Post Traumatic Stress Disorder (PTSD)

Michael Coupland, CPsych, Rpsych, CRC

INTEGRATED MEDICAL case solutions
 INTEGRATED MEDICAL case solutions
National Panel of Psychologists
• Biopsychosocial Pain Evaluations
• Trauma and PTSD Evaluation and Treatment
• Functional Psychological Evaluations
• Opioid Assessment and Intervention
• Early Identification of Chronic Pain and Delayed Recovery

Michael Coupland, CPsych, CRC

Charter and Registered Psychologist (AB) specializing for 35 years in
Occupational testing and measurement;
Developer of the AssessAbility Functional Evaluation (FME) system utilized in
over 150,000 functional evaluations
Author: AMA text on Functional Evaluation / IAIABC Article Chronic pain
Expert to the Federal Government Social Security Disability Determination
projects;
Police Fire and Aviation Crash Psychologist for 20 years
Integrated Medical Case Solutions
Where?

~750 National Providers

 Rapid Response to A Traumatic Event

CISD
• ~90% of all exposed recover and do not
need further follow up
• Of those that need follow up care, 50%
recover within 8-12 weeks of appropriate
care
• The delayed recovery cases likely are not
receiving appropriate care or have pre-
existing and co-morbid issues prolonging
and perpetuating symptoms
Diagnosis of PTSD: DSM-5
Diagnostic Criteria
A. The person has been exposed to actual or
threatened death, serious injury, or sexual violence in
one of the following ways:
i. Directly experiencing the traumatic event(s)
ii. Witnessing, in person, the event(s) as it occurred to others
iii. Learning that the traumatic event(s) occurred to a close family
member or friend
iv. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s); this does not apply to exposure through media
such as television, movies, or pictures

(2) the person's response involved intense fear,

helplessness, or horror.
Diagnosis of PTSD
B. The traumatic event is persistently re-experienced in one (or more) of the
following ways:
(1) recurrent and intrusive distressing recollections of the event, including
images, thoughts, or perceptions. Note: In young children, repetitive play
may occur in which themes or aspects of the trauma are expressed.
 (2) recurrent distressing dreams of the event. Note: In children, there may be
frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense
of reliving the experience, illusions, hallucinations, and dissociative flashback
episodes, including those that occur upon awakening or when intoxicated).
Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event.
Diagnosis of PTSD
C. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the trauma),
as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with
the trauma
(2) efforts to avoid activities, places, or people that arouse recollections
of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a
career, marriage, children, or a normal life span)
Diagnosis of PTSD
D. Persistent symptoms of increased arousal (not present before the
trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
Diagnosis of PTSD
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is
more than one month.
F. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Diagnosis of PTSD
Differential Diagnoses and Rule-outs
Acute stress disorder has the same symptoms as PSTD but with
shorter duration.
other anxiety disorders,
depressive disorders,
obsessive-compulsive disorder.
Although substance abuse is a frequent complication of PTSD,
substance abuse may be the primary problem instead.
Alcoholics and heavy drug abusers often overemphasize the role of a
distant trauma as the cause of their problems and use it to justify their
habits.
Various personality disorders can also resemble PTSD with
borderline personality disorder having the closest resemblance to
PTSD. 
PTSD Causality
Causality
Is the diagnosis causally related to the
injury or accident?
Is the treatment causally related to the
injury or accident
Is there a history or co-morbidities, prior
injuries and/or pre-existing conditions that
impact on the current injury or accident?
 PTSD Causality
The cause of PTSD is multifactorial. Some studies
have presented a model that does suggest that
exposure to trauma has a relationship. The classical
conditioning model combined with operant learning
lends credibility to the acquisition and persistence of
fear[1]. A study of heart rate reactivity to audio
reminders has reinforced this model[2]. Furthermore,
Amnesia appears to protect against PTSD fears.

[1] Kuch k, Evans RJ, Watson PC, Bubela C, Cox, BJ. Road vehicle accidents and
phobia in 60 patients with fibromyalgia. Journal of Anxiety Disorders 1994;8:181-7
[2] Blanchard EB, Hickling EJ, Taylor AE, Loos WR, Gerardi RJ. The psychophysiology
of motor vehicle accident related posttraumatic stress disorder. Behavior Therapy
1995;25:453-67
 PTSD Causality
PTSD Dose Response studies: A dose response
relationship between the severity of an MVA related
trauma and the level of psychopathology has not been
demonstrated[1], and the textbook on PTSD found no
gradient between the severity of the trauma and the
development of PTSD[2]

[1] Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents.

