City Health Information
Volume 33 (2014) New York City Department of Health and Mental Hygiene No. 1; 1-8
 

IN THIS ISSUE

 

Diagnosing and Managing the Mental Health
Needs of Adults Exposed to Disaster
  • Educate patients about physical and emotional symptoms of normal stress reactions.
  • Ask patients about their exposure and reactions to disaster.
  • Identify patients who may have posttraumatic stress disorder, depression, generalized anxiety disorder, or a substance use disorder and use standard screening tools for further evaluation.
  • Encourage patients to take advantage of psychotherapy, pharmacotherapy, or both.

 

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder may develop in individuals exposed to traumatic events involving the threat of serious injury or death to self or others (12). Posttraumatic stress disorder is characterized by all of the following symptoms, arising either immediately after the event or after a lag time and causing significant distress or impaired functioning for more than a month (12):

  • Reexperiencing the traumatic event such as experiencing distressing memories, nightmares, or flashbacks;
  • Avoiding reminders of the event such as thoughts, feelings, conversations, activities, places, or people; inability to recall an important aspect of the trauma; feeling emotionally detached or numb;
  • Chronically increased arousal symptoms such as insomnia, irritability, poor concentration, hypervigilance, or an exaggerated startle reaction.

Screening

Posttraumatic stress disorder can be difficult to recognize, because many patients are reluctant to disclose traumatic experiences unless asked (8). Patients with PTSD may initially report somatic complaints (8,13) with increased functional impairment. Certain nonspecific symptoms often associated with trauma include:

  • Palpitations
  • Shortness of breath
  • Insomnia
  • Nausea
  • Unexplained pain
  • Tremor
  • Mood swings

If the patient reports being affected by the disaster, or you suspect exposure to trauma, use the Primary Care PTSD Screen (Box 2) (12).

Patients with PTSD may also suffer from other psychiatric disorders, such as major depressive disorder or another anxiety disorder, that place them at higher risk of suicidal thoughts and behaviors (14-17).

Diagnosis

Symptoms of PTSD can overlap with those of depression or other anxiety disorders. Therefore, PTSD can be missed if the patient hasn't disclosed a traumatic event. New diagnostic criteria for PTSD (18) are available at the US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder (NCPTSD). Diagnostic tools conforming to the new criteria are being updated. Check the NCPTSD website regularly or sign up for e-mail updates (Resources) to obtain the new criteria. Refer patients to mental health providers if you are unsure of the new criteria.

Treatment

Counsel the patient in a supportive manner. Explain that PTSD symptoms result from psychological and biological reactions to overwhelming stress and that psychotherapy and pharmacotherapy (Box 3), alone or in combination, can be beneficial (8,19). Always consider comorbid conditions when selecting treatment.

Psychotherapy (8,20). Exposure-based cognitive behavioral therapy helps to reduce the arousal and distress associated with memories of trauma and has proven efficacy in treating PTSD. Exposure therapy is often combined with relaxation and breathing techniques that help patients manage anxiety and cope with stress. Individual or group trauma-focused therapy, eye movement desensitization and reprocessing (EMDR), and stress management are also effective in the treatment of PTSD. Non-trauma-focused approaches such as supportive therapy, nondirective counseling, and psychodynamic therapy are less effective in reducing PTSD symptoms. Other psychotherapeutic interventions may be effective, but further research is needed to determine efficacy. See Resources—Referrals for information on locating mental health services.

BOX 2. PRIMARY CARE PTSD SCREEN (12)

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you

1. have had nightmares about it or thought about it when you did not want to?

2. tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. were constantly on guard, watchful, or easily startled?

4. felt numb or detached from others, activities, or your surroundings?

Patients who answer yes to 3 of the 4 questions may be suffering from PTSD.

PDF version of Box 2

BOX 3. PHARMACOTHERAPY FOR PTSD

Two selective serotonin reuptake inhibitors (SSRIs), sertraline (Zoloft®*) and paroxetine (Paxil®), are FDA approved for treatment of PTSD. Zoloft is especially effective in treating non-combat-related PTSD. If there is no response to an SSRI, try venlafaxine (Effexor®) or other antidepressants such as mirtazapine (Remeron®) and duloxetine (Cymbalta®). For treatment-resistant PTSD, consider tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Because of their side effects, do not consider TCAs and MAOIs as first-line treatment.

For patients who show partial response to antidepressants, an additional psychotropic medication (antiadrenergic medications, antianxiety agents, and atypical antipsychotics) may be helpful. A combination of psychotherapy and pharmacotherapy may be indicated for some patients. Always account for other co-occurring psychiatric comorbidities before deciding on treatment.

* Use of brand names is for informational purposes only and does not imply endorsement by the New York City Department of Health and Mental Hygiene. Please consult product prescribing information, including Boxed Warnings, for complete safety information.

PDF version of Box 3

 

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