Identifying And Treating VA Medical Care Patients With Undetected Sequelae Of Psychological Trauma And Post-Traumatic Stress Disorder

Julian D. Ford, Ph.D., Josef I. Ruzek, Ph.D., & Barbara L. Niles, Ph.D.

NCP Clinical Quarterly 6(4): Fall 1996

We believe that improvements in identification of trauma-related psychological problems in primary care settings can help maximize patient satisfaction and cost efficiency in health care. As Friedman and Schnurr (1) point out, patients with undetected and untreated stress- and trauma-related impairment suffer not only psychologically, but also in terms of their physical health. The fiscal costs to DVA, as a result of excess medical services utilization and disability compensation, are not known but are likely high. On the other hand, when specialized screening for psychological stress and trauma leads to efficient, individualized, and specialized mental health care, it is likely that all health care outcomes will be improved, costs reduced, and patient satisfaction enhanced. Thus, targeted stress and trauma evaluation and treatment is directly congruent with Under Secretary Kizer's call in "Prescription for Change" for cost-efficient multidisciplinary continuity of care for all patients of the Veterans Health Administration.

When specialized protocols are utilized, trauma and stress screening and treatment can be accomplished with little extra workload for health care providers. Mental health management of patients with trauma-related impairment can unburden health care workers and greatly enhance efficiency. Moreover, we, as mental health specialists, benefit from offering trauma and stress screening in medical care settings by an expanded referral base, increased participation in multidisciplinary clinical care teams, and enhanced access to multidisciplinary policy and planning groups. In this article, we briefly review epidemiological evidence suggesting the need for trauma screening, and with the help of case examples from the trauma and PTSD screening projects now ongoing at several VAMCs across the country, we illustrate the kinds of cost-effective interventions mental health and PTSD specialists can provide within the emerging multidisciplinary primary health care environment in the DVA (2).

Undetected PTSD

Most adults and almost half of all children and adolescents have been exposed to psychological trauma (Table 1).

Table 1: Trauma Exposure Prevalence

Military veterans with warzone service have even higher rates of trauma exposure; compared to community samples, warzone veterans are two to four times more likely to have been exposed to psychological trauma (11, 20). Studies outside the DVA health care system show that patients with histories of exposure to psychological trauma represent a sizable group in need of specialized evaluation and treatment for post-traumatic psychosocial impairment (see Table 2).

Table 2: Prevalence Of Untreated Post-Traumatic Psychosocial Impairment In Health Care (3, 21, 22)

As many as one in ten women and one in fifteen men in community samples experience PTSD at some point in their lifetimes. Among military veterans who served in a warzone, the PTSD rate is substantially higher than in community samples -- as much as 50% for Desert Storm veterans and 500% for Vietnam veterans. It is estimated that one in fifteen veterans in DVA primary health care who were exposed to combat -- as many as one million veterans -- have undiagnosed and untreated PTSD (Table 3).

Table 3: Veterans, PTSD, and VA Health Care

Many more veterans have subthreshold symptoms and other unrecognized and untreated trauma-related psychosocial impairments. In addition, many patients currently identified in primary care settings as suffering from depression or anxiety are likely unrecognized trauma survivors whose post-traumatic symptoms are not effectively addressed.

Despite the specialized mental health and PTSD services available in DVA, many veterans' PTSD symptoms continue to go unrecognized and untreated. Even among veterans who have service-connected disabilities for PTSD, a large proportion do not use specialized services in VA hospitals or clinics; Rosenheck and Fontana (23) found that 40% of PTSD service-connected veterans -- 30,000 individuals -- did not utilize these services in 1995. Current evidence suggests that the prevalence of untreated post-traumatic stress impairment is comparable to that of depression or non-trauma-related anxiety disorders.

Three case examples will serve to illustrate how psychological consultation can help to identify and manage post-traumatic stress impairment in the health care setting.

Case 1.

AG is a 48-year-old male Vietnam combat veteran with a chronic history of poorly controlled brittle diabetes. AG's severe PTSD was detected after fifteen years of VA health care when his physician suspected that polydrug dependency was a major factor in a series of emergency room admissions and intensive care hospitalizations for life-threatening blood sugar dysregulation. A PTSD specialist evaluated AG upon admission to a VA substance abuse clinic, and established an ongoing case management relationship despite AG's relapse into substance use, denial of any trauma exposure in Vietnam, and refusal to attend any specialized PTSD treatment. AG became willing to join a PTSD therapy group several years later when his health had deteriorated severely as a result of anorexia and his life had become restricted to that of a virtual shut-in due to increasing depression. Always taciturn, shy, cynical by nature and upbringing, AG showed evidence of agoraphobia, suicidality, and schizoid characterological impairment due to utterly anhedonic emotional and social isolation.