BMJ 1993;307:647-51; O’Brien M. Loss of memory is protective [letter] BMJ
1993;307:1283
[2] Yehuda R, ed. Risk factors for posttraumatic stress disorder. Washington DC,
American Psychiatric Press; 1999
 PTSD is diagnosed in 7%-12% of the general population
exposed to a trauma[1], but is found at a rate of 85% when an
opportunity to claim compensation is present[2]. Outcomes vary
greatly. Most individuals subjected to an experience outside the
normal realm of human experience never become symptomatic.
Complete recovery occurs within 3 months in about 50% of the
cases of PTSD while others have symptoms lasting longer than
12 months after the trauma. Some individuals improve but when
under a new stress may have a period of recurring PTSD
symptoms. A subset of individuals with PTSD develop a lifelong
illness marked by exacerbations and remissions that makes it
extremely difficult to maintain employment or close relationships.
[1] Breslau N. The epidemiology of post-traumatic stress disorder: what is the extent of the problem? J Clin Psychiatry.
2001;62(suppl 17):16-22
[2] Rosen GM. The Aleutian Enterprise Sinking and posttraumatic stress disorder:misdiagnosis in clinical and forensic
settings. Prof Psychol Res P. 1995;26:82-87
Treatment for PTSD
Best Practices
PTSD has shown the best response when Cognitive Behavioral
Therapy (CBT) is utilized.
CBT utilizes principles of learning and conditioning to treat this
disorder and includes components from both behavioral and
cognitive therapy.
Exposure/Desensitization is a treatment recognized as being
effective in treating PTSD. Types of exposure therapy include
imaginal exposure, which involves exposure to the traumatic
event through mental imagery; and in vivo therapy, where a
client confronts the actual scene or similar events that are
associated with the trauma.[1]
[1] Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence; National Academy of
Sciences; Fall 2007.
Treatment for PTSD
Medications can be utilized in addition to CBT. Patient
preference and involvement need to be considered as part of
the decision to prescribe specific medications. The severity of
symptoms should also be considered. Two selective serotonin
reuptake inhibitors (SSRIs) have been approved by the FDA to
treat PTSD; sertraline (Zoloft) and paroxetine (Paxil). SSRIs
address all common symptom clusters of PTSD.
Benzodiazepines (Valium and Klonopin) should be avoided “as
there is no evidence they are beneficial in the treatment of
chronic PTSD and [there is] some evidence that they can
increase the likelihood of developing PTSD when prescribed in
the acute aftermath of trauma exposure.”[1]
[1] Care for Returning Service Members: Providing Mental Health Care for Military Service Members
Returning from Iraq and Afghanistan; Christopher Erbes, et al; Minnesota Psychologist, November 2007.
[1] Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence; National Academy of
Sciences; Fall 2007.
Biopsychosocial Model of Health & Disability
Lifestyle: Exercise,
Smoking, Alcohol and
Drugs, Obesity / Diet
Inju
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Depression / Anxiety
Hy d
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Personality Disorders

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Chronic Pain
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Disability Perceived Injustice
(retribution owed)
Behavior
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R
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ss sm (Guarding)
Streneurotran
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Catastrophic Thinking
How to Treat Biopsychosocial Factors without ‘Buying’
an unwarranted Psych Claim
Health and Behavior Assessment CPT 96150
Health and Behavior Intervention CPT 96152
Reasonable and necessary for the patient (CMS Definition):
• Who has an underlying physical illness or injury, and
• For whom there is reason to believe that a
biopsychosocial factor may be significantly affecting the
treatment, or medical management of an illness or an
injury, and
• For whom there is documented need from the patient’s
attending physician that he or she needs psychological
assessment to successfully manage his/her physical
illness to resolve the psychological barriers to the
management of his/her physical disease and activities of
daily living
Coupland, M. Psychosocial Interventions for Chronic Pain Management The International Journal of
Industrial Accident Boards and Commissions; Fall 2009
Questions?

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