1. Post Traumatic Stress Disorder for the Primary Care and Emerg PA Ron Andersen CCPA

2. Disclosures I am employed by the CF, currently. I am employed by the CF, currently. I have no financial disclosures or sponsorships to disclose. I have no financial disclosures or sponsorships to disclose. I am NOT a psychiatrist. I am NOT a psychiatrist.

3. Objectives Review the Diagnostic Criteria as per DSM – IV and preview the DSM-5 (released March 2013) Review the Diagnostic Criteria as per DSM – IV and preview the DSM-5 (released March 2013) ID someone in crisis ID someone in crisis Where to turn for more information…(the second most important section) Where to turn for more information…(the second most important section)

4. What does PTSD look like?? Can anyone easily identify someone with PTSD?? Can anyone easily identify someone with PTSD?? Can you quickly see who is at risk?? Can you quickly see who is at risk??

5. What does PTSD look like…

10. Who is vulnerable???

11. DSM – IV - TR Criteria Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper- arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper- arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning

12. DSM – IV – TR Criteria Cont. Criterion A: stressor Criterion A: stressor The person has been exposed to a traumatic event in which both of the following have been present: The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behaviour. The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behaviour.

13. DSM – IV – TR Criteria Criterion B Criterion B: intrusive recollection Criterion B: intrusive recollection The traumatic event is persistently re-experienced in at least one of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content

14. DSM – IV – TR Criteria Criterion B Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,including those that occur upon awakening or when intoxicated). Note: in children, trauma- specific reenactment may occur. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,including those that occur upon awakening or when intoxicated). Note: in children, trauma- specific reenactment may occur. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

15. DSM – IV – TR Criterion C Criterion C: avoidant/numbing Criterion C: avoidant/numbing Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma

16. DSM – IV – TR Criterion C Inability to recall an important aspect of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Feeling of detachment or estrangement from others Restricted range of affect (e.g., unable to have loving feelings) Restricted range of affect (e.g., unable to have loving feelings) Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

17. DSM – IV – TR Criterion D Criterion D: hyper-arousal Criterion D: hyper-arousal Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following: Difficulty falling or staying asleep Difficulty falling or staying asleep Irritability or outbursts of anger Irritability or outbursts of anger Difficulty concentrating Difficulty concentrating Hyper-vigilance Hyper-vigilance Exaggerated startle response Exaggerated startle response

18. DSM – IV – TR Criteria Cont. Criterion E: duration Criterion E: duration Duration of the disturbance (symptoms in B, C, and D) is more than one month. Criterion F: functional significance Criterion F: functional significance The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more Specify if: Specify if: With or Without delay onset: Onset of symptoms at least six months after the stressor

19. DSM-5 (not released) May 2013(ish) A. Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways: A. Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways: directly experiencing the traumatic event(s) directly experiencing the traumatic event(s) witnessing, in person, the traumatic event(s) as they occurred to others witnessing, in person, the traumatic event(s) as they occurred to others

20. DSM-5 (not released) May 2013(ish) Criterion A cont’d learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

21. DSM-5 (not released) B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.) spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.) recurrent distressing dreams in which the content or affect of the dream is related to the event(s) (Note: In children, there may be frightening dreams without recognizable content. ) recurrent distressing dreams in which the content or affect of the dream is related to the event(s) (Note: In children, there may be frightening dreams without recognizable content. )

22. DSM-5 (not released) Criterion B cont’d dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. (Note: In children, trauma-specific reenactment may occur in play.) dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. (Note: In children, trauma-specific reenactment may occur in play.) intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) marked physiological reactions to reminders of the traumatic event(s) marked physiological reactions to reminders of the traumatic event(s)

23. DSM-5 (not released) C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by avoidance or efforts to avoid one or more of the following: C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by avoidance or efforts to avoid one or more of the following: distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) external reminders (i.e., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s) external reminders (i.e., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s)

24. DSM-5 (not released) D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following: D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following: inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia that is not due to head injury, alcohol, or drugs) inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia that is not due to head injury, alcohol, or drugs) persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). (Alternatively, this might be expressed as, e.g., “I’ve lost my soul forever,” or “My whole nervous system is permanently ruined”). persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). (Alternatively, this might be expressed as, e.g., “I’ve lost my soul forever,” or “My whole nervous system is permanently ruined”).

25. DSM-5 (not released) Criterion D cont’d persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s) persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s) persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) markedly diminished interest or participation in significant activities markedly diminished interest or participation in significant activities feelings of detachment or estrangement from others feelings of detachment or estrangement from others persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing) persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing)

26. DSM-5 (not released) E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: irritable or aggressive behavior irritable or aggressive behavior reckless or self-destructive behavior reckless or self-destructive behavior hypervigilance hypervigilance exaggerated startle response exaggerated startle response problems with concentration problems with concentration sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)

27. DSM-5 (not released) F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributed to the direct physiological effects of a substance (e.g., medication, drugs, or alcohol) or another medical condition (e.g. traumatic brain injury). H. The disturbance is not attributed to the direct physiological effects of a substance (e.g., medication, drugs, or alcohol) or another medical condition (e.g. traumatic brain injury).

28. DSM-5 (not released) Rationale of changes; Rationale of changes; Revision of Criterion A1 – to remove ambiguities and tighten the definition of “traumatic event” Revision of Criterion A1 – to remove ambiguities and tighten the definition of “traumatic event” Deletion of Criterion A2 – because it has no utilitity Deletion of Criterion A2 – because it has no utilitity Slight revision to Criterion B Slight revision to Criterion B

29. DSM-5 (not released) Rationale of Changes cont’d B1 clarified to define “intrusive recollection” and eliminate depressive rumination B1 clarified to define “intrusive recollection” and eliminate depressive rumination B2 slight changes make the criterion more applicable across cultures B2 slight changes make the criterion more applicable across cultures B3 clarified to indicate that flashbacks are dissociative symptoms that occur on a continuum B3 clarified to indicate that flashbacks are dissociative symptoms that occur on a continuum Dividing DSM-IV Criterion C into two separate clusters (e.g., DSM-5 Criteria C and D) Thereby resulting in four, rather than three distinct diagnostic clusters. Dividing DSM-IV Criterion C into two separate clusters (e.g., DSM-5 Criteria C and D) Thereby resulting in four, rather than three distinct diagnostic clusters.

30. DSM-5 (not released) Revising and adding diagnostic symptoms for Criterion D (Negative Cognitions and Mood) Revising and adding diagnostic symptoms for Criterion D (Negative Cognitions and Mood) D2 (DSM-IV “foreshortened future”) clarified & expanded to encompass exaggerated negative beliefs and expectations about the future D2 (DSM-IV “foreshortened future”) clarified & expanded to encompass exaggerated negative beliefs and expectations about the future D3 (new symptom) –persistent distorted blame of self or others D3 (new symptom) –persistent distorted blame of self or others D4 (new symptom) – persistent negative emotional state D4 (new symptom) – persistent negative emotional state

31. DSM-5 (not released) Rationale of Changes cont’d Revising and adding diagnostic symptoms for Criterion E (“Alterations in Arousal and Reactivity”) Revising and adding diagnostic symptoms for Criterion E (“Alterations in Arousal and Reactivity”) E1 – clarifying that this pertains to behaviour (“irritable or aggressive”) E1 – clarifying that this pertains to behaviour (“irritable or aggressive”) E2 (new symptom) = reckless or self-destructive behaviour E2 (new symptom) = reckless or self-destructive behaviour Eliminating the Acute vs. Chronic specifier Eliminating the Acute vs. Chronic specifier Addition of a Preschool Subtype Addition of a Preschool Subtype Addition of a Dissociative Subtype Addition of a Dissociative Subtype

32. The ID of someone in crisis There is no doubt most of you working in primary care knows how to ID someone in a mental health crisis….but…. There is no doubt most of you working in primary care knows how to ID someone in a mental health crisis….but….

