can present clinically as an extremely labile mood, tearfulness, and despair, alternating with a sense that the trauma “didn’t really happen” or that “nothing feels real. b. A patient can appear “spacey” and inattentive, or hypervigilant and prone to startle. The individual can be oblivious to the consequences of the event or preoccupied with the trauma, 327328 38 + Approach to the Patient Following a Traumatic Event ¢. Traumatic memories have an intrusive quality; they are unbidden and feel uncontrol- lable. They can intrude as nightmares, which are repetitive and disruptive to sleep. Memories can impair daily functioning and may be so vivid that patients feel as if they ‘are reocurring in the present, a so-called flashback. Traumatic memories are easily trig- gered by environmental cues that are associated with the traumatic event. Physiological arousal may occur with reminders of the trauma, involving intense feelings of fear, rapid palpitations. profuse sweating, and shortness of breath. Frequently a traumatized person will be concerned that he or she is “going crazy.” d. Patients may attempt to avoid memories of the trauma. This can lead to an avoidance of talking and thinking about the trauma and avoidance of any environmental triggers. ‘There may be a constriction of mood and affect as intense feelings of any kind can pre- cipitate a traumatic recollection. Often patients fee! detached and estranged from others and isolate themselves, even from close friends and family. There may be a feeling that “fe has lost its meaning,” and a feeling that the future is limited. . Patients may complain of a set of symptoms related to an overall feeling of increased arousal; sleep is disrupted and there can be marked irritability and uncharacteristic out- bursts of anger. Concentration and attention can be impaired. £. Under normal circumstances, intrusive preoccupations and avoidant behaviors resolve as individuals come to terms with the trauma and adapt to its consequences. Consistent themes emergé as patlynts confront the reality of the trauma, such as fear of retrauma- tization, shame, humiliation, aft helple3spess. Frequently victims blame themselves as a way to maintain a feeling 6f contro], Feelings of intense rage are common and can be overwhelming. . An acute stress disorder is diagnosed, according to DSM-IV, if the characteristic trauma response causes clinically significant impairment that lasts at least 2 days, persists up to 4 weeks, and occurs within 4 weeks of the traumatic experience. The features of an acute stress disorder include the following: a, exposure to a traumatic event b. at least three of the following dissociative symptoms: (1) a sense of numbness and detachment, (2) being in a daze, (3) a feeling that one is unreal, (4) a feeling that one’s environment is not real, and (5) an inability to remember important aspects of the trauma ¢. intrusive reexperiencing of the trauma 4. avoidance of stimuli that lead to recollection of the trauma . symptoms of increased arousal and anxiety . The diagnosis of posttraumatic stress disorder (PTSD) is made, according to DSM-IV, when the characteristic trauma response causes clinically significant impairment and lasts more than 1 month. The diagnosis is made on the basis of intrusive reexperiencing of the trauma, avoidance, numbing, and symptoms of hyperarousal. The disorder is con- sidered acute if the symptoms have lasted less than 3 months and chronic if the symp- toms last for more than 3 months. The onset of posttraumatic stress disorder can be delayed if symptoms emerge after 6 months following a traumatic event. }. Disorders of Extreme Stress Not Otherwise Specified. Children exposed to physi- cal or sexual abuse or adults exposed to prolonged and repeated trauma may develop long-standing problems in psychological and interpersonal functioning. There can be difficulty tolerating feelings, especially the management of anger, leading to impul- sive behavior. Dissociation, self-destructive behavior, and suicidal ideation are not uncommon. There may be attachments to powerful and abusive figures. New rela-38 + Approach to the Patient Following a Traumatic Event 329 tionships may be difficult to form, as these persons can feel an intense need for close- ness but also fear being controlled or abandoned. There is a diminished sense of agency and a passive and helpless stance toward the world. Somatization is common. These patients are at risk to be repeatedly victimized. B. Epidemiology 1. There is a 1 to 3 percent lifetime risk for developing posttraumatic stress disorder (PTSD) in community samples. 