Post Traumatic Stress Disorder

Post Traumatic Stress Disorder

TREATMENT PATH STAGE I: IDENTIFYING POST TRAUMATIC | TREATMENT PATH STAGE II: REFERRALING | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING | TREATMENT PATH STAGE IV: TREATING PTSD | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS

This Clinical Information Guide¹ is one in a series of guides designed to assist caseworkers and supervisors in identifying and managing clients who need mental health services. These guides use the treatment pathways model,² which outlines five stages to assist you in obtaining the best possible mental health services for your clients. Each guide is designed to highlight the primary casework task that needs to be accomplished at each stage, and to address common questions that you might have as you complete each task.

What are the five stages of the Treatment Pathways Model?

In the identification stage, you gather information concerning the identified problems, consult with your supervisor and the behavioral health consultant, and decide whether or not your client needs to be referred to a mental health specialist. In the referral stage, you follow established procedure by completing required documentation and selecting the appropriate mental health specialist. In the assessment and diagnosis stage, you assist the specialist by furnishing relevant information concerning your client. In the treatment stage, you work collaboratively with the clinician to identify treatment goals and secure the most effective treatment available for your client. In the monitoring and reviewing stage, you ensure that reasonable treatment goals are achieved.

TREATMENT PATH STAGE I: IDENTIFYING POST TRAUMATIC STRESS DISORDER

Primary Casework Task: To gather information to decide whether or not your client exhibits the symptoms of Post Traumatic Stress Disorder (PTSD) and to consult with your supervisor and the behavioral health consultant to determine if referral for evaluation or clinical intervention is needed.

What is PTSD?

PTSD is a psychiatric disorder that can develop after exposure to a terrifying event or ordeal in which serious physical harm occurred or was threatened. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat. Some of the people at risk for developing PTSD include military troops who served in the wars such as those in Afghanistan or the Persian Gulf; rescue workers involved in the aftermath of disasters like the terrorist attacks on New York City and Washington, D.C.; survivors of accidents, rape, physical and sexual abuse, or other crimes; immigrants fleeing violence in their countries; survivors of earthquakes, floods or hurricanes; and people who witness traumatic events. Families of victims can also develop the disorder.

What are the Symptoms of PTSD?

Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than 1 month. The severity and duration of the illness varies: Some people recover within 6 months, while others suffer much longer.

How Common is PTSD?

About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million people) have PTSD during the course of a given year. The prevalence of PTSD in children is unknown. About 30 percent of the men and women who have spent time in war zones experience PTSD. One million war veterans developed PTSD after serving in Vietnam. PTSD has also been detected among veterans of the Persian Gulf War, with some estimates running as high as eight percent.

Do Symptoms differ in Children?

PTSD can develop at any age, including in childhood. Symptoms typically begin within three months of a traumatic event, although occasionally they do not begin until years later. Loss of trust in adults and fear of the event occurring again are responses seen in many children and adolescents who have been exposed to traumatic events. Other reactions vary according to age:

Children 5 years of age and younger sometimes exhibit fear of being separated from the parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions and excessive clinging. Parents may also notice children returning to behaviors exhibited at earlier ages (these are called regressive behaviors), such as thumb sucking, bedwetting, and fear of darkness. Children in this age bracket tend to be strongly affected by parents' reactions to the traumatic event.

Children 6 to 11 years old may show extreme withdrawal, disruptive behavior, and/or inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger and fighting are also common in traumatized children of this age. Children may complain of stomach aches or other bodily symptoms that have no medical basis. Schoolwork often suffers. Depression, anxiety, feelings of guilt and emotional numbing or "flatness" are often present as well.

Adolescents 12 to 17 years old may exhibit responses similar to those of adults, including flashbacks, nightmares, emotional numbing, avoidance of any reminders of the traumatic event, depression, substance abuse, problems with peers, and anti-social behavior. Also common are withdrawal and isolation, physical complaints, suicidal thoughts, school avoidance, academic decline, sleep disturbances, and confusion. The adolescent may feel extreme guilt over his or her failure to prevent injury or loss of life, and may harbor revenge fantasies that interfere with recovery from the trauma.

