Post-Traumatic Stress Disorder

SCREENING

As mentioned in the Mental Health section, we recommend against routine screening for a history of traumatic events in refugee patients. However, since a lot of refugees and refugee claimants will have experienced or witnessed traumatic events, physicians should be aware of potential post-traumatic stress disorder (PTSD) symptoms such as hyperarousal, intrusive thoughts avoidance, guilt, irritability, and sleep disturbance (especially nightmares).

Remember that refugee patients with underlying psychiatric disorders will often complain of somatic symptoms first.

In patients who have experienced traumatic events, the Primary Care PTSD Screen for DSM-5 can be used as a screening tool:​

  1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?
     
  2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
     
  3. Been constantly on guard, watchful, or easily startled?
     
  4. Felt numb or detached from people, activities, or your surroundings?
     
  5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

    → Patients who answer “yes” to 3 or more questions should definitely be assessed further for PTSD.

 

DIAGNOSIS

PTSD is diagnosed in patients older than 6 years old who meet all of the following DSM-5 criteria:

  • The person has been exposed to actual or threatened death, serious injury, or sexual violation in ≥1 of the following ways:​

Directly experienced or witnessed the traumatic event, learned that trauma occurred to close family member or friend (actual or threatened death must have been violent or accidental), experienced repeated exposure to aversive details of trauma.

  • Presence of ≥1 of the following intrusion symptoms associated with the trauma:

Recurrent, involuntary, and intrusive distressing memories, distressing dreams, dissociative reactions (e.g., flashbacks), psychological or physiological distress at reminders of trauma.

  • Persistent avoidance of stimuli associated with the trauma, including ≥1 of the following:

Avoidance of distressing memories or feelings and external reminders (e.g., people, places) of the trauma.

  • Negative alterations in cognitions and mood associated with the trauma, including ≥2 of the following:

Inability to recall important aspect of the trauma, diminished interest or participation in activities, feeling of detachment or estrangement from others, persistent negative beliefs, distorted blame, and negative emotional state.

  • Marked alterations in arousal and reactivity associated with the trauma, including ≥2 of the following:

Irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance.

  • Duration of disturbance >1 month.

  • Symptoms cause clinically significant distress or impaired functioning.

  • Specify whether with dissociative symptoms (depersonalization or derealization) or with delayed expression (full criteria not met until at least 6 months after the event).

 

TREATMENT

Patients with confirmed or suspected PTSD should be screened for comorbid conditions such as substance abuse, mood disorders, and suicidality. These patients should also be referred to a Psychiatrist for diagnostic assessment and management. While waiting for the referral, family physicians should initiate treatment.

Treatment for PTSD consists of 2 main components - psychotherapy and pharmacotherapy:​

PSYCHOTHERAPY

Trauma-focused therapy that includes exposure should be strongly encouraged in PTSD patients. Physicians seeing refugee patients should inquire about local therapists who have experience treating PTSD.

PHARMACOTHERAPY

  1. Address sleep concerns first

If the patient’s sleep is disturbed, we usually start with a trial of prazosin. It works well for PTSD-related nightmares and night-time hyperarousal (can be combined with SSRI or SNRI). We usually start with 1 mg at bedtime and increase the dose progressively. Dose titration differs between men and women: females usually require lower doses, and doses can be titrated up more rapidly in males (see the Psychopharmacology Algorithms by the Harvard Medical School). Remember that this is an anti-hypertensive agent and thus patients should watch for symptoms of orthostatic hypotension. Prazosin should not be discontinued suddenly because of the risk of rebound hypertension.

Trazodone can also be tried if sleep onset is impaired.

  1. Consider a trial of SSRI or SNRI

If symptoms persist after addressing the sleep disturbances or if sleep is not a concern, antidepressants such as SSRIs and SNRIs can be used to reduce PTSD symptoms. We usually start these medications at a low starting dose and titrate up the dose gradually (every 3-4 weeks) until a response is achieved. Doses for PTSD are similar to the ones used for depression. In the literature, the recommended first-line agents are: fluoxetine, paroxetine, sertraline and venlafaxine.

At the Calgary Refugee Health Program, our preferred first-line agent is sertraline (starting dose: 25-50 mg daily) because it is usually better tolerated. If sertraline is not effective or not well tolerated, we then recommend trying venlafaxine (starting dose: 37.5 mg daily). We sometimes try venlafaxine before sertraline when the noradrenergic component is needed, rather than the sedating potential of sertraline.

We usually avoid paroxetine because of its side effect profile and risk of discontinuation syndrome (which can be a significant issue in refugee patients). Second-line agents are not covered in these guidelines.

We suggest not using benzodiazepines in PTSD patients.

>> Refer to the Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders for more extensive guidelines.

>> The Psychopharmacology Algorithms by the Harvard Medical School also provide a useful algorithm for the treatment of PTSD.