PTSD: Earlier Identification is Paramount

Introduction

In the last couple of decades there has been a great deal of work in the field of Post-Traumatic Stress Disorder (PTSD). The focus has been on the affects of war on Service Members that have come back from Iraq, Afghanistan, and other areas around the world. This is just the beginning of this research because the signs and symptoms are not as noticeable as those that are external. The concentration on this population is one that has been ignored for generations, but what about others, such as first responders? Are people more susceptible if they had a traumatic event in their childhood? It is my theory that adults in the military (and other highly actioned environments) that had traumatic events in their childhood have a higher likelihood of having PTSD. Are there tools to identify these possible events to assist in the expedition treatment of these individuals? Are there specific genetic bio-markers that could possibly be identified to improve the prediction of PTSD? The research leads us to believe there is. A person doesn’t realize the impact of the entire family one a loved one is diagnosed with PTSD until it has touched their own family. I have been directly impacted by this visually hidden disorder and my passion to expedite care to those impacted is one I will not surrender.

Statistics of Interest

There are several sources on the internet with varying statistics as they pertain to PTSD. I have selected a site that appears to have credible and up to date statistics for a variety of populations. This is important to distinguish because there is no one specific population that is more important than another when it comes to PTSD.

Prevelence in the US and Around the World

According to UptoDate.com, “in a United States sample of 5692 respondents, 82.7 percent were exposed to severe and potentially traumatic events, and 8.3 percent of the trauma exposed were diagnosed with lifetime PTSD”. This is an alarming statistic, but if we think about it, what categorizes a traumatic event? UpToDate.com stated that their analysis was from a survey based on 24 countries which estimated the conditional probability of PTSD for 29 types of traumatic events.

Furthermore, UpToDate.com found the women are four times more likely to develop PTSD than men. Additionally, according to UpToDate.com, “Higher rates of PTSD have been found in population subgroups in the United States compared with the general population, including Native Americans living on reservations and refugees from countries where traumatic stress was endemic. In two large samples of Native Americans, lifetime prevalence of PTSD ranged from 14.2 to 16.1 percent” Also, “Among Cambodian refugees, two decades after resettling in the United States, 62 percent met criteria for PTSD…”. This is another startling statistic.

Cost to Society

According to PTSDUnited.org, “The annual cost to society of anxiety disorders is estimated to be significantly over $42.3 billion, often due to misdiagnosis and under treatment. This includes psychiatric and non-psychiatric medical treatment costs, indirect workplace costs, mortality costs, and prescription drug costs.” But there is not only a monetary cost to society. The affects are generational. When we look at the military population it is reported by the VA that “up to 20 % of Operation Enduring Freedom and Operation Iraqi Freedom veterans, up to 10 % of Gulf War veterans, and up to 30 % of Vietnam War veterans have experienced PTSD. Consequently, demand for PTSD treatment continues to grow”. Veterans diagnosed with PTSD may experience problems sleeping maintaining relationships, and returning to their previous civilian lives. This now has become exponential.

Basic Biological Mechanisms of PSTD

The basic biological mechanisms of PTSD have been studies of great interest in recent years.

Genetic Predispositions

According to the paper titled Functional network topology associated with posttraumatic stress disorder in veterans, “PTSD has been associated with hyperactivity of limbic brain regions, such as the amygdala, and hypo-activity of brain areas involved in emotional regulation, such as the ventromedial prefrontal cortex.” It was also reported in this article that “functional magnetic resonance imaging (fMRI) studies have emerged investigating neurobiological effects of treatment in PTSD. Task-based activation studies reported pre-treatment differences in the prefrontal cortex, anterior cingulate cortex and amygdala activation that normalized to control levels after treatment. Pre-treatment differences in hippocampal and anterior cingulate structure and amygdala, ACC and superior parietal lobule function have been shown to be markers of treatment outcome. This suggests that some neurobiological characteristics of PTSD may restore after treatment, while other features are stable markers for treatment outcome.”

