Post-Traumatic Stress Disorder and Medical Comorbidities: Screening and Intervention in Collaborative Care Settings Andrea Auxier, PhD Senior Strategist, Colorado Associated Community Health Information Enterprise/ Colorado Community Managed Care Network Senior Clinical Instructor, Department of Family Medicine University of Colorado Denver School of Medicine Christine Runyan, PhD, ABPP Associate Clinical Professor and Director, Fellowship in Clinical Health Psychology Department of Family Medicine and Community Health University of Massachusetts Medical School Collaborative Family Healthcare Association 14 th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Session # D3b October 5, 2012
Session # D3b October 5, 2012. Post-Traumatic Stress Disorder and Medical Comorbidities: Screening and Intervention in Collaborative Care Settings. Andrea Auxier, PhD Senior Strategist, Colorado Associated Community Health Information Enterprise/ Colorado Community Managed Care Network - PowerPoint PPT Presentation
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Post-Traumatic Stress Disorder and Medical Comorbidities:
Screening and Intervention in Collaborative Care SettingsAndrea Auxier, PhDSenior Strategist, Colorado Associated Community Health Information Enterprise/ Colorado Community Managed Care NetworkSenior Clinical Instructor, Department of Family MedicineUniversity of Colorado Denver School of Medicine
Christine Runyan, PhD, ABPP
Associate Clinical Professor and Director, Fellowship in Clinical Health Psychology
Department of Family Medicine and Community Health
University of Massachusetts Medical School
Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.
Session # D3bOctober 5, 2012
Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
Objectives
• List reasons for PTSD screening in primary care
• Describe how a screening procedure can be implemented
• Discuss how health information technology can be utilized to conduct practice-based assessment
• Describe how interventions can be designed in collaborative care settings.
PTSD – DSM 5
Experienced, witnessed an event involving actual or threatened death/ serious injury, or threat to physical integrity of self/ others
Intrusion Symptoms Persistent Avoidance Alterations in Cognitions and Mood Hyperarousal and Reactivity Symptoms
Three new symptoms: Erroneous self- or other-blame Negative mood states Reckless and maladaptive behavior
Complex PTSD: – captivity– psychological fragmentation– loss of a sense of safety, trust, self-worth, &
coherent sense of self – a tendency to be revictimized– pervasive insecurity– often disorganized-type attachment– poor affect regulation– . . .
Basic Facts
• Prevalence: 8% Lifetime
• Not everyone who experiences a traumatic event will develop PTSD– 8% of men and 20% of women develop
PTSD after a trauma
Risk Factors
• A previous traumatic event• Psychological difficulties prior to the event• Family hx of of psychological difficulties• Extent to which there was a threat to life• Amount of support following the event• Emotional response during the event• Dissociation• Being a child• Being a woman• Being a recent immigrant from a troubled country
Why Primary Care?
• It’s the principal point of contact• 12% of pts in community settings have PTSD
compared to 8% in general population
BUT . . .• Patients don’t come in saying they have PTSD• It’s up to us to identify it
Psychiatric Comorbidities
88% of men and 79% of women with PTSD meet criteria for another psychiatric disorder.
Men: alcohol abuse/dependence; MDD; conduct disorders; drug abuse/dependence.
Women: MDD; simple phobias; social phobias; and alcohol abuse/dependence.
U.S. Department of Veteran Affairs, National Center for PTSD
Arousal, vigilance, startle, conditioned emotional responses via locus coeruleus (NE)
Mineralcorticoid (MR’s)
Glucocorticoid (GR’s)
Cortisol in PTSD
• Persistently low, with spikes during times of stress
• A relatively small stressor to most people will trigger a biochemical cascade in someone with PTSD, manifesting as general hyper-reactivity and avoidant numbing, respectively.
• No other emotional condition, including depression, panic attacks, or anxiety disorders will produce this profile.
Trauma Affects Language
Alexithymia: Inability to verbally describe emotions
The “I was so upset I couldn’t think straight” phenomenon, magnified.
vigorous exercise, writing• Promote mastery and self-help• Write down any medical instructions – assume that under
stress people aren’t taking in all the information they need
In 15 Minutes?! …Key Principles of Trauma Informed Care
• Recognize trauma’s central role in health and illness• Validate patient’s experience• Link symptoms to past experiences of trauma• Meet patient where they are• Encourage patient to play an active role in goal setting• Build trust in relationship• Facilitate choice whenever / as much as possible• May get worse before it gets better• Talk less … Listen more• Healing is Possible – Evidence Based Treatments
Adopted from Weinreb, L. NIAAA Manual
Intervention Goals
• Break silence about trauma and abuse• Shift blame from survivor• If relevant, establish short term safety plan
– Give the patient control and choice • Contextualize and normalize the experience• Validate coping strategies• Integrate trauma factors in how you conceptualize and
address problems• Maintain positive relationship• Offer referrals for services
Healing is PossibleEvidence Supported Treatments (A Level Recommendation*)
• Narration (oral, written, past tense, imaginal) *• Cognitive Therapy, Cognitive Processing Therapy (CPT) *• Exposure Therapy *• Stress Inoculation Training (SIT) *• Psychoeducation *• Eye Movement Desensitization and Reprocessing• DBT Strategies• Mindfulness Based Strategies• Complementary and Integrative Modalities (Yoga,