Are You at Risk for PTSD?

Several years ago, I was working on my final project at the University of Washington which was required to obtain a DNP (doctor of nursing practice) degree. My topic was PTSD (post-traumatic stress disorder) As I did research into PTSD, I came to realize that it was primarily thought of as a problem experienced by soldiers who had been exposed to combat situations. However, the medical definition of PTSD is not limited to those in the military. I was working in an orthopedic hand clinic at the time as a Nurse Practitioner. We saw many patients with the diagnosis of “mangled hand injury” and realized that PTSD was a potential problem with these patients. Mangled hand injury sounds terrible, and it is. However, it is a medical category used for persons who have sustained severe injury such as a blast, a crush or an amputation. I was concerned that the orthopedic hand clinic where I was working might not be identifying all of the patients at risk for PTSD who presented with this diagnosis. It is this group on which my study was based. The Diagnostic and Statistical Manual of the American Psychiatric Association states that the first criterion for diagnosing PTSD is that the person has experienced trauma. The severity of the trauma is NOT included as a diagnostic criterion. The APA divides the symptoms into four clusters:

1. Intrusion (re-experiencing the event)

2. Avoidance (not willing to think about the event)

3. Negative alteration in cognition and mood (behavior changes such as anger, withdrawal)

4. Alterations in arousal and reactivity (acting out in anger, over responding to stimuli)

Additionally, there has been research which suggests that PTSD actually changes the brain in a measurable way. A study of 17 adult patients (Aaron er al. 2011) showed activity in the amygdala, which regulates emotional responses to trauma, was enhanced in PTSD and was been shown to correlate positively with anxiety scores and PTSD symptoms. It has been further suggested that up to 40% of civilians who experience civilian trauma experience PTSD in the first 12 months after injury.

Recently, I was consulting with a patient who had sustained a wrist fracture. It was a fairly severe fracture which required surgery and metal fixation to restore the normal anatomical position. There were several clues, even at the beginning, that she might be developing PTSD. She had a claustrophobic feeling about the splint which was initially applied and felt it might be too tight. She worried about the fact that her fingers were swollen, but most troubling was the extreme pain which she experienced. Pain has been found to be associated with increased levels of traumatic stress symptoms and is a primary risk factor for PTSD. Her pain was so severe that she required a period of hospitalization after her surgery for pain management. She continued to have problems tolerating cast immobilization which persisted until the cast could be removed. The most concerning thing, however, was that she would wake up in the middle of the night screaming (referred to clinically as sleep terrors). It was at this point that I decided to ask her the following four screening questions which I had located in the literature while doing my study:

1. Have you had nightmares about the injury or thought about it when you didn’t want to?

2. Have you tried hard not to think about the injury or went out of your way to avoid situations that reminded you of it?

3. Are you constantly on guard, watchful or easily startled?

4. Have you felt numb or detached from others, activities, or your surroundings?

A positive answer to 2-3 questions would have been enough to suggest that she was at risk for PTSD and should see a therapist. She answered “yes” to all of the questions.

Armed with this knowledge, she was referred then to a therapist by her surgeon and diagnosed with PTSD. She is currently under treatment and seems to be doing well. She is no longer experiencing sleep terrors and is less fearful. The message here is clear. Ask yourself or ask another the four questions listed above. They came from a rigorous and systematic study which was scientifically evaluated and proven to be effective in identifying anyone at risk for PTSD. If you answer “yes” to 2-3 questions, ask your medical provider to refer you to a therapist. It is very important to identify this problem at the early stages of recovery from trauma in order to prevent progression. Once PTSD becomes chronic, it is much more difficult to treat.

Cook,R.A.,Brown,M.,Allan, C.,Schepp,K.,Voss,J.G.(2017). Screening for posttraumatic stress disorder in civilians with mangled hand injury: A practice enhancement approach. Orthopaedic Nursing, 36(6),432-438.

Prins,A.,Ouimette,P.,Kimerling,R.,Cameron,R.P.,Hugeishofer,D.S.,Shaw-Hegwer,J.,Sheikh,J.(2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9(1),9-14.