PTSD

2.6 CONTACT HOURS Know the warning signs By Jessica Gill, RN, CRNP, PhD Leorey N. Saligan, RN, CRNP, PhD Wendy A. Henderson, CRNP, MSN, PhD Sarah Szanton, ANP, MSN, PhD osttraumatic stress disorder (PTSD) is an anxiety disorder that commonly occurs in primary care patients. Patients with PTSD experience declines in physical and psychological health. Although these declines are often observed by NPs and other primary care providers (PCPs), PTSD is not routinely assessed in primary care. PTSD develops after exposure to a traumatic event and is associated with debilitating physical and psychological health declines. Symptoms of PTSD include re-experiencing the traumatic event through intrusive