A Primary Care Guide to PTSD Screening and Management: Answers to Frequently Asked Questions
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Tamar Rodney, PhD, RN, PMHNP-BC, CNE, FAAN provides answers to questions asked by audience members during the live presentation, “Shedding Light on PTSD in the Community: Guideline-Based Care for Primary Providers ,” at CCO’s 2024 MEDX Primary Care Regional Conference Series.
Are there any data available regarding the prevalence of post-traumatic stress disorder (PTSD ) in children or adolescents? What are your recommendations for treatment of pediatric patients?
The US Department of Veteran Affairs reports that 15% to 43% of girls and 14% to 43% of boys experience at least 1 form of trauma and 3% to 15% of girls and 1% to 6% of boys develop PTSD. There are also higher risks when considering the type of trauma. For example, the risk for developing PTSD ranges from 25% to 50% with sexual abuse and from 30% to 40% with physical abuse.
Therapy that includes identifying the type of trauma present is important. Also, remember that PTSD symptoms look different in children of different ages.
How can we effectively screen for trauma such as adverse childhood experiences (ACEs)?
There are no definitive solutions for effectively screening for trauma. It will be important to remember that the impact of a traumatic experience will present differently and at different times. However, screening and follow-up screening can help with early identification of symptoms that can lead to timely interventions and reduce the negative impacts of these experiences.?
Using age-appropriate language is also critical. This may mean adapting the screening tool and process based on the child's age and cognitive level. The role of the caregiver is also essential for younger children, while adolescents may be able to answer questions themselves.
Tools that can also be helpful and provide a baseline for future screening include:
What approach would you take with a patient when you suspect trauma/PTSD but they are unwilling to speak about it?
The first step is building a therapeutic relationship that emphasizes trust; patients must be secure in feeling that they can trust you as a provider or as an adult. Never push one's ideas of what we think the trauma is as this may retraumatize them. Rather, ask general questions that are noninvasive and open-ended, such as, “How have you been lately? Has anything changed recently?” Always leave the door/conversation open. This may mean verbally saying, “It is okay if you're not ready to talk about it right now. I'll be here whenever you're ready.”
Do you have any tips for differential screening and diagnosis of PTSD vs depression vs generalized anxiety in a busy practice?
There is a lot of overlap between these conditions, so the key difference is likely to include specific hallmark symptoms for each disorder. PTSD is triggered by a traumatic event, while depression and generalized anxiety disorder (GAD) are usually not. Depression involves low mood and loss of pleasure; although this may also be a symptom of PTSD, it would be more pronounced in depression. GAD is marked by persistent worry and physical tension across multiple life areas; neither PTSD nor depressive disorder would typically be characterized by persistent worry.
What is your experience with memory issues in PTSD?
There are several considerations regarding memory, which can be one of the more disturbing symptoms for many people with PTSD. Intrusive memory (reliving the event or parts of the event) can include flashbacks of the event and trigger an emotional and physical reaction: very distressing! Some individuals avoid thinking about the trauma and may have difficulty recalling what happened. This avoidance can also be a protective mechanism to minimize emotional distress. Generally, patients can have both short-term memory and working memory problems. The impact for some people is difficulty focusing on tasks or remembering to do things in their daily life.?
Can you expand on different types of psychotherapy available for PTSD? How do you choose between them for an individual patient?
The key element is based in patient choice/preference. Another question is, “At what stage in trauma recovery is the patient best able to participate in psychotherapy?”, whether in an individual or group therapy setting, depending on the type of trauma experienced.
The recommendation for therapy is to start with individual, time-limited, trauma-focused therapy. Best results have been documented with cognitive behavioral therapy (CBT), which is effective when the patient is able to tolerate talking about the trauma and if a short term of treatment (up to 16 sessions) is a goal. Another form of therapy to consider is cognitive processing therapy, which helps patients recognize and reframe distorted thoughts related to the trauma (eg, self-blame, guilt), typically within 12 individual or structured group sessions. Narrative exposure therapy may also be effective for patients with complex trauma or multiple traumas; this format allows the person to recount their life story, alternating between positive and traumatic memories, to help them place the trauma in the context of their whole life and make sense of it.
