Post-Traumatic Stress Disorder: When Current Events Cause Relapse
Ms. N is a 64-year-old unmarried woman who came to her primary care physician with complaints of headaches and difficulty sleeping. Ms. N is employed as a legal secretary and chose Dr. R from the panel of physicians who participate in her employer’s health insurance plan. She has been her patient for the past 8 years, coming in annually for health maintenance visits. Dr. R has found it difficult to get to know Ms. N, as she does not engage readily in conversation. She is very meticulous about following up with appointments and is always very specific when describing her complaints. When Dr. R asked when the headaches began, Ms. N began crying. She told Dr. R that she has slept little since watching the first reports of the earthquake and tsunami in South Asia. When Dr. R tried to comfort her, Ms. N told her that she cannot keep the images of the dead children out of her head, often thinking that she sees herself among the piles of bodies
Dr. R asked if Ms. N has any family members who can be contacted. Ms. N told her that she was placed in a series of group homes and foster care since she was 8 years old after her parents were sent to prison for the beating and murder of her two younger brothers. Ms. N was the victim of severe emotional, physical, and sexual abuse from her parents. Her treatment in foster care was also at times traumatic. At the age of 14 she was placed in a boarding school run by a religious organization that was strict but provided consistency and the opportunity for Ms. N to complete high school and attend secretarial school. She has worked for the same law firm for the past 35 years, has never married, and lives a solitary life. Ms. N works long hours and feels safe when she is at the law firm. She reported that after the events of 9/11 she felt anxious, but was not as affected as she is now.
Ms. N told the physician that the vivid pictures of children and the stories of so many people finding their dead relatives is “making her crazy,” but she also feels that she cannot escape the news coverage. Dr. R asked Ms. N if she had any suicidal thoughts. Ms. N responded that she would have killed herself long ago if she really wanted to. Dr. R made numerous telephone calls, arranging for Ms. N to be seen the next day by a psychiatrist, and gave her a prescription for a hypnotic medication. Ms. N went back to work, stating that she would rather be sitting at her desk than at home. She agreed to keep the appointment with the psychiatrist and to call Dr. R if her symptoms worsened.
Post-traumatic stress disorder (PTSD) is characterized by intense fear, helplessness, and horror that occur in response to a severe or extreme traumatic event.1 Patients often develop symptoms of hyperarousal, re-experiencing the trauma through images and flashbacks, and may try to avoid things that remind them of the experience. Symptoms of reduced involvement with others, restricted affect, and diminished interest in things also may occur, which results in patients being viewed as detached or distant. The resulting symptoms often become chronic, disabling, and interfere with the ability to function.1,2 The symptoms need only be present for 4 weeks to establish a diagnosis of PTSD; however, patients with the disorder often have active symptoms for an average of 5 years prior to diagnosis.3
Older adults have often lived through significant traumatic events including wars, illness, and loss of loved ones, and many have been the victims of violent crimes.4 Catastrophic events, such as the Oklahoma City bombings, September 11th terrorist attacks, and news coverage of worldwide tragedies, often trigger memories of past traumatic experiences. An older adult may have a past history of PTSD but recovered to return to normal functioning. Exposure to new trauma, even through television or newspaper coverage, may cause a relapse in symptoms. Some patients do not display symptoms immediately but suffer from delayed-onset PTSD, which develops 6 months or more following the traumatic event.1-3
Post-traumatic stress disorder has an 8-9% lifetime prevalence in adults.1,2 Women are more than two times more likely to develop the disorder than men, with a 10-14% prevalence found in women compared to 5-6% in men.2,3 Risk factors associated with PTSD include the presence of a pre-existing mood or anxiety disorder, loss of a spouse and other social supports, unresolved bereavement issues, poor parental attachments, comorbid personality disorders, and prior exposure to other traumatic events.4 Early childhood deprivation, trauma, and abuse are significant risk factors for PTSD across the lifespan. Older women live longer than men, are more likely to be widowed, have limited social supports, and are disproportionately the victims of violent crimes including mugging and robbery. As they are often dealing with issues of loss, grief, bereavement, and depression, older women are at high risk for developing PTSD when faced with a traumatic event in their lives.6
It is important for the physician to recognize the characteristic signs and symptoms of PTSD, such as nightmares, flashbacks, anxiety, preoccupation with the trauma, emotional detachment, and avoidance of things associated with the event. It is a disorder associated with an overall poor health status compared to those without PTSD.2 Patients with PTSD are more likely to engage in high-risk behaviors, suffer from alcohol and drug abuse, and have multiple medical problems. Their suicide rate is six times that of the general population.3 Prevalence of PTSD among primary care populations is high, ranging from 12-39%. Somatic complaints are common, and visits to primary care physicians are frequent.5 This provides an opportunity for the physician to explore the patient’s emotional state, current level of functioning, and availability of social support, and to evaluate the severity of symptoms. Referrals for counseling should be considered anytime there is impairment in psychosocial functioning or significant distress. Medication should be considered if mood or anxiety symptoms are distressing, when insomnia is severe, and if psychotic or suicidal ideation is present. Inpatient treatment may be necessary if the psychotic symptoms or suicidal ideation place the patient at risk for harm and if social supports are lacking.
Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), are commonly used to treat PTSD.1,2,5 They are generally well tolerated by the elderly. Sertraline and paroxetine are specifically approved by the FDA for the treatment of PTSD, but others have been utilized in clinical trials and practice (Table I).1,2,5 As insomnia is often a prominent feature, a limited course of a sedative-hypnotic agent during the initial 2-3 weeks of treatment in addition to an antidepressant may be helpful. Ongoing use of benzodiazepines is not therapeutic in the treatment of PTSD and may lead to confusion, falls, and fractures in older adults.5 Mood stabilizers, such as valproate and carbamazepine, may be helpful as adjuncts to antidepressant medications when irritability, anger, and impulsivity remain problematic. Antipsychotic agents should be considered when prominent psychotic features are present.
Delusions and hallucinations may occur in up to 40% of patients with PTSD.2 Psychosocial interventions, including cognitive-behavioral therapy and individual psycho- therapy (Table II), help the patient confront painful memories and understand how the experience has affected his or her relationships and beliefs.1,2,3,5 Group therapy treatment using a structured program of education focusing on issues of safety, trust, esteem, and intimacy have been shown to reduce symptoms and maintain recovery over time. Relaxation training using breathing techniques, guided imagery, and the promotion of social support networks have all been useful in the management of the anxiety that accompanies PTSD. One type of intervention, psychological debriefing, a technique that uses review and re-enactment of the traumatic event, has not been shown to be effective and may worsen symptoms.2,5 Primary care physicians are a valuable source of education and counseling for patients with PTSD. Information for physicians, patients, and families is available through the National Center for Posttraumatic Stress Disorder (www.ncptsd.org) and the Posttraumatic Stress Disorder Alliance (www.ptsdalliance.org).
OUTCOME OF THE CASE PATIENT
The patient was evaluated by the psychiatrist and was found to be suffering from a severe form of PTSD related to her early childhood abuse and deprivation. Given the severe abuse, neglect, and trauma that she experienced at an early age, Ms. N was actually functioning at a high level. She was experiencing significant symptoms, which were very chronic. Ms. N refused any medications, stating that she did not want to take drugs of any kind. She had a negative experience in the past with a psychotherapist who encouraged her to focus on her childhood trauma, and Ms. N made it clear that she was not going to discuss this in detail. She was willing to return to see the psychiatrist on an individual basis, but refused referral to a group program for survivors of trauma. The patient has shown some response to cognitive behavioral therapy, and was able to utilize thought-stopping techniques and relaxation training with home work assignments. The psychiatrist remains concerned that Ms. N has few social supports, but she does have some relationship with her coworkers. She continues to devote long hours to her job and maintains a solitary lifestyle. Ms. N continues in treatment with the psychiatrist and is gaining a greater sense of trust. Plans include discussing medication again in the future and helping Ms. N expand her social supports, while continuing with cognitive behavioral therapy.