Treating Posttraumatic Stress Disorder in Primary Care

You are the embedded psychiatrist working at a Family Health Center. Dr. Matthews, a primary care physician, refers Mrs. R to you for psychiatric consultation. Mrs. R is a 32-year-old woman whom Dr. Matthews recently began following for dizziness and migraine headaches. He suspects there is a component of anxiety to his patient’s presentation and would like treatment recommendations.

During your interview with her, Mrs. R reports worsening mood for the past month. She describes feeling “on edge” and needing to watch her surroundings. In the past year she had felt similar symptoms, but they seemed to be controlled until recently. She denies persistent depressed mood, suicidal ideations, or changes in appetite, hopelessness, or helplessness. She states that about a month and a half ago she ran into a man who had sexually abused her five years previously. Since running into him again, she notices increased frequency of episodes of reliving the assault (about three times per week), daily nightmares with nighttime awakening, and not feeling rested. She wakes up sweating and very distressed, and she experiences palpitations and extreme fear. She has been staying home more than usual because she fears running into this man again. Her family members are concerned that she has cancelled plans with them several times in the past few weeks and seems distant. She denies auditory or visual hallucinations. She denies symptoms of paranoia but describes a general sense of being unsafe. She complains of having “dizzy spells” during the day and frequent headaches. Mrs. R is not receiving any type of psychiatric treatment. She takes only multivitamins and ibuprofen for headaches as needed.

At this point, what is the most likely diagnosis?

Mrs. R reports that she grew up in an unstable home environment. She witnessed domestic violence between her parents until age 12, when they separated and she moved to a shelter for victims of abuse. She denies being physically abused by her father but has clear memories of the injuries her mother suffered. As a child she had trouble in school. She remembers going to the nurse’s office often because of abdominal pain or headaches and being sent home. She had difficulty focusing on the lessons and endorsed frequent fear for her mother’s well-being. Her mother was diagnosed as having major depressive disorder and PTSD. Mrs. R believes her father was an alcoholic, but she is unsure of other family psychiatric history. Mrs. R denies past suicide attempts but admits to having thoughts that life is not worth living since early in her life.

Which screening measure would have been most helpful if the primary care physician had used it during Mrs. R’s visit?

What recommendations would you provide for Dr. Matthews?

It is estimated that PTSD prevails in 7% to 8% of the general population; about 10% of women and 5% of men develop this disorder at some point in their lives. Because patients often go to primary care providers to seek medical care for the issues associated with PTSD, this rate is two to three times higher in primary care settings. Data suggest that approximately 30% of women will be sexually abused at some point in their lifetimes. As a result, 25% to 50% of those women will develop PTSD. For men, violence, especially combat-related violence, is the leading cause of the disorder (1).

Because patients approach primary care providers first to receive health care, primary care providers play a central role in mental illness management in the United States. Primary care providers treat 40%−60% of patients with mental disorders and prescribe 80% of antidepressant medications and around 60% of all psychotropic drugs (2). However, many primary care settings are ill-prepared to manage the mental health needs of patients because of a lack of resources. The collaborative care model has been successful in addressing this issue by shifting the focus from intervening at the individual level to restructuring the primary care delivery system to integrate a set of coordinated components.

It is often observed that patients with general medical complaints have been exposed to traumatic events and have PTSD symptoms but have not received appropriate diagnosis and mental health care. In primary care settings, these patients are not often recognized and do not receive necessary counseling and referral to a mental health provider. Because PTSD patients tend to avoid trauma reminders, it is very unlikely that they will report their traumatic experiences and related symptoms spontaneously. Therefore, primary care providers need to look for signs and symptoms of PTSD, which can be further validated by using appropriate screening tools. There are several PTSD screening tools available; however, the PC-PTSD is considered one of the most useful instruments for primary care providers. This four-item tool helps address unique PTSD symptoms such as reexperiencing, avoidance/numbing, and hyperarousal.

PTSD is generally treated with a combination of psychotherapy and pharmacotherapy. Popular psychotherapy approaches include trauma-focused CBT, stress inoculation training, cognitive processing therapy, eye movement desensitization and reprocessing therapy, and exposure therapy. SSRIs are the first-line pharmacological therapy used to manage chronic and acute PTSD. Second-line therapeutic options such as other classes of antidepressants, benzodiazepines and nonbenzodiazepine hypnotics, second-generation antipsychotics, and mood-stabilizing agents are also used in addition to cognitive therapy and SSRIs to target specific symptoms of PTSD.