AG attended the weekly PTSD group led by a Vietnam nurse counselor and a civilian psychologist, for many months sitting motionless and making almost no eye contact, and speaking only to give perfunctory answers to occasional questions. AG's agoraphobia and anorexia improved little, but he was no longer suicidal and he had only one emergency room visit due to severe hypoglycemia in the next year. Close to the first anniversary of his group attendance, AG came to group for the first time distraught and related a memory (triggered by listening to other group members' trauma processing) of helplessly witnessing the drowning of the only man who had befriended him in Vietnam. AG had a severe blood sugar crisis within a month, but returned to group visibly moved by having received visits and phone calls while hospitalized from several group members and leaders. AG gradually began recounting a series of terrifying and lonely encounters with death on reconnaissance patrols in Vietnam, and describing how symptoms that he now could acknowledge as beginning with these traumas were "making me like a dead man." Despite complaining that his diabetes medication and dietary regimens were "impossible," over the next year he went for the longest period in two decades without a blood sugar crisis. Periodic consultation by the PTSD specialist and group leaders with AG's physician confirmed this first real positive response to medical care.

However, AG continued to use marijuana daily and was defensive when gently "called" on this addictive pattern by group leaders and members. He remained isolated, despite initiating some social contact with group members, and his wife of many years finally decided to leave the marriage because, according to AG, "she can't stand being responsible for my life." AG had a severe blood sugar crisis requiring intensive inpatient care. The PTSD providers convened a special meeting with AG's physician, and crafted a treatment plan calling for more frequent sugar monitoring and clinic visits, as well as immediate substance abuse treatment. The whole team met with AG to present this written plan, insisting that continued care would be harmful and therefore unethical unless AG agreed to participate actively in several corollary self-care steps specified in the plan. The PTSD providers helped AG to problem solve ways to deal with barriers and lapses, and set very specific behavioral parameters to monitor AG's adherence. AG seemed relieved, saying "Well I finally can't play some of you off the others any more! I guess it's my life to live now."

AG's recovery was neither immediate nor without lapses: he completed substance abuse treatment without a genuine commitment to abstinence, relapsed, withdrew from social and group participation, and his blood sugar became unstable. However, before a crisis occurred, AG sought out the group leaders and asked for help in getting some "real addiction treatment before I kill myself." The leaders coordinated with the PTSD specialist and AG was enrolled in a joint substance abuse/PTSD program, which he was required to complete before returning to group. The substance abuse treatment was utilized as an opportunity to closely monitor AG's medical regimen adherence, providing helpful guidance both to AG and his physician. AG rejoined the PTSD group, and remained sufficiently clean and sober and in adherence with his medical regimen to be able to successfully undertake intensive inpatient PTSD treatment.

An unanticipated benefit emerged from the ongoing consultation with AG's physician. This physician was a very senior clinician and scientist who had been noncommittal and skeptical about the validity of PTSD and the value of PTSD care for veterans. After the significant change demonstrated in AG's chronically unstable and refractory medical condition, the physician was not only appreciative but became a strong advocate for continued clinical program and research funding for PTSD within the VA and the academic community.

Case 2.

NR is a 45-year old male Vietnam veteran whose right leg required two amputation surgeries within six months. NR had a long history of polysubstance dependency and violent antisocial behavior. A PTSD specialist was called upon by the rehabilitation medicine physician following NR during nursing home convalescence, because the physician knew of the specialist's ongoing consultation with a geriatric rehabilitation unit for which she served as medical director. The PTSD specialist conducted an on-site PTSD and psychosocial assessment, made several behavioral recommendations for symptom management to the veteran (e.g., sleep hygiene and nightmare processing), and provided the physician and rehabilitation medicine staff team with practical education and clinical management tactics that helped them to understand, empathize with, and set firm therapeutic limits with the veteran around rehabilitation adherence and PTSD symptom management.

NR had never been in PTSD treatment before: "I made everyone too nervous because they thought all I felt was angry and out of control. Nobody ever asked if I had bad memories." The physician was particularly concerned that the veteran's physical rehabilitation and substance sobriety would be compromised if he returned to the streets, where he had been living without a home for several years. The PTSD specialist was able to coordinate a temporary admission for NR to the homeless domiciliary, and enrolled NR in a pre-admission group in preparation for admission to a new PTSD Residential Rehabilitation Program (PRRP). NR completed the application process with the specialist's help, completed a successful stay in the PRRP, and established a stable residence in the community after another 3 months domiciliary residence. He enrolled in an ongoing weekly PTSD group and completed adjustment to a leg prosthesis over the next 18 months. Despite these successes, NR relapsed on substances shortly after receiving a large retroactive VA disability cash payment, and was asked to discontinue PTSD group until he completed substance abuse treatment and had regained sobriety.