2. For victims of rape and war veterans with combat experience, lifetime risk for devel- oping PTSD begins around 30 percent and reaches 90 percent for brutalized prisoners of war. 3. An acute stress disorder puts a patient at risk for, but does not invariably lead to, PTSD. ‘Those patients with PTSD may or may not have suffered from the acute disorder. Ill. Evaluation Immediately Following a Traumatic Event A. Immediately following a traumatic event the initial goal should be to help the patient regain a sense of mastery and control. Most people adapt to traumatic events without pro- fessional help. The intervention should focus on helping the patient face the reality of the traumatic event, identify useful coping skills, access social and community supports, and anticipate the characteristic symptoms that follow a traumatic event. Often a thorough and thoughtful evaluation can be the beginning of an effective intervention and provide an opportunity to assess the need for ongoing care. During the evaluation the physician should keep in mind that although the traumatic aspects of an event may appear self-evident, itis critical to establish the personal meaning that the trauma has for the patient. It is im- portant to identify what the patient hopes to gain from the encounter with the physician. ‘An evaluation should include and be guided by the following principles: 1, Rapport should be established with the patient. Acknowledging the seriousness of the traumatic event, offering condolences if appropriate, and following usual social customs can set the patient at ease. 2, Attention should be paid to the practical and immediate concerns brought about by the traumatic event. The physical and medical status of the patient and any other victims should be evaluated. The availability of basic human necessities such as food, shelter, and safety should also be established. 3. A brief survey of the patient’s mental status is important to determine if the patient can safely manage with currently available support. It is not uncommon for patients to either be overwhelmed with emotion or feel detached and numb. Patients can become markedly disorganized or surprisingly controlled. Suicidally prone behavior should be monitored. 4, The patient should be gently encouraged to review the trauma and surrounding events. Allow the patient to share his or her feelings about the trauma, including fee!- ings of helplessness, guilt, shame, and anger. Inquire about what specific actions were taken or not taken by the patient or others that could have affected the outcome of the traumatic event. Identify the aspect of the trauma that was most distressing to the patient. However, also pay careful attention to the patient's ability to tolerate the telling of the story. The patient's characteristic coping style must be respected. It is important for patients to have a sense of control over the pace and intensity of the interview and at the same time for the physician to offer overwhelmed patients a sense of direction and structure.330 38 + Approach to the Patient Following a Traumatic Event 5. Risk factors associated with the development of posttraumatic stress disorder should be assessed. The stressor is the most important risk factor; sudden, severe, prolonged trauma, intentionally inflicted and intended to humiliate, puts the victim at risk for PTSD. Social support following an event is a critical variable in an individual's response. Previous trauma, low intelligence, and prior psychiatric history, especially conduct disorder. antisocial and narcissistic personality disorders, put patients at risk for PTSD. 6. Know the patient’s strengths and customary manner of managing stress. 7. Assess whether a patient is at risk for ongoing victimization. For instance, the physician should be aware that spousal abuse is a common problem in all socio- economic groups. A concerned but nonjudgmental manner is crucial in allowing a victim of domestic violence to tell her story. IV. Treatment Immediately Following a Traumatic Event A. The primary care provider should do the following things: 1. Maintain a calm, empathic, and hopeful attitude, which can have a powerful effect on the patient immediately after a traumatic event. While acknowledging the profoundly disruptive effect of the trauma on the patient, the physician can also underline the fact that the patient is a survivor. Convey whatever information is known about the traumatic event to the patient. Having the facts on hand can help the patient organize chaotic and confusing feelings. Tolerate the patient's feelings and help put them into context. It can be greatly “reassuring for a patient to know that feelings of fear, helplessness, guilt, shame, and anger are expectable responses to a traumatic event. The patient may need to be reas- sured that he or she is not “going crazy.” 