Why is it important to be aware of trauma and PTSD in health care settings?
There are a number of reasons why health care providers should assess patients for a history of trauma exposure. Some of the most important reasons are:
Trauma and trauma-related problems are common. About 60% of men and 50% of women experience at least one trauma such as a disaster, war, or a life-threatening assault or accident at some point in their lives (1). Nearly 8% of the population has PTSD in their lifetimes, and PTSD is highly comorbid with other disorders such as panic, phobic, or generalized anxiety disorders; depression; or substance abuse.
PTSD affects health. Reviews of the literature on trauma and health emphasize the role of PTSD as a mediator between trauma exposure and health effects (2-3). Such health effects include a variety of medical disorders as well as significant behavioral health risks. To learn more, see PTSD and Physical Health.
Trauma exposure affects utilization of services. The literature reviews also cite findings of high medical utilization rates for survivors of different types of trauma (2-3).
PTSD is underrecognized by practitioners. Research shows that many patients who seek physical healthcare have been exposed to trauma and have posttraumatic stress symptoms but have not received appropriate mental health care (4). As with other anxiety disorders and depression, most patients with PTSD are not properly identified and are not offered education, counseling, or referrals for mental health evaluation. Keep in mind that avoidance of trauma reminders is a prominent symptom of PTSD. This makes it even more likely that patients will not spontaneously report their trauma experiences or related symptoms.
What can health care providers do?
Health care providers can increase the chances of improved health outcomes for their patients by following these steps:
Identify a PTSD consultant
Screen for PTSD
Discuss the results
Provide a referral
Provide educational materials
Follow up with the patient
Identify a PTSD consultant
The first step is to identify a mental health care provider trained in PTSD. This provider should be able to provide you with consultation, and your patient with education, assessment, and counseling. PTSD therapists come from a range of disciplinary backgrounds including psychiatry, clinical psychology, social work, and psychiatric nursing. An excellent place to find a provider trained in dealing with trauma and PTSD is Where to Get Help for PTSD.
Screen for PTSD
Providers can use the questions from the screen listed below to ask about trauma-related symptoms. Alternatively, a practitioner can distribute a self-report screening instrument prior to a medical appointment. Completed screens are collected and reviewed by the physician, nurse, physician's assistant, or a mental health consultant to identify patients who are likely to be experiencing distressing posttrauma reactions. Screening items can also be added to the standard medical history forms that patients complete at first visits.
The Primary Care PTSD Screen (PC-PTSD) shown below has been designed for use in primary care and other medical settings (5-6). The PC-PTSD is brief and problem-focused. The screen does not include a list of potentially traumatic events. There are two reasons for this:
Studies on trauma and health in both male and female patients suggest that the active mechanism linking trauma and physical health is the diagnosis of PTSD (2-3). In other words, the relationship between trauma and health appears to be mediated through a current PTSD diagnosis.
A symptom-driven screen, rather than a trauma-focused screen, is attractive to health care staff who may not be able to address a patient's entire trauma history during their visit . A trauma-focused inquiry might be especially problematic with a VA population where the average number of traumatic events meeting criterion A for PTSD is over 4.
Primary Care PTSD Screen (PC-PTSD)
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
Have had nightmares about it or thought about it when you did not want to?
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your surroundings?
Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. A positive response to the screen does not necessarily indicate that a patient has PTSD. However, a positive response does indicate that a patient may have PTSD or trauma-related problems, and further investigation of trauma symptoms by a mental health professional may be warranted. Patients who screen positive for PTSD should be explicitly screened for suicidal ideation as well.
Discuss the results
The following suggestions may facilitate your discussing with the patient his or her responses to the PTSD screen:
Provide an appropriate context for the discussion and respond empathically
Ensure privacy by closing the door and keeping family members out of the room.
Inform patients that traumatic events and the distress they create can have important effects on the body and on health as well as on the patient's mental health.
Make no assumptions about the meaning or impact of traumatic events for an individual; your assumptions may be inconsistent with the patient's feelings and experience.
Acknowledge any reported distress (e.g., "I'm sorry you have had such terrible nightmares").
Show interest and concern, and tell the patient that you are glad that he or she has told you about the symptoms.
Offer empathic support. Unless you have appropriate mental health training and will be the person to evaluate or treat the patient, it is not advisable to elicit a detailed account of the trauma or to challenge the patient's report in any way.
If the PC-PTSD screening instrument is utilized, clarify responses to determine:
Whether the patient has had a traumatic experience. "I notice from your answers to our questionnaire that you experience some symptoms of stress. At some point in their lives, many people have experienced extremely distressing events such as combat, physical or sexual assault, or a bad accident, and sometimes those events lead to the kinds of symptoms you have. Have you ever had any experiences like that?"
Whether reported symptoms are really trauma-related. "I see that you have said you have nightmares about or have thought about an upsetting experience when you did not want to. Can you give me an example of a nightmare or thinking about an upsetting experience when you didn't want to?" If a patient gives an example of a symptom that does not appear to be in response to a traumatic event (e.g., a response to a divorce rather than to a traumatic event), it may be that he or she is ruminating about a negative life event rather experiencing intrusive thoughts about a traumatic stressor.
Whether reported symptoms are disruptive to the patient's life. "How have these thoughts, memories, or feelings affected your life? Have they interfered with your relationships? Your work? How about with recreation or your enjoyment of activities?"
Positive responses to these questions in addition to endorsement of trauma symptom items on the PC-PTSD Screen indicate an increased likelihood that the patient has PTSD and needs further evaluation.
Ascertain whether traumatic events are ongoing in a patient's life
If ongoing traumatic events are a part of the patient's life, it is critical that the health care practitioner determine whether the patient needs an immediate referral for social work or mental health services. The practitioner might ask: "Are any of these dangerous or life-threatening experiences still continuing in your life now?"