Pertinent Bio-markers

According to UpToDate.com, “researchers suspect that genetics may contribute to an individual’s susceptibility to PTSD through an interaction with environmental factors. However, research studies on the genetics of PTSD have generally been small and findings have been inconclusive. As an example of a potential gene-environment interaction, the presence of one of four polymorphisms at the stress-related gene FKBP5 was found to be associated with an increased risk for PTSD in patients with a history of child abuse, but not in patients without history of child abuse.”

Exposure Types

According to UpToDate.com, some of the exposure types are as follows:

* Sexual relationship violence - 33 percent (eg, rape, childhood sexual abuse, intimate partner violence).
* Interpersonal-network traumatic experiences - 30 percent (eg, unexpected death of a loved one, life-threatening illness of a child, other traumatic event of a loved one).
* Interpersonal violence - 12 percent (eg, childhood physical abuse or witnessing interpersonal violence, physical assault, or being threatened by violence).
* Exposure to organized violence - 3 percent (eg, refugee, kidnapped, civilian in war zone).
* Participation in organized violence - 11 percent (eg, combat exposure, witnessing death/serious injury or discovered dead bodies, accidentally or purposefully caused death or serious injury).
* Other life-threatening traumatic events - 12 percent (eg, life-threatening motor vehicle collision, natural disaster, toxic chemical exposure).

Identifying the specific exposure early in the treatment process can have significant benefit to the patient and their family members. It is also important to examine the possibility that a person could have been exposed to multiple exposure types. This may cause some difficulties in treatment, but is vital to identify.

Natural Courses of the Disorder

According to the article written by Judith A. Cohen, “Most individuals who experience truly life-threatening events manifest posttraumatic symptomatology immediately.” She further goes on to say that only approximately 30% of people that have experienced a truly life-threatening event don’t show any symptoms in the first month. This is why PTSD is not diagnosed until after the first month.

Dr. Cohen goes on to say that young children may have early manifestations of new aggression, oppositional behaviors, regression in developmental sills (such as speech or toilet training), and even some new fears not associated with the event (such as fear of the dark or being alone in a room).

Furthermore, early childhood PTSD increases risk for a number of problems later in childhood, adolescence, and adulthood. Dr. Cohen mentioned that some of the symptoms of PTSD can be proportional to the duration of the children’s trauma exposure. Children that have been exposed to sexual abuse have a higher likelihood of adverse outcomes as they get older, such as substance abuse, conduct disorders, and depression.

Adults that have been diagnosed with PTSD related to childhood trauma have higher rates of depression, suicide attempts, drug use, hospitalizations, and relationship issues. This isn’t surprising. If there has not been treatment to deal with these issues as a child, adults will have struggles coping as they get older.

Identification of Disorder

According to UpToDate.com, most individuals who experience trauma react to some degree when experiencing reminders of the trauma. Patients with PTSD, however, experience marked cognitive, affective, and behavioral responses to stimuli, leading to flashbacks, severe anxiety, and fleeing or combative behavior. These individuals compensate for such intense arousal by attempting to avoid experiences that may begin to elicit symptoms; this can result in emotional numbing, diminished interest in everyday activities, and, in the extreme, may result in detachment from others.

Furthermore, most individuals who develop PTSD experience its onset within a few months of the traumatic event. However, epidemiologic studies have found that approximately 25 percent experience a delayed onset after six months or more

Additionally, UpToDate.com used eight categories of possible identification. However, a diagnosis of PTSD is made for patients older than age six years who meet all of the following DSM-5 criteria:

A. Exposure to actual or threatened death, serious injury, or sexual violence
B. Presence of one (or more) intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred
F. Duration of the disturbance (Criteria B, C, D, and E) is more than one month
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
H. The disturbance is not attributable to the physiological effects of a substance (eg, medication, alcohol) or another medical condition

These criteria seem to be very thorough. I believe that there is room for improvement in this assessment.

Another screening tool that was located concentrated on children and adolescents. An abbreviated version from the University of California at Los Angeles is referenced in the article written by Judith A. Cohen. There are problems such as “I try to stay away from people, places, or things that make me remember what happened.” This assessment, and many others, only ask about things that have happened in the last two weeks or month. This should be modified for those that have trauma that has been hidden for years and years. Some people are very literal and will view these timelines as exact. An accurate description of ones mental health stability should not be judge in the last two weeks or month.