4, Educate patients about the common responses to trauma, which can help them feel more in control of their experiences. Patients should be told that they may expe- rience insomnia, nightmares, intrusive memories, and irritability in the first few months or so after the trauma, but these symptoms should then begin to subside. 5. Educate patients about possible maladaptive responses to trauma. Alcohol abuse and other substance abuse are common as patients attempt to manage hyperarousal and intrusive symptoms. 6. Review how the patient has managed crises in the past and help the patient recall and revitalize those strengths. Following a trauma, patients frequently lose sight of previously attained coping mechanisms. Fatigue, terror, and loss may predispose patients to less adaptive ways of negotiating with the world. It can be helpful for the physician to focus on concrete tasks that may be facing the patient. For cases involv- ing interpersonal traumatization, such as with a battered woman, the physician may need to help the patient consider and then access the legal system. Patients who face persistent threat should be encouraged to write out a “safety plan” that details con- crete steps the patient will take to avoid future traumatization. These steps may include involving local law enforcement authorities. The physician can encourage the patient to take steps to protect himself or herself, but ultimately it is the patient who must make that decision. 7, Encourage the patient to use existing supports. Although the patient may feel ashamed and reluctant to call on friends or family, the physician may need to encour- 238 + Approach to the Patient Following @ Traumatic Event 331 age those contacts. Frequently the patient's social network, family, friends, and wider community play an important role in recovery from trauma. 8. Use medication sparingly. There is no long-term benefit from heavily sedating patients following a trauma, Severe anxiety, agitation, and insomnia may be treated with benzodiazepines, such as lorazepam (Ativan) at doses of 1 mg b.i.d. and has. Supplies should be given for not more than several days and are contraindicated in patients with a history of alcohol or substance abuse. Schedule a follow-up office visit or phone call after a traumatic event. It is help- ful to orient the patient toward the future; it is reassuring to the patient not to feel alone in the process of recovery. 10. Tell the patient that a referral to a psychiatrist or other mental health profes- sional is available. Patients with underlying psychiatric illness should be referred directly to a psychiatrist. Patients with a history of PTSD or a history of trauma should be monitored for difficulty in functioning. Patients who have suffered severe, intentional trauma, such as rape or domestic abuse, should have a follow-up appoint- ment for psychological counseling. Patients whose symptoms persist or become debilitating will also require a referral. 2 V. Evaluation and Treatment Weeks to Months Following a Traumatic Event A. It is very difficult to predict how an individual will respond to a traumatic event over time. Some people have severe symptoms soon after the trauma, but go on to adapt very well. Some individuals do seemingly well after a trauma, but later develop PTSD months or even years after the event. An earlier trauma can leave a person vulnerable to the effects of a subsequent one. For example, a patient may do well following a car acci- dent, despite suffering injuries, but then years later may develop a debilitating array of posttraumatic symptoms following a minor accident. B. The time course of the patient’s symptoms has important clinical implications. Symptoms may cause clinically significant impairment in the first month, as acute stress disorder, or in the following 2 months as posttraumatic stress disorder. About half of patients will improve and return to an acceptable level of functioning, with some residual symptoms; the rest will go on to have chronic PTSD. After 3 to 4 months and definitely by 6 to 8 months PTSD is a chronic psychiatric illness. C. Weeks to months following a traumatic event it is important to evaluate how the patient is adapting and to determine the extent of his or her posttraumatic symptoms. 1. Offer the patient an opportunity to recount the traumatic event, if not already done so, with the physician. It is important to allow the patient to modulate the telling of the story and not necessarily therapeutic for a patient to simply “get all of the feelings out.” It is useful to note how much or how little the patient is able to talk about the traumatic event. Ideally, the patient will find some relief in being able to talk about the event, and therefore, repeated tellings may have a therapeutic value. Some patients may be so overwhelmed they think or speak of nothing else: others may be so over- whelmed that they are not able to speak of the trauma at all. 2. Review the symptoms of PTSD with the patient and assess the severity and extent of the patient's symptoms. Are there intrusive symptoms such as nightmares and flash-332 38 + Approach to the Patient Following a Traumatic Event backs? How frequently? How does the patient manage thoughts and feelings about the trauma? Are there significant attempts to avoid these thoughts and feelings? Patients may not complain directly of feeling numb and detached, but these symptoms can be disabling. Does the patient have hyperarousal with hypervigilance, insomnia, and an exaggerated startle response? 3. Evaluate the patient's overall psychological, social, and occupational functioning. Has the patient been able to resume his or her usual activities? Is there inordinate difficulty in resuming routine activities that the patient associates with the trauma? How is the patient relating to family and friends? Is there an increase in social isolation or a feel- ing of alienation? 4, Formulate a differential diagnosis, as several psychiatric illnesses share characteristics of PTSD. Psychotic disorders, major depressive and bipolar affective disorders, other anxiety disorders, and factitious illnesses may present with symptoms that overlap or mimic PTSD. 5, Screen and treat the patient for comorbid psychiatric illnesses that can complicate treatment and recovery. a, Alcohol abuse and other substance abuse b. Major depressive disorder c. Somatoform disorders 4. Dissociative disorders e. Eating disorders associated with childhood sexual or physical abuse. 6. Anticipate that if a court case is pending, the patient's condition may remain static or deteriorate until the case is resolved. Increasingly, PTSD is being implicated in court cases involving personal injury claims. Even in cases where the diagnosis of PTSD is. clear-cut, legal involvement complicates recovery. 7, Evaluate for ongoing traumatization. PTSD may leave patients less able to discrimi- nate between threatening and nonthreatening situations, leading to revictimization. C. The treatment approach for patients weeks to months following a traumatic event is similar to the one immediately following a trauma; establish rapport, review the trau- matic event, educate the patient about the characteristic trauma response, and involve social and community supports. Critical treatment goals at this stage include helping the patient cope with posttraumatic symptoms, treating comorbid conditions, and evaluating the need for referral to a mental health professional. 1. Monitor the intensity and frequency of the intrusive symptoms and take note of any stimuli that worsen or improve them. Avoidant symptoms need to be addressed directly; for instance, a patient who has been in a car accident may need ongoing, step- wise encouragement to return to driving. Outbursts of anger may need to be antici- pated and actively controlled. 2. Medicate specific symptoms that interfere with functioning. Medication can help diminish the symptoms of PTSD and can play an important role in a comprehensive treatment plan that includes social, psychological, and behavioral interventions. Treatment can be initiated with a selective serotonin reuptake inhibitor, and other medications can be added as the patient’s symptoms require. Depending on the treat- ing physician's experience with psychopharmacology, he or she may want to refer to, or consult with, a psychiatrist if an initial SSRI trial is not adequate to relieve the patient’s symptoms.88 + Approach to the Patient Following a Traumatic Event 333 » a. Selective serotonin reuptake inhibitors have been found to be the most helpful in treat- ing intrusive and avoidant symptoms, and they are somewhat helpful for hyperarousal. Fluoxetine (Prozac) 20 mg per day has been formally studied, but clinical experience suggests that sertraline (Zoloft) 50 to 200 mg per day and paroxetine (Paxil) 20 mg per day are also equally effective. Tricyclic antidepressants are somewhat helpful for intru- sive symptoms and insomnia. . Propranolol (Inderal) 20 to 60 mg per day or clonidine (Catapres) 0.1 to 0.2 mg bid. or hs. can be helpful with intrusive symptoms, especially nightmares. c. Clonazapam (Klonopin), lorazepam (Ativan), or other benzodiazepines can be helpful for hyperarousal. Caution is advised in using these medications because tolerance and abuse are common complications. They are best used during episodes of acute distress. The use of benzodiazepines in patients with a history of alcohol or other substance abuse is contraindicated. 