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Can exposure therapy worsen PTSD symptoms for some patients? How do you manage this possibility?
Yes, exposure therapy can temporarily worsen PTSD symptoms for some patients, especially early in treatment. Although it is one of the most effective treatments for PTSD, confronting trauma-related memories, feelings, or situations can increase distress and anxiety before symptoms improve. Managing this possibility requires careful planning, patient education, and ongoing monitoring. Sharing what the process is like with the patient is also helpful, to let them emotionally prepare and instill the expectation that this is a part of the therapeutic process.
Do you have any experience with eye movement desensitization and reprocessing (EMDR) in patients with PTSD?
I do not personally practice EMDR, but I do have patients who have completed EMDR sessions. The goal of EMDR is to lower the intensity of negative thoughts and emotions through individual therapy sessions that are usually time limited in phases.
What is your approach with patients who request medication for symptoms of PTSD but are resistant to therapy or counseling?
It would be my professional responsibility to share with them that the first-line treatment for PTSD is trauma-focused psychotherapy. However, a request for medication would also be discussed in the context of a symptom-based approach to PTSD: emphasizing that the patient can choose to address bothersome symptoms with medication first, with a goal of more immediate relief. The decision would also include a recommendation to use 1 of the 2 FDA-approved SSRIs, sertraline or paroxetine, dependent on a good match with potential side effect considerations.
What treatment would you recommend when insomnia is the primary symptom or patient complaint, or insomnia persists after other symptoms have responded well to treatment?
Combining behavioral interventions like CBT with education around sleep hygiene would be a start to address persistent insomnia. If an SSRI has already been tried, then other medications can be considered as off-label options, as long as they are appropriate given side effect profile and any other health considerations. These include prazosin (monitor blood pressure) or low doses of the second-generation antipsychotics quetiapine or olanzapine.
Are there any comparative data available for brexpiprazole vs aripiprazole in PTSD?
To date, there are no peer-reviewed published comparative data for brexpiprazole and aripiprazole in PTSD. A Cochrane review with comparative data in schizophrenia is available, however it is difficult to use this to make any conclusive comparison regarding PTSD treatment as the symptom profiles are different for these disorders. Brexpiprazole may soon be approved for treatment of PTSD, which would allow us to gather better comparative data.
What is your experience with cannabis use in patients with PTSD?
Cannabis can help some people with PTSD by reducing symptoms like anxiety, insomnia, and nightmares, but this comes with risks. Some individuals find relief, but others may experience worsened anxiety or become dependent. Cannabis can also affect memory and thinking, which can be a problem for people already dealing with these issues as a result of their trauma experience. The effects of cannabis vary depending on the mode by which it is taken, making exact effects difficult to predict. It would be critical to have a discussion with anyone wanting to choose this as a potential treatment option, to review pros and cons and use cannabis as part of a broader treatment plan, not the only solution.
What can be the role of family or other loved ones in PTSD treatment? How can you discuss this with patients or otherwise engage them?
Family and loved ones can play an important role in helping someone with PTSD. They can provide emotional support, have a better understanding of what the person is going through, and help them be consistent with their treatment plan. Loved ones can offer comfort during tough times, remind them to take medications or go to therapy, and create a safe, supportive environment. Sometimes, it can help to involve family members in therapy sessions so everyone can learn to communicate better and work through any issues together.
When talking to a patient about this, it’s important to ask if they’re comfortable involving a family member or friend and explain how it can help. Not everyone wants the same level of involvement, so it’s key to respect the patient’s wishes. Even small gestures from loved ones—like listening without judgment or being there in moments of crisis—can make a big difference in recovery.
What resources are available to identify trauma specialists or trauma-informed services in my area?
What is your experience assessing and caring for patients with PTSD in your practice? Join the conversation at one of CCO’s upcoming expert webinars or by sharing a comment or asking a question below.