33. The ID of someone in crisis …the difficulty ID’ing a member of the EMS, Police, Fire, military member or Primary Care worker in crisis lies with their years of training. …the difficulty ID’ing a member of the EMS, Police, Fire, military member or Primary Care worker in crisis lies with their years of training. Whether it be the way they are dressed, appearance or attitude…they often just don’t fit the crisis ‘mold’…. Whether it be the way they are dressed, appearance or attitude…they often just don’t fit the crisis ‘mold’….

34. The ID of someone in crisis ….so what does that mean…doesn’t fit the mold? ….so what does that mean…doesn’t fit the mold? Well ultimately it may rest upon you to dig that little bit deeper, and to prod your SP just that little bit extra…after all wouldn’t you rather be the PA that gets someone a little mad about asking all those dumb questions? Well ultimately it may rest upon you to dig that little bit deeper, and to prod your SP just that little bit extra…after all wouldn’t you rather be the PA that gets someone a little mad about asking all those dumb questions?

35. Treatment Modalities There are several types of treatment for PTSD; There are several types of treatment for PTSD; Pharmacological, including Pharmacological, including SSRIs SSRIs SNRIs SNRIs Atypical anti-psychotics (not supported in some trials) Atypical anti-psychotics (not supported in some trials) Benzodiazipines Benzodiazipines Alpha-adrenergic receptor blockers (prazosin) Alpha-adrenergic receptor blockers (prazosin) Combinations of many of these….(this often leads to the patient feeling like a guinea pig, or an experiment) Combinations of many of these….(this often leads to the patient feeling like a guinea pig, or an experiment)

36. Treatment Modalities Psychotherapy which can include; Psychotherapy which can include; Cognitive Behavioral Therapy Cognitive Behavioral Therapy Re-exposure therapy Re-exposure therapy EMDR (Eye movement desensitization and reprocessing) EMDR (Eye movement desensitization and reprocessing) Trauma focused Trauma focused Coping mechanism optimization Coping mechanism optimization Psychodynamic Psychodynamic Eclectic Eclectic

37. Questions?? Comments? Okay the good stuff is next…..

38. Resources Veterans Affairs Canada Veterans Affairs Canada http://www.veterans.gc.ca/eng/crisis-help-line http://www.veterans.gc.ca/eng/crisis-help-line http://www.veterans.gc.ca/eng/crisis-help-line This will give you a crisis line number for your patient to call to be in contact with any number of resources. This will give you a crisis line number for your patient to call to be in contact with any number of resources. National Center for PTSD (US Dept of Veterans) National Center for PTSD (US Dept of Veterans) http://www.ptsd.va.gov/index.asp http://www.ptsd.va.gov/index.asp http://www.ptsd.va.gov/index.asp This website is incredible, it will overwhelm at first but take the time to see all that it has. This website is incredible, it will overwhelm at first but take the time to see all that it has.

39. Resources PTSD Association PTSD Association http://ptsdassociation.com/index.php http://ptsdassociation.com/index.php http://ptsdassociation.com/index.php A Canadian take on PTSD and help available. A Canadian take on PTSD and help available. Tema Conter Memorial Trust Tema Conter Memorial Trust http://www.tema.ca/ http://www.tema.ca/ http://www.tema.ca/ Another great site for EMS, Police, Fire and Military personnel. Another great site for EMS, Police, Fire and Military personnel. DSM-IV- TR DSM-IV- TR http://dsm.psychiatryonline.org/book.aspx?bookid =22 http://dsm.psychiatryonline.org/book.aspx?bookid =22

40. Resources DSM-5 DSM-5 http://www.dsm5.org/Pages/Default.aspx http://www.dsm5.org/Pages/Default.aspx Centre for Addictions and Mental Health CAMH Centre for Addictions and Mental Health CAMH http://www.camh.ca/en/hospital/Pages/home.aspx http://www.camh.ca/en/hospital/Pages/home.aspx