Some children are more vulnerable to trauma than others, for reasons scientists don't fully understand. It has been shown that the impact of a traumatic event is likely to be greatest in the child or adolescent who previously has been the victim of child abuse or some other form of trauma, or who already had a mental health problem. A child who lacks family support is more at risk for a poor recovery.

TREATMENT PATH STAGE II: REFERRAL

Primary Casework Task: To complete the required referral process, including gathering supporting documentation, and to select the appropriate mental health specialist to assess, diagnose, and treat your client.

What kinds of mental health specialists can evaluate my client?

Psychologists (Ph.D., Psy.D.), physicians (M.D., including psychiatrists), licensed clinical social workers (L.C.S.W.), and psychiatric nurses (R.N.) have the training and background to conduct an initial evaluation for PTSD.

These mental health specialists can be found at community mental health agencies, the psychiatry department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, or private clinics. Specialty clinics that treat PTSD are listed in Appendix B of this Clinical Information Guide.

TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING PTSD

Primary Casework Task: To assist the mental health specialist by furnishing relevant information concerning your client's mental health.

The first step to getting appropriate diagnosis and treatment for PTSD is a thorough diagnostic evaluation by a mental health specialist. The clinician will gather a complete history of symptoms, including when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated, and what treatment was given. The clinician should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history will include questions about whether other family members have had a psychiatric illness and, if treated, what treatments they may have received that were effective.

Individuals are diagnosed with PTSD when they meet the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual Fourth Edition (DSM-IV). According to the DSM-IV, an individual with PTSD has been exposed to a threatening or stressful event and is responding with intense fear or helplessness (or disorganization in children). The individual also exhibits at least one of the following:

(1) Re-experiencing of the traumatic event (nightmares, flashbacks, intense reactions situations resembling traumatic event)

(2) Avoidance or numbing

(a) avoidance of thoughts, feelings, situations, or conversations resembling the traumatic event

(b) inability to recall trauma

(c) detachment from others

(d) restricted range of feelings

(3) Persistent increased arousal

(a) difficulty sleeping

(b) irritability

(c) difficulty concentrating

(d) exaggerated startle response

These symptoms must persist for at least one month and they must impair social, occupational, or academic functioning.

TREATMENT PATH STAGE IV: TREATING PTSD

Primary Task: To secure the most effective treatment available for your client's PTSD and to work collaboratively with the treating clinician to identify treatment goals and objectives.

The most effective kind of treatment for PTSD is cognitive-behavioral psychotherapy. Medication is sometimes used in conjunction with cognitive-behavioral therapy for patients who are at risk to hurt themselves or others, have symptoms that are extremely debilitating, or who do not respond to psychotherapy.

Cognitive-behavioral psychotherapy

Cognitive-behavioral therapy involves working with the individual's thoughts to change the way he or she thinks, feels, and acts. Exposure therapy, a form of cognitive-behavioral therapy that is especially effective for PTSD, requires the patient to imagine the trauma in a safe, controlled environment. The therapist helps the patient confront and gain control of the fear and distress that is associated with the trauma. While the patient recalls the traumatic memories, he or she uses relaxation skills to cope with the distress brought about by recalling the trauma. Relaxation skills are taught early in the treatment and may include meditation, progressive muscle relaxation, and breathing retraining. Cognitive-behavioral therapy may also include cognitive restructuring, in which the patient learns new ways of thinking about the trauma that minimize anxiety, guilt, or depression. Patients also learn to recognize "triggers" for the symptoms and use coping skills such as relaxation and cognitive restructuring to minimize the likelihood of experiencing a complete relapse of symptoms.

Cognitive-behavioral therapy with children should involve parents or caretakers, so that they learn about PTSD and how to help their children when symptoms arise. Play therapy may be used with very young children who are not mature enough to confront painful experiences directly. In play therapy, the therapist uses games, drawing, or other techniques to help young children confront painful memories in a less direct way than in exposure therapy.

Eye Movement Desensitization and Reprocessing is a new psychotherapy designed for people with PTSD that involves using eye movements, hand taps, or sounds to shift the individual's attention while they recall traumatic memories. This treatment has not yet been proven effective, and should not be used for DCFS cases at this time.

Medications

There has been considerable research on the use of medications for adults with PTSD, but not much research with children. Thus, clinical knowledge of which medications to use with children is based primarily upon research with adults. Medications are sometimes used to reduce the overwhelming symptoms of arousal, such as sleep disturbances, exaggerated startle reflex, intrusive thoughts, and avoidance. Medications can also reduce symptoms that accompany PTSD, such as depression or panic.

The most effective medications for treating PTSD symptoms are antidepressants that target a neurochemical in the brain called serotonin. The most commonly used medications in this class include Serotonin Reuptake Inhibitors ("SSRIs") such as Prozac and Paxil, and tricyclic antidepressants such as imipramine and amytriptyline. Medications such as Propranolol and Clonidine are sometimes used to treat the arousal symptoms of PTSD.

Where can my client obtain information about PTSD?

Sources for information concerning the diagnosis and treatment of PTSD are outlined in the Resources for Clients section at the end of this Clinical Information Guide. TREATMENT GOALS

How do I collaborate with the mental health specialist and my client to design treatment goals?

Developing treatment goals is a critical step in the treatment process. Clear, objective treatment goals enable the client, family, and service provider to address the client's mental health needs.

There are two broad kinds of treatment goals: Administrative and clinical. Administrative goals involve the completion or non-completion of services. Examples of administrative goals include the number of psychotherapy sessions or medication monitoring sessions that a client attends. Clinical treatment goals address two domains related to a client's overall functioning: symptom or behavior change, and changes in daily functioning ability

a) Symptom change -- A change in the symptoms or behaviors associated with PTSD, such as a decrease in flashbacks or nightmares.

b) Functional change -- A change in the areas of functioning that are typically affected by PTSD. These areas include:

· home or family (for example, improved ability to get along with family members,

or increased participation in family chores)

· school or work (for example, increased attendance, better grades, or improved

performance evaluations at work)

· friends or community (for example, more frequent socializing with friends).

You will need to collaborate with your client and the mental health specialist to create treatment goals that address your client's symptoms and the areas of functioning that are critical to your client fulfilling his or her service plan. You will need to work with the mental health specialist to determine the manner and frequency with which treatment goals will be measured.

TREATMENT PATH STAGE V: MONITORING AND REVIEWING

Primary Task: To ensure that you receive timely and appropriate documentation from the mental health specialist that reviews progress towards treatment objectives.

How do I know if treatment is working?

Usually within several months after starting treatment, your client will report feeling better and will probably seem more cheerful and optimistic. The client's performance at school or work may improve. Friends, family, teachers, and employers may report improvements in the client's demeanor.

Treatment Outcomes

What role do I play in monitoring my client's treatment goals?

Usually the mental health specialist will gauge the success of intervention services by observing changes in your client's behavior and functioning, and by administering standardized rating scales for PTSD when appropriate. Because of your extensive knowledge of the client's behavior, the specialist may ask you about the client's functional change in different areas. For example, the specialist may ask you about your client's ability to get along with peers or other family members.

If your client is not improving, you will want to talk with the mental health specialist or physician concerning factors in the client's life that could be complicating recovery. Perhaps after treatment began, additional life stress or change occurred in the client's life, such as the death of a loved one or a change of job. Sometimes a client in psychotherapy may not find the treatment helpful, and other forms of treatment may need to be added, such as medication.

What kind of documentation should I expect from the mental health specialist?

You should expect quarterly treatment summaries that highlight your client's progress toward all administrative and clinical treatment goals. If you review a treatment summary and find that it differs significantly from your observations of the client, you will want to contact the mental health specialist to discuss your concerns. You will also want to contact the specialist if you believe that new goals should be added to your client's treatment plan.

RESOURCES FOR CLIENTS

Where can my client obtain information about PTSD?

There are numerous resources for information concerning the diagnosis and treatment of PTSD. Your clients can obtain information about PTSD by contacting the following agencies:

National Institute of Mental Health

Information Resources and Inquiries Branch

6001 Executive Boulevard, Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

(301) 443-4513

www.nimh.nih.gov

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue, N.W.

Washington, DC 20016

(202) 966-7300

www.aacap.org

American Psychiatric Association

1400 K Street, N.W.

Washington, DC 20005

(202) 682-6000

www.psych.org

National Center for PTSD
215 N. Main Street
White River Junction, VT 05009
Phone: 802-296-5132

www.ncptsd.org

American Psychological Association

750 First Street, N.E.

Washington, DC 20002

(202) 336-5500

www.apa.org

Treatment Path Stage Clinical Information Casework & Administrative

Tasks

I. Identification of problem	Individual was exposed to a threatening or stressful event and current experiences intense fear or helplessness. The individual has nightmares, flashbacks, avoids situations resembling the traumatic event, or is constantly physiologically aroused (for example, difficulty sleeping, constant irritability, etc).	Casework Tasks: a) Obtain input from client and caregivers. b) Observe client c) Review clinical records d) Consult with supervisor & behavioral health team Administrative Task: · Document in case record
II. Referral	Licensed mental health specialists that evaluate for PTSD are: a) Physicians (M.D., including psychiatrists) b) psychologists (Ph.D., Psy.D.) c) Licensed clinical social workers (LCSW) d) Psychiatric Nurses (RN)	Administrative Tasks: a) Complete referral to licensed mental health specialist. b) Include relevant clinical and case records with your referral. c) Document in case record.
III A. Assessment	Assessment by mental health specialist must include: a) Interview of client and parent b) Review of case and clinical records Assessment may also include: a) Clinical rating scales	Administrative Task: Insure that mental health specialist has all relevant casework and clinical records.
III B. Diagnosis	Individual has been exposed to a threatening or stressful event and is responding with intense fear or helplessness (or disorganization in children) Individual also exhibits at least one of the following: 1. Re-experiencing of traumatic event (nightmares, flashbacks, intense reactions situations resembling traumatic event) 2. Avoidance or numbing a) avoidance of thoughts, feelings, situations, or conversations resembling traumatic event b) inability to recall trauma c) detachment from others d) restricted range of feelings 3. Persistent increased arousal a) difficulty sleeping b) irritability c) difficulty concentrating d) exaggerated startle response 4. Symptoms persist for at least one month and impair social, occupational, or academic functioning.	Administrative Task: Insure mental health specialist has all relevant casework and clinical records.
IV. Treatment	Cognitive-behavioral therapy that involves 1. Developing coping skills to reduce anxiety and avoidance 2. Gradual exposure to trauma-related cues 3. Education about PTSD for client and parent 4. Relapse prevention training to identify triggers and minimize the likelihood that disorder recurs. Eye movement desensitization and reprocessing (EMDR) therapy, which involves having the client move their eyes back-and-forth while imagining the trauma, has not been shown to be effective and should not be used for DCFS cases. Medication is sometimes added to psychotherapy to manage PTSD symptoms. The most commonly used medications include: 1. Antidepressants, especially serotonin-reuptake inhibitors or tricyclic antidepressants. 2. Medications such as Clonidine and propranolol to reduce arousal symptoms	Casework Task: Work collaboratively with mental health specialist to establish clear, measurable administrative and clinical treatment goals that assess your client's attendance and his or her change in: a) PTSD symptoms b) functioning in areas relevant to the case plan. These areas might include home, school, work, and relations with family and friends.
V. Monitoring & Review of Treatment	The frequency and method of monitoring treatment goals depends on the kind of treatment: a) Cognitive behavioral psychotherapy -- Mental health specialist collects data from client by interview and rating scales and from reports by significant others (including caseworker). b) Medication -- Physician monitors by reports from client and significant others and by conducting laboratory tests.	Casework Tasks: a) Work with mental health specialist and client to evaluate progress toward treatment goals. b) If necessary, work with specialist to revise treatment goals or to consider other kinds of treatment. Administrative Tasks: a) Obtain copies of quarterly, written treatment summaries from mental health specialist. Summaries should document client's progress toward clinical and administrative treatment goals, using standardized measures when appropriate. b) Document in case record.

APPENDIX B

LOCAL CLINICAL RESOURCES

1 Portions of this Clinical Information Guide are adapted from Helping Children and Adolescents Cope with Violence and Disasters, a patient information guide published by the National Institute of Mental Health, and PTSD in Children and Adolescents, an information guide published by the National Center for PTSD.

2 The treatment pathway for PTSD is summarized in Appendix A.

TREATMENT PATH STAGE I: IDENTIFYING POST TRAUMATIC | TREATMENT PATH STAGE II: REFERRALING | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING | TREATMENT PATH STAGE IV: TREATING PTSD | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS