Identifying PTSD in Traumatically Injured Patients for Early Screening and Intervention
The Injury Research Center at the Medical College of Wisconsin has funded several layers of work on post traumatic stress disorder (PTSD), from research linking PTSD to quality of life in trauma patients, to the development of a new trauma related screening tool for PTSD.
Froedtert Hospital attempts to screen every trauma patient for PTSD as a result of this research. Providers are now able to target patients who might be at greatest risk for PTSD. Ultimately, this is a replicable model of improved screening and patient care post injury, which will lead to more appropriate health care delivery and services for trauma patients.
Challenge and Strategies
Dr. Karen Brasel, MCW and Froedtert trauma surgeon, was interested in pursuing the psychosocial link to trauma recovery and paired up with several other MCW clinical researchers to apply for IRC’s CDC Injury Control Research Center Funding in 2001. The team received a 6-year funding award and found that PTSD, social support, functional status and depression are correlated with diminished quality of life after traumatic injury.
Armed with these new findings, Dr. Brasel focused on translating the research to the clinical setting. She hired Dr. Terri deRoon-Cassini to join the trauma team with a clinical/research focus. Both are now members of the IRC’s Research & Development Core. Dr. deRoon-Cassini’s direct participation on the trauma team as a dedicated health psychologist enables her to participate in screenings and interventions. It is unlikely that the majority of patients at risk for PTSD are identified or helped within typical health care systems. Through their partnership with the IRC, the clinicians were awarded funding to develop and began validation of a new PTSD screening instrument.
Her most recent IRC research grant created an opportunity for Dr. deRoon-Cassini to lead a PTSD Trauma study to prospectively follow single incident trauma survivors to document trajectories of resiliency and psychopathology. Many individuals experience a stress response months after the initial trauma. For others, it has rapid onset, yet decreases over time. There is yet another group who experience an immediate and chronic level of post traumatic stress symptoms , often accompanied by depression. Dr. deRoon-Cassini’s work examines factors that predispose post trauma patients to PTSD, including at the neurobiological level.
PTSD responds well to a psychotherapeutic approach incorporating both cognitive and behavioral aspects of therapy. However, if the affected individual is no longer inpatient at a hospital and may have already recovered from their physical trauma, patients may not know where to receive services or even what type of services to look for to help alleviate their symptoms. Psychologically, many trauma patients experience the trauma incident over and over again. They may begin to avoid other people, become emotionally numb and isolate themselves and, as a result, find it difficult to seek care. The applied effect of this research centers on the clinical actions that can be taken to prevent chronic and delayed distress in patients before they are discharged from inpatient level of care.
The PTSD Trauma study prospectively followed single incident trauma survivors at a Level 1 trauma center to document trajectories of resiliency and psychopathology. Funded by the most recent IRC grant, the study was designed to follow participants at 1, 3 and 6 months to examine latent PTSD symptoms.
This injury research would not be possible without the dedication of many partners along the way. Drs. deRoon-Cassini and Brasel worked closely with Dr. Mark Rusch, Associate Professor of Plastic Surgery at MCW and affiliate faculty member of the IRC, along with University of Wisconsin Milwaukee psychology professors Drs. Shawn Cahill and Christine Larson. Together, they analyzed both the psychological and neurobiological mechanisms of emotional reactivity with symptoms of PTSD.
This IRC-funded study led to findings that indicate a majority of individuals demonstrate resilient psychological functioning after injury. This was clinically significant in illustrating the individual variation in response to trauma. An extension of this finding is the need for improved assessment of factors predicting who will cope with potentially traumatic injury and who might benefit from clinical intervention.
Those who exhibited psychopathology did so in three distinct ways; either having:
a chronic, ongoing distress that started immediately post trauma;
distress that was not present during their inpatient stay, but manifested itself at a later time; or
distress initially that diminished with the passage of time.
Study findings indicate that coping self efficacy, education, assaultive trauma type and anger directly correlated with individual’s membership into certain psychopathologic groups. For example, increase education decreased the likelihood of delayed or recovered PTSD symptoms compared to those who are resilient. Anger, on the other hand, increased the likelihood that the individual would exhibit chronic PTSD.
Although inserting psychological treatment into the trauma rehabilitation process may be challenging due to underlying stigmas surrounding psychiatric issues, the stigma is deemphasized when a patient’s clinical health care team acknowledges that psychiatric health has to be addressed for optimal healing. According to Dr. deRoon-Cassini, a comprehensive health care approach to PTSD helps to normalize the symptoms of PTSD, making them more easily accepted as part of overall health care delivery.
Researchers have found that individuals experience a dramatic loss of resources after a trauma event, ranging from personal resources (self esteem, personal mastery, self efficacy) to material resources (car, home, etc.). Another area of further research is the effects of Psychological First Aid on inpatient trauma patients. Psychological First Aid is an evidence-based approach to assist individuals in the immediate aftermath of disaster and terrorism and is designed to reduce the initial distress caused by traumatic events, and to foster short- and long-term adaptive functioning and coping.
Dr. deRoon-Cassini’s inpatient treatment with the above mentioned gunshot patient paid off, even though the patient was not immediately experiencing PTSD while inpatient. About a year after discharge, deRoon-Cassini received a phone call from the woman, indicating that she was experiencing symptoms of PTSD for which deRoon-Cassini had asked her to self-monitor. The resulting diagnosis was that she was one of the 40 percent who experienced PTSD. Armed with knowledge of this potential at discharge, the woman was able to help herself and connect with Dr. deRoon-Cassini for ongoing outpatient treatment when needed.
Deemed the most influential paper published in the Journal of Rehabilitation Psychology 2010, deRoon-Cassini and Rusch, along with their co-authors, received the 2010 Harold Yuker Award for Research Excellence for their publication on the research results. Dr. deRoon-Cassini is submitting a National Institutes of Health K23 award, a career development, clinical grant award, and will pursue more training in fMRI research with Drs. Christine Larson and Cecilia Hillard, Director of the Neuroscience Research Center at MCW.
The applied implications of this IRC-funded study are noteworthy. Going forward, providers at Level 1 trauma centers will be able to deliver more appropriate care to trauma patients. The research will help capture more patients with the potential for PTSD through improved screening and patient care post injury.
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