Care Management or Prevention

The VA uses a PTSD Checklist that assesses the 20 DSM-5 symptoms of PTSD. according to the US VA, there are a variety of purposes of this self-reporting tool, including, but not limited to the following:

  • Monitoring symptom change during and after treatment
  • Screening individuals for PTSD
  • Making a provisional PTSD diagnosis

Additionally, there has been some research conducted on the safety and effectiveness of cannabis for anxiety as it relates to PTSD. According to Seth Gilliam’s article Is Marijuana the Answer to Anxiety Problems?, marijuana can have some calming effects, but have the possibility of leading to more extreme chemical dependency issues.

So what are some alternatives to marijuana use for dealing with distressing emotions like anxiety?

  • Exercise
  • Tending our thoughts
  • Gradual exposure to our fears
  • Meditation and other mindfulness practices
  • Eating a healthful diet
  • Meaningful engagement in life

Informatics Applications

In recent years there have been several advances in mobile applications for those diagnosed with PTSD. The majority of them have concentrated on anxiety and coping. The way that some of these apps have chosen to mitigate the advancement of PTSD is through meditation. Furthermore, there appears to be a higher focus on the management of PTSD and anxiety for veterans.

Smith’s Lawyers

There are five top apps listed as follows:

App Name Best Used for
Headspace Those looking for a flexible and engaging app that helps to reduce stress and worry through meditation practices.
Calm Guided meditation exercises that you can squeeze into work lunch breaks or at times of high anxiety and stress. Available in both iOS and Android. Free with paid options via In-App Purchases.
SAM App Monitoring your anxious thoughts and behaviour through exercises that encourage self reflection.
Happify Those seeking exercises that helps them to learn skills and habits that reduce negative thinking, improves the mood and trains the brain for positivity.
PTSD Coach Australia Veterans, Defence Force personnel and anyone else seeking effective tools and techniques for managing PTSD.

BrainLine

There are 12 Free Military apps recommended below:

App Name Helps With
Anger and Irritability Management Skills (AIMS) Anger, Mood, PTSD
Breathe2Relax Anxiety, Stress, PTSD
CBT-I Coach PTSD, Sleep Issues
Concussion Coach Diagnosis, Symptom Management
Life Armor Anger, Anxiety, Family Concerns, Depression, PTSD, Sleep Issues
Mindfulness Coach Anxiety, Depression, Headache, PTSD, Stress
Mood Coach PTSD, Depression, Mood, Behavior
Moving Forward Anxiety, Family Concerns, PTSD, Stress
mTBI Pocket Guide Assessment, Treatment, Symptom Management
T2 Mood Tracker Anxiety, Anger, Depression, PTSD
Tactical Breather Anxiety, Anger, Emotions, PTSD, Stress
VetChange Alcohol & Substance Use, PTSD

Commercial Potential for Informatics

Even though there are a number of informatic tools on the market to assist with the management of PTSD there is a potential for additional commercial informatic tools. For example, I would like to see an improved digital patient survey to assist with the detection of PTSD in all populations. There are questionnaires, assessment tools, and checklists.

In my opinion there should be an electronic assessment tool that is sent to the patient prior to their referral appointment to the psychologist, psychiatrist, or neurologist. This assessment tool should be variable dependent on the suspected cause of the PTSD. If the patient is a child, the assessment should be sent to the parent and filled out with their assistance.

Understanding that this can be challenging for some parents to do with their children, a guardian ad litem can possibly assist. Many therapist may need to perform these in their offices. It is vital that this information is available to the next level of care provider prior to the patient’s visit in order expedite treatment. There is far too much money spent on this phase of the treatment.

Key Areas of Potential Research

There are several areas of potential research in the diagnosis and treatment of PTSD. According to an article written by Heather Landi titled Geisinger Study Using EHR Data to Develop PTSD Prediction Tool, Geisinger Health System is conducting a study attempting to identify key predictors of mental health issues in recently deployed National Guard members and Reservists using its electronic health record (EHR), a predictive tool and diagnostic interviews. The aim of the study is to identify specific genetic risk factors to determine which Service Members are at higher risk of developing PTSD and other conditions.