4. If insomnia is a persistent problem, trazodone (Desyrel) 50 to 100 mg or tricyclic anti- depressants, such as doxepin (Sinequan) 25 to 50 mg or amitriptyline (Elavil) 25 to 50 mg hs., can be helpful. e. If mood lability or anger outbursts are particularly distressing, a trial of the anticon- vulsants valproic acid (Depakote) or carbamazepine (Tegretol), with therapeutic blood levels, may stabilize these symptoms. £. Neuroleptics are not generally used in the treatment of PTSD. However, if the patient is prone to disorganized episodes of near psychotic levels, low-dose antipsychotic med- ication can be used and then discontinued as soon as possible. Risperidone (Risperdal) 0.5 to 2.0 mg per day is sufficient. . Comorbid psychiatric conditions should be treated. | A referral to a mental health professional should be considered if the patient's symp- toms become debilitating or persistent. Psychiatric treatment for PTSD involves social, psychological, behavioral, and pharmacological interventions. The intense physiological and psychological reactivity to the trauma and its associated stimuli are modified by behavioral techniques of desensitization and by the previously mentioned medications. In individual psychotherapy, maladaptive patterns of adaptation are iden- tified and addressed. The patient's traumatic memory is modified by constructing a narrative of the event, which allows for mastery of overwhelming feelings. Group treatment can also be helpful in providing social support and solutions to the problems that survivors face. VI. Evaluation and Treatment Months to Years Following a Traumatic Event ‘A. Adaptation to trauma takes place over time. Individuals may be able to return to func- tioning and yet still bear invisible scars. For some there may be underlying depression or circumscribed phobias. Others, however, can successfully master and integrate the expe- rience into their lives leading, at times, to personal growth. Even months or years later, new challenges or setbacks can trigger traumatic memories and feelings for survivors. Of particular relevance for primary care physicians, these patients may experience an emer- gence of trauma-related feelings in the context of their medical care. A patient with a childhood history of sexual abuse may become anxious at the time of a physical exam and fear being retraumatized. Invasive procedures may be experienced by the patient as a replay of an abusive past. In these situations clinicians should gently inquire about a334 38 + Approach to the Patient Following a Traumatic Event history of trauma and work with the patient so that he or she can feel more in control of the exam or procedure. . Chronic posttraumatic stress disorder is a complex psychiatric illness. In almost all cases there are comorbid psychiatric disorders. Ongoing retraumatization is common and needs to be addressed before any improvement can be expected. Patients with debilitat- ing, chronic PTSD should be referred to a mental health professional for comprehensive treatment. Treatment is helpful when it begins by addressing the patient's current life stressors and works to help the patient regain control of daily living. Suggested Readings American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. ‘Washington, DC: American Psychiatric Association: 1994; 424-432. Herman JL: Sequelae of prolonged and repeated trauma: evidence for a complex posttraumatic syndrome (DESNOS). In: Davidson JRT, Foa EB, eds. Posttraumatic Stress Disorder: DSM-IV and Beyond. ‘Washington, DC: American Psychiatric Press; 1993; 213-228. Horowitz MJ: Stress Response Syndromes. Northvale, NJ: Jason Aronson; 1986. ‘Marmar CR, Foy D. Kagan B, et al: An integrated approach for treating post-traumatic stress. In: Oldham JM, Riba MB, Tasman A, eds. Review of Psychiatry, Vol. 12. Washington, DC: American Psychiatric Press; 1993: 239-273. Meichenbaum D: A Clinical Handbook/Practical Therapist Manual for Assessing and Treating Post- Traumatic Stress Disorder. Waterloo; Ontario: Institute Press; 1994. Tomb DA, Allen SN: Phenomenology of Posttraumatic Stress Disorder. Psychiat Clin North Amer 1994: 17(2):237-250. van der Kolk B, McFarlane AC, Weisaeth L, 5: Traumatic Stress, New York; Guilford Press: 1996: