Post-Traumatic Stress Disorder and the Trauma Healthcare Provider

Educational Objectives

The goal of this program is to improve management of posttraumatic stress disorder (PTSD) in health care providers. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate PTSD from acute stress disorder.
2. Relate the risk for PTSD to depression, alcohol use or substance use disorders.
3. Recognize the benefits of psychedelic drugs for treatment of PTSD.

Summary

Background: posttraumatic stress disorder (PTSD) is distinct from workplace stress, provider burnout, acute upset following stress, or exacerbation of depression or anxiety; PTSD typically develops ≥1 mo after an event; PTSD is not an immediate or short-term response to trauma; immediate reactions may signal potential future issues; trauma includes direct harm, threat of harm, or witnessing harm; healthcare providers, especially in emergency settings, face significant exposure to trauma; stress involves a causative event leading to an internal pathologic response

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Criteria for PTSD

Exposure: to actual or threatened death, serious injury, or sexual violence in ≥1 ways; encompasses direct experience, witnessing the event, or family members or friends experiencing a violent event; repeated or extreme exposure to adverse details (eg, first responders dealing with human remains) qualifies as exposure

Presence of symptoms: intrusion of >1 symptoms which are associated with the traumatic event; presence of intrusion symptoms involves recurrent, distressing memories, distressing dreams, and dissociative reactions or flashbacks which occur without warning and may occur without immediate recognition; psychological distress may be triggered by cues which resemble the traumatic event

Avoidance of stimuli: persistent and/or intentional avoidance of stimuli which are associated with the traumatic event

Negative alterations in cognitions or mood: alterations are event-specific and differ from major depression; distortions in cognition may manifest as an inability to recall crucial aspects of the traumatic event, persistent negative beliefs about oneself or others, and distorted thoughts regarding the cause or consequences of the event

Marked alterations in arousal and reactivity: manifest as irritable behavior, anger outbursts, aggression, reckless behavior, hypervigilance, exaggerated startle response, concentration difficulties, and sleep disturbance with intrusive dreams

Presentation: PTSD manifests as a set of symptoms which emerge following exposure; symptoms typically last >1 mo and start ≤3 to 4 mo after the event; the distressing and impairing nature of the disturbance may include dissociative symptoms (eg, depersonalization, derealization); transient experiences of depersonalization may have causes other than PTSD, eg, sleep-deprivation; however, depersonalization is a significant symptom in patients with PTSD

Differential diagnosis: acute stress disorder (ASD) occurs immediately in response to severe trauma typically within the initial month, but not lasting beyond that period; a significant percentage of individuals may experience ASD in association with trauma; patients who witness a comparable trauma for the second time have higher odds of developing more sustained PTSD

Course of illness: PTSD may become chronic if untreated; one-third of patients have signs of recovery at 1 yr; PTSD may produce depression, alcohol abuse, or substance use; the diagnostic focus may shift to newly emerged issues; the underlying PTSD remains untreated; PTSD which persists impacts occupational, social, and intimate aspects of life

Sequelae: PTSD is associated with physiological consequences, eg, coronary artery intimal changes in women which may be associated with hyperarousal; PTSD is linked to non-psychiatric medical conditions, contributes to occupational issues and interpersonal problems and violence; PTSD is associated with an increased risk for suicide

Suicide and PTSD: a significant concern in veterans; the National Comorbidity Survey demonstrated a robust link between PTSD and suicide attempts, and other anxiety disorders; studies from the Veterans Administration (VA) indicate that depression with PTSD plays a substantial role in veteran suicides; PTSD coupled with traumatic brain injury further increases risk; PTSD and TBI in combination may affect persons other than military personnel

Song et al (2023): analyzed ≈2500 child and adolescent victims of firearm injury; survivors were compared to non-survivors and matched controls; survivors showed a 68% increase in psychiatric disorders and a 144% rise in substance use compared with controls; parents of surviving victims experienced a 30% increase in psychiatric disorders; psychiatric disorders rose by 2.3-to-5.3-fold in family members of non-survivors; mental health visits increased by 15.3-fold in parents of non-survivors

Risk factors: physical injury is a greater risk factor than nonphysical injury; history of trauma or prior exposure, past history of depression, family history, gender (women are at greater risk), childhood adversity, poverty and associated issues, exposure to violence, low socio-economic status, education, and poor social support; ethnicity is not associated with an increased risk for PTSD

Prevalence: women exhibit a higher rate of PTSD; the rate of PTSD in veterans of the second Iraq war is 16% to 18%; the rate of PTSD in male prisoners is 20%; urban populations have higher rates than veterans in terms of current symptoms; continuous exposure to stressors has been suggested as an explanation; female prisoners experience high rates of PTSD symptoms

PTSD among trauma care providers: trauma care providers in the emergency department (ED) experience rates of PTSD similar to veterans; the forming of immediate relationships with trauma victims contributes to PTSD; providers are exposed to secondary trauma and encounter distinct challenges in comparison with observers; individual risk factors, eg, depression, substance use, may be present; psychosocial issues, eg, expectations, biases, and historical factors, eg, sleep deprivation, contribute to risk; trauma care providers may struggle to access adequate care and develop individual coping mechanisms

Prevalence: trauma providers and surgeons in the ED exhibit a point prevalence of PTSD 2-fold greater than that of the lifetime prevalence in the general population (8%); studies have consistently found a prevalence rate of 15% to 16% in trauma providers; rates are higher in providers with initial exposure to traumatic events, eg, ED nurses and emergency medical services (EMS) workers; increased rates of PTSD in nurses are not attributable to gender; the risk for suicidality among physicians is compounded by exposure to trauma and potential for PTSD; suicide rates between female students and male students equalize in medical school; the suicide rate in female doctors is 130% higher than women who are not doctors; male physicians exhibit a 40% higher suicide rate than men in the general population; the increase in suicidality among both genders in medicine sets clinicians apart from other groups where gender differences persist; most suicide attempts by physicians are successful

Treatment: access to effective treatments for PTSD is impeded by scarcity of mental health professionals; 60% of US counties lack a psychiatrist; scarcity of providers exacerbates difficulties for victims of urban violence; prompt access to care is hindered and quality is subpar; veterans in the VA system face a cumbersome multi-month process; medical providers contend with potential stigma and licensure concerns which impacts the ability to seek care

Focus of treatment: addressing comorbid psychiatric conditions is paramount; a significant number of patients with PTSD experience major depression, social anxiety, agoraphobia, generalized anxiety disorder, panic, and alcohol use; 12% to 21% of patients with PTSD have no comorbid psychiatric conditions; interventions should focus on symptom clusters and target affective instability, anger attacks, impulsivity, and sleep disturbances; normalizing sleep architecture should be prioritized because of the profound impact sleep has on distress and the development of PTSD-related symptoms; aggressive treatment approaches extend to parasomnias, rapid eye movement-abnormal behaviors, and the associated risks of alcohol and substance use

Treatment Modalities

Psychotherapy: a front-line modality for treating PTSD; cognitive behavioral therapies may be beneficial; access to treatment may be challenging

Exposure based therapies: include prolonged exposure therapy and written exposure therapy; various communication methods between the individual and therapist are attempted; group settings provide an environment to foster discussion and comparison of experiences

Psychedelic therapies: not officially indicated for PTSD; potential benefits with time-limited treatments have been seen; ketamine may be administered through infusion or intranasally; psilocybin from mushrooms is under consideration for approval; treatment is 1 to 2-exposures; methylenedioxymethamphetamine (MDMA) was formerly banned but is being researched for treatment of PTSD and depression; promising remission rates with 2 extended sessions have been seen in studies, including a VA investigation; the cannabinoids tetrahydrocannabinol and cannabidiol have demonstrated efficacy in fear extinction and disrupting fear memory reconsolidation; however, regulatory challenges and limited testing complicate the use of cannabinoids; dimethyltryptamine (DMT, Ayahuasca) is often used in religious ceremonies; altered consciousness and potential healing effects depend on anecdotal reports; alternative treatments may be valuable for limited, non-continuous use which avoids prolonged reliance on medication

Readings

Bryant RA. Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry. 2019;18(3):259-269. doi:10.1002/wps.20656; Carter RT, Kirkinis K, Johnson VE. Relationships between trauma symptoms and race-based traumatic stress. Traumatology. 2019;26(1). doi:https://doi.org/10.1037/trm0000217; DeLucia JA, Bitter C, Fitzgerald J, et al. Prevalence of post-traumatic stress disorder in emergency physicians in the United States. West J Emerg Med. 2019;20(5):740-746. Published 2019 Aug 28. doi:10.5811/westjem.2019.7.42671; Krediet E, Bostoen T, Breeksema J, van Schagen A, Passie T, Vermetten E. Reviewing the potential of psychedelics for the treatment of PTSD. Int J Neuropsychopharmacol. 2020;23(6):385-400. doi:10.1093/ijnp/pyaa018; Rawat BPS, Reisman J, Pogoda TK, et al. Intentional self-harm among US veterans with traumatic brain injury or posttraumatic stress disorder: Retrospective cohort study from 2008 to 2017. JMIR Public Health Surveill. 2023;9:e42803. Published 2023 Jul 24. doi:10.2196/42803; Regier DA, Kuhl EA, Kupfer DJ. The DSM-5: Classification and criteria changes. World Psychiatry. 2013;12(2):92-98. doi:10.1002/wps.20050; Sibrava NJ, Bjornsson AS, Pérez Benítez ACI, Moitra E, Weisberg RB, Keller MB. Posttraumatic stress disorder in African American and Latinx adults: Clinical course and the role of racial and ethnic discrimination. Am Psychol. 2019;74(1):101-116. doi:10.1037/amp0000339; Song Z, Zubizarreta JR, Giuriato M, et al. Firearm injuries in children and adolescents: health and economic consequences among survivors and family members. Health Aff (Millwood). 2023;42(11):1541-1550. doi:10.1377/hlthaff.2023.00587; Stern CA, Gazarini L, Vanvossen AC, et al. Δ9-Tetrahydrocannabinol alone and combined with cannabidiol mitigate fear memory through reconsolidation disruption. Eur Neuropsychopharmacol. 2015;25(6):958-965. doi:10.1016/j.euroneuro.2015.02.001.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Fanelli's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Fanelli was recorded at the 3rd Annual How to Save a Life: IR and Surgical Management of the Trauma Patient Conference, held November 6-8, 2023, in Lake Buena Vista, FL, and presented by the University of Chicago Pritzker School of Medicine. For information on upcoming CME activities from this presenter, please visit https://cme.uchicago.edu/SaveALife2023#group-tabs-node-course-default4. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.50 CE contact hours.

Lecture ID:

GS710302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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