Additionally, I feel that there is a need for additional research in children and adolescents in lower income social situations, children in foster care systems, or those identified at birth to have been born to parents with known chemical dependency.

Conclusion

The PTSD epidemic in the US and around the world is a growing field of interest. Before researching this topic more in-depth I had no idea the severity of this disorder. In the future I would like to develop an easy-to-use electronic tool for those receiving treatment for PTSD. I believe this tool should be geared to children suffering from traumatic events. If we can pin point the specific cause of the event earlier in the progression we can mitigate the issues that will undoubtedly arise as time goes on.

Further, this tool needs to be used to assist Service Members in different stages of their careers to identify whether or not they have a higher likelihood of PTSD. There should be a tool at the initial in-processing of Service Members. This can hone in on those that appear to have been exposed to previous traumatic events, and therefor can be treated accordingly.

References

* BrainLine. (2018, December 18). 12 Free Military Apps for Managing Life with Brain Injury. Retrieved from BrainLine: https://www.brainline.org/article/12-free-military-apps-managing-life-brain-injury
* Carroll, K. K., Lofgreen, A. M., Weaver, D. C., Held, P., Klassen, B. J., Smith, D. L., . . . Zalta, A. K. (2018, November 17). Negative posttraumatic cognitions among military sexual trauma survivors. Retrieved from ScienceDirect: https://www.sciencedirect.com/science/article/pii/S0165032717326411?via%3Dihub
* Cohen, J. A. (2018, November 18). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder. Retrieved from Journal of the American Academy of Child & Adolescent Psychiatry: https://www.jaacap.org/article/S0890-8567(10)00082-1/fulltext
* David Yusko, P. (2018, December 15). Post-Traumatic Stress Disorder: Symptoms, Causes, Treatment, and Coping. Retrieved from Anxiety.org: https://www.anxiety.org/post-traumatic-stress-disorder-ptsd#prevalence-of-ptsd
* Gillihan, S. J. (2018, December 19). Is Marijuana the Answer to Anxiety Problems? Retrieved from Psychology Today: https://www.psychologytoday.com/us/blog/think-act-be/201812/is-marijuana-the-answer-anxiety-problems
* Kennis, M., Rooij, S. v., Heuvel, M. v., Kahn, R., & Geuze, E. (2018, December 17). Functional network topology associated with posttraumatic stress disorder in veterans. Retrieved from ScienceDirect: https://www.sciencedirect.com/science/article/pii/S2213158215300474
* Misaki, M., Phillips, R., Zotev, V., Wong, C.-K., Wurfel, B. E., Krueger, F., . . . Bodurk, J. (2018, November 18). Connectome-wide investigation of altered resting-state functional connectivity in war veterans with and without posttraumatic stress disorder. Retrieved from ScienceDirect: https://www.sciencedirect.com/science/article/pii/S2213158217302735
* Nini, J. (2018, December 15). 5 Free Apps to Help with Post-Traumatic Stress (PTSD). Retrieved from Smith's Lawyers: https://www.smithslawyers.com.au/post/5-free-ptsd-apps
* PTSD United. (2018, December 12). PTSD Statistics. Retrieved from PTSDUnited.org: http://www.ptsdunited.org/ptsd-statistics-2/
* Sareen, J. (2018, December 18). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. Retrieved from UpToDate.com: https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis
* Sulker, H., Tajirian, T., Paterson, J., Mucuceanu, D., MacArthur, T., Strauss, J., . . . Jankowicz, D. (2018, December 14). Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report. Retrieved from Jamia Open: https://academic.oup.com/jamiaopen/advance-article/doi/10.1093/jamiaopen/ooy044/5128775
* U.S. Department of Veteran Affairs. (2018, December 17). PTSD: National Center for PTSD. Retrieved from U.S. Department of Veteran Affairs: https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

2019-02-07