If ongoing family violence is suspected, it is imperative that the patient be told the limits of confidentiality for medical professionals, who are mandated to report suspected ongoing abuse of children and dependent adults. Discussion of possible abuse should take place in the absence of the suspected perpetrator; if the abuser is present, victims may deny abuse for fear of retaliation.
If ongoing threats to safety are present:
Acknowledge the difficulty in seeking help when the trauma or threat is ongoing.
Determine if reporting is legally mandated. If it is, develop a plan with the patient to file the report in a way that increases rather than decreases the safety of the patient and his or her loved ones.
If reporting is not appropriate, provide written information (or oral if written might stimulate violent behavior in the perpetrator) about local resources that might help the situation. Establish a plan that the patient will agree to in order to move toward increased safety. The National Domestic Violence Hotline is available to guide callers to local resources: 1-800-799-SAFE or TTY: 1-800-787-3224.
Provide a referral
After a review of the screen results and a discussion with the patient, the provider can decide whether the patient may benefit from further specialized mental health evaluations. Patients with positive screens may be referred to specialized PTSD treatment, behavioral medicine, or more general mental health services for further evaluation and possible treatment.
If it appears that a patient does have active PTSD symptoms
Explain why the screen results lead you to recommend that he or she seek further evaluation and/or treatment. Let the patient know that the screen does not mean that he or she definitely has PTSD, but that you think further evaluation is needed.
Encourage the patient to voice any reservations or concerns he or she might have about evaluation or treatment. You may be able to facilitate pursuit of treatment by listening to these concerns, acknowledging their validity, and addressing some of the patient's questions about what to expect during mental health evaluation and treatment.
Make sure the patient understands that he or she is not crazy.
Normalize the idea of treatment. Explain that treatment involves common sense activities that include learning more about PTSD, finding and practicing ways of coping with trauma-related symptoms and problems, taking steps to improve relationships with family and friends, and making contact with other patients who experience similar problems.
Provide the patient with a written referral to a mental health professional.
The mental health professional to whom you refer the patient should be given:
A copy of the PC-PTSD results
Any relevant information about health events or injuries that might have been traumatic
Information about any suspected negative impact of the patient's posttraumatic symptoms on health or medical compliance
If the patient refuses referral to mental health care
Many patients are reluctant to participate in mental health treatment. Common reasons include discomfort with the idea of seeing a psychologist or psychiatrist, a perceived stigma associated with treatment, previous negative experiences with mental health providers, negative attitudes towards health care agencies, a lack of confidence in the helpfulness of counseling, or a reluctance to open up old emotional wounds. Faced with this situation, the primary practitioner can do several things to raise the likelihood that a mental health referral will be accepted:
Suggest an evaluation rather than treatment. Sometimes, it is useful to suggest that the patient meet with a mental health professional so that he or she can learn more about posttraumatic stress, ask questions, and consider with the mental health provider whether more contacts will be useful.
Explain the need for treatment. Explain to patients that although a wish to avoid reminders of the trauma is natural and common, this avoidance may actually interfere with recovery. This avoidance may prohibit helpful processes that can result from talking through the experience, receiving social support, or receiving specialized treatment.
Give the patient educational materials that describe PTSD and its common co-morbid conditions (depression, substance abuse), treatment for PTSD, and coping with PTSD. Sometimes he or she will read the materials at a later time and begin to think more carefully about participation in treatment.
Give information about different ways the patient can seek assistance. Avenues for assistance include local mental health services; online resources; and local community, spiritual, and mental health resources.
Consider involving the patient's spouse or partner in the discussion if it seems appropriate and the patient gives his or her permission. This may help clarify for the patient the impact of PTSD on others in his or her life and increase his or her motivation to seek help.
Provide educational materials
Patients who screen positive for PTSD (and their families) may also benefit from educational materials about trauma and PTSD, such as those on the National Center for PTSD website.
Follow up with the patient
At the patient's next visit, it is important to ask whether he or she followed through with the referral for mental health evaluation or care. If the patient did follow through, the practitioner can ask if the referral was perceived as helpful. If the patient did not follow through with the referral and is still in need of care, the provider can try to learn what the obstacles were to obtaining care.
Consider scheduling frequent brief office visits or telephone follow-ups. Regular check-ins with patients about their current functioning as well as follow-ups on referrals are important for keeping patients involved in their own recovery process.
Trauma-related problems are common among the general population, and such problems can affect physical and psychological functioning as well as use of health care services. However, PTSD is often underrecognized by medical practitioners, with the result that patients with posttraumatic stress are not offered the effective treatments that are available. It is recommended that health care providers routinely screen individuals for trauma-related symptoms. Use of a PTSD screen increases a health care provider's ability to detect PTSD and to initiate appropriate referral. We suggest specific strategies that health care providers can use to improve outcomes for patients with PTSD.
Kessler, R.C., Sonnega, A., Bromet, E. Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048-1060.
Friedman, M.J. & Schnurr, P.P. (1995). The relationship between trauma, post-traumatic stress disorder, and physical health. In M.J. Friedman, D.S. Charney, & A.Y. Deutch (Eds.), Neurobiological and clinical consequences of stress: From normal adaptation to post-traumatic stress disorder (pp. 507-524). Philadelphia: Lippincott Raven.
Ford, J.D., Ruzek, J.I., & Niles, B.L. (1996). Identifying and treating VA medical care patients with undetected sequelae of psychological trauma and post-traumatic stress disorder. National Center for PTSD Clinical Quarterly, 6(4), 77-82.
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9-14
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2004). The primary care PTSD screen (PC-PTSD): Corrigendum. Primary Care Psychiatry, 9, 151
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