NR's case illustrates how timely trauma and PTSD screening can facilitate both the medical care and the entry into specialized PTSD care of veterans with undetected and untreated PTSD. While the unpredictable influence of complex characterological and institutional factors can unfortunately undo many of the benefits accrued by the patient, we can provide patients with a solid base for further treatment and recovery from even severe relapses. Here too, unanticipated systemic benefits occurred for the PTSD programs at this VAMC. The physician became Associate Chief of Staff for a major Division in that VAMC, and was a strong proponent of the new PRRP and for the allied PTSD treatment programs during several subsequent institutional upheavals.

Case 3.

KB is a 65 year old male Korean War veteran who had never sought mental health treatment prior to the death of his wife two years previously. KB had a long history of complicated care for chronic coronary heart disease, hypertension, and ulcerative colitis. After his wife's death KB became severely depressed, recovering significantly but not fully in a year's care with a therapist at the VAMC's Behavioral Medicine Clinic. KB's therapist was not able to continue treatment beyond one year, and felt that PTSD, not depression, was the primary issue at that point. The therapist contacted a PTSD specialist for consultation, asking that the specialist assume case management responsibility if the veteran's PTSD warranted ongoing treatment. The therapist confided that although KB was very engaging, he exhibited a histrionic, aggressive, and antisocial personality style that made it difficult to set limits or to believe his often grandiose stories of personal exploits. The PTSD specialist confirmed that KB had served in combat in Korea, and that a diagnosis of PTSD was warranted despite the possibility of factitiousness in some of his trauma and symptom accounts.

KB was seen in individual treatment for one year with a focus on completing bereavement and beginning to address post-traumatic sequelae, showing continued improvement in mood, renewed social and familial involvement, and reduced emotional numbing. Initially, KB refused to discuss war trauma because "I don't have to prove to you or anyone else that I'm living in hell with those war memories since (his wife) died." Gradually, he shifted to a dramatic and bellicose recounting of "war stories," but ultimately was able to do genuine trauma exposure work with several key Korean War memories. His medical status, which had been poor initially, stabilized according to the cardiovascular clinic team, and he was able to tolerate a reduction in pain and ulcer medication. KB was gradually weaned from individual therapy and required--despite his objections at first -- to join an older veterans’ group. When he became disruptive in challenging the "old codgers" to "stop making nice," KB was assisted in transferring to a Vet Center group in which he was well-accepted by Vietnam veterans. KB applied for and completed a stay in the PRRP, became a valued volunteer "grandfather" for a number of veterans in that program, and in helped sponsor several projects such as a therapeutic greenhouse and transitional housing for formerly homeless PTSD veterans.

KB's case illustrates how a difficult medical care patient can benefit from the combination of therapeutic processing and limit setting, as well as the re-involvement in relationships associated with investment in a therapeutic relationship and milieu. The PTSD specialist's willingness to accept the responsibility of case management for someone considered a "resistant " patient by the Behavioral Medicine staff proved to be an important first step in forging a strong collaborative relationship between the previously disconnected PTSD and Behavioral Medicine programs. That alliance has proved valuable as the new VISN structure has led to a consolidation of these programs in an Anxiety and Affective Disorders product line.

What's The Payoff Of Health Care Screening For Mental Health Specialists?

Providing screening, referral, and treatment services for stress- and trauma-impaired health care patients enables mental health specialists to tangibly demonstrate the need for -- and benefits of -- specialized mental health care to medical and nursing professionals. Several favorable outcomes can result from achieving a well-deserved "positive halo" in this way.

First, specialized care can be extended to some of the estimated 1,000,000 veterans who may have untreated PTSD. Services launched in general health settings may help to bypass reluctance to enter mental health treatment. Moreover, stress-related interventions may enable PTSD specialists and other mental health practitioners to expand current work with those suffering from severe chronic PTSD to offer briefer, cost-effective treatments for individuals with less severe trauma-related symptomatology.

Second, this approach may help reach some of the 30,000 PTSD-service-connected veterans who are not currently in PTSD treatment. These services may help practitioners play a proactive role in maintaining and extending adaptive community functioning and in hastening identification and provider response to symptom exacerbation ("relapse prevention").

Third, we can reduce the stigma attached to the many patients presenting with health concerns who suffer from PTSD or other trauma-related impairments. Patients such as KB or NR often are considered not only difficult but even "hateful" by health care providers, as a result of treatment-resistant psychiatric symptoms or characterologic impairments that manifest in such forms as grandiosity, histrionics, dependency, rage, addictive substance use, poor adherence to medical regimens, missed appointments, and noncommunicativeness. With consultation on clinical management, and assistance through accurate evaluation and targeted psychological treatment, not only the patient but also the health care provider often feels relief and gratitude.

Fourth, severe illnesses (and some medical procedures) themselves have recently been conceptualized as traumatic stressors which may lead to stress reactions or PTSD problems amenable to psychological care (24). For example, life-threatening illnesses such as AG's (or cancer or heart disease) can exacerbate stress or PTSD symptomatology and also place an extreme emotional and practical burden upon already overdrawn caregivers and family members. Chronic life-altering illnesses or medical procedures can exacerbate PTSD and cause significant clinical management problems, as shown by the case of NR. Even apparently innocuous procedures or illness events can trigger intense post-traumatic reactions with which medical and nursing providers are not really prepared to cope. For example, a veteran with a history of serving as a "tunnel rat" in Vietnam required careful therapeutic assistance when undergoing a claustrophobia-triggering MRI.

Fifth, trauma and stress screening offer an excellent bridge across which trauma specialists can join effectively with mental health colleagues in such areas as behavioral medicine, neuropsychology, or anxiety disorders. Close collaboration can reduce duplication of services, increase PTSD patients' access to high-demand clinics such as pain management or neuropsychology, and increase the likelihood of detection of trauma and PTSD in those clinics and in the medical clinics with which they affiliate. When collaboration is required post haste by major institutional restructuring, such as occurred at the VAMC where KB was seen, personal and professional relationships can be the difference between turf battles and a shared commitment to mutual cooperation.

Finally, as all three case examples illustrate, the good will and networking generated by helpful and timely screening and consultation can contribute to the development of genuinely multidisciplinary teams that ensure continuity of care. In this era of managed care and reinvented government, it is also very important to have friends in positions of influence -- for example, medical and nursing colleagues who can recommend one's services to a Chief of Staff or a VISN strategic planner as essential to patient care!

Conclusion

Mental health liaison can assist primary care practitioners in substantially increasing rates of detection, appropriate referral, and effective clinical management of patients with trauma- and stress-related impairments. Although stress and trauma screening is in its infancy within DVA and in the wider public and private health care sectors, mental health specialists have an opportunity to adapt models already developed for identifying and initiating treatment for depression (26) and panic disorder (by NIMH). As we do so, it will be important to remain aware of the need to target assessment and treatment to signs and symptoms whose change has value to patients and providers, because "more" is not always better, even with high quality and continuity of care (Bickman, 1996). Stress and trauma screening, education, and consultation in medical and nursing settings offers a window of opportunity for a significant evolution in services delivered by PTSD specialists that can extend well into the next century.

Resources Available!

In light of the estimated prevalence of undetected and untreated PTSD in the DVA health care system and the profound impact of trauma upon health and medical care, the Department of Veterans Affairs National Center for PTSD has convened a working group on "Trauma and Primary Health Care Education." This multidisciplinary national working group of psychiatry, psychology, social work, medical, and nursing clinicians and researchers has developed two Clinician Guides to "Stress and Trauma Screening in Health Care" -- one guide for mental health professionals and a companion for medical/nursing providers. We will send a copy of these guides to every DVA specialized PTSD program and we invite you to use them to enhance the services that your team or clinic offers to the many patients who suffer from undetected and untreated psychological impairment due to stress and trauma.

For additional information or intensive training, please contact the National Center for Post-Traumatic Stress Disorder:

References

1. Friedman, M.J., & Schnurr, P. P. (1996). Trauma, health, and PTSD. National Center for PTSD Clinical Quarterly, 6, .

2. Ford, J. D. (1996). Practitioner network: Primary care. National Center for PTSD Clinical Quarterly, 6, 7.

3. Breslau, N. & Davis, G. C. (1992). Posttraumatic stress disorder in an urban population of young adults: Risk factors for chronicity. American Journal of Psychiatry, 149, 671-675.

4. Kessler, R. C., Sonnega, A., Bromet, E., & Hughes, M. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.

5. Norris, F. H. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical Psychology, 60, 409-418.

6. Turner, R. J., Wheaton, B., & Lloyd, D. A. (1995). The epidemiology of social stress. American Sociological Review, 60, 104-125.

7. Resnick, H.S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best, C. L. (993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984-991.

8. Boney-McCoy, S. & Finkelhor, D. (1995). Psychosocial sequelae of violent victimization in a national youth sample. Journal of Consulting and Clinical Psychology, 63, 726-736.

9. Sutker, P. B., Uddo, M., Brailey, K., & Allain, A. N. (1993). War-zone trauma and stress-related symptoms in Operation Desert Shield/Storm (ODS) returnees. Journal of Social Issues, 49, 33-50.

10. Wolfe, J., Brown, P. J., & Kelley, J. M. (1993). Reassessing war stress: Exposure and the Persian Gulf War. Journal of Social Issues, 49, 15-31.

11. Kulka, R. C., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D.S. (1993). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.

12. Sibai A. M., Armenian H. K., & Alam, S. (1991). Wartime determinants of arteriographically confirmed coronary artery disease in Beirut. Middle East Journal of Anesthesiology, 11, 25-38.

13. Leserman, J. and Drossman, D. A. (1995). Sexual and physical abuse history and medical practice. General Hospital Psychiatry, 17, 71-74.

14. Walker, E. A., Katon, W. J., Hansom, J., Harrop-Griffiths, J., et al. (1995). Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics, 36, 531-540.

15. Aghabeigi, B., Feinmann, C., & Harris, M. (1992). Prevalence of post-traumatic stress disorder in patients with chronic idiopathic facial pain. British Journal of Oral Maxillofacial Surgery, 30, 360-364.

16. Toomey, T. C., Hernandez, J. T., Gittelman, D. F., & Hulka, J. F. (1993). Relationship of sexual and physical abuse to pain and psychological assessment variables in chronic pelvic pain patients. Pain, 53, 105-109.

17. Wurtele, S. K., Kaplan, G. M., & Keairnes, M. (1990). Childhood sexual abuse among chronic pain patients. Clinical Journal of Pain, 6, 110-113.

18. Reiter, R. C., Shakerin, L. R., Gambone, J. C., & Milburn, A. K. (1991). Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. American Journal of Obstetrics and Gynecology, 165, 104-109.

19. Koss, M. P., Woodruff, W. J., & Koss, P.G. (1991). Criminal victimization among primary care medical patients: Prevalence, incidence, and physician usage. Behavioral Sciences and the Law, 9, 85-96.

20. Green, B. L., Grace, M. C., Lindy, J. D., & Gleser, G. C. (1990). Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans. American Journal of Psychiatry, 147, 729-733.

21. Fifer, S. K., Mathias, S. D., Patrick, D. L., Mazonson, P. D., Lubeck, D. P., & Buesching, D. P. (1994). Untreated anxiety among adult primary care patients in a health maintenance organization. Archives of General Psychiatry, 51, 740-750.

22. Brom, D. , Kleber, R. J., & Witztum, E. (1991). The prevalence of posttraumatic psychopathology in the general and the clinical population. Israel Journal of Psychiatry and Related Sciences, 28, 53-63.

23. Rosenheck, R. and Fontana, A. (1996). Personal communication.

24. Shalev, A.Y., Schreiber, S., & Galai, T. (1993). Post-traumatic stress disorder following medical events. British Journal of Clinical Psychology, 32, 247-253.

25. Bickman, L. (1996). A continuum of care: More is not always better. American Psychologist, 51, 689-701.

26. Regier, D. A., Hirschfeld, R. M., Goodwin, F. K., Burke, J. D., et al. (1988). The NIMH Depression Awareness, Recognition, and Treatment Program: Structure, aims, and scientific basis. American Journal of Psychiatry, 145, 1351-1357.

Julian Ford.............

Joe Ruzek is Associate Director for Education at the National Center for PTSD based at the VA Palo Alto Health Care System in Palo Alto, California. Dr. Ruzek is actively involved in providing training and support services for VA specialized PTSD program staff and other healthcare providers. He received a doctorate in clinical psychology from the State University of New York at Stony Brook, and his current interests include the interaction of PTSD and substance abuse, trauma-related cognitive processes, and PTSD in the medical setting. Barbara Niles is a staff psychologist at the Behavioral Sciences Division of the National Center for PTSD at the Boston VAMC and is an instructor at the Tufts University School of Medicine Department of Psychiatry. In addition to her interest in physical health consequences of PTSD, Dr. Niles has investigated the longitudinal course of PTSD in a follow-up study of veterans evaluated that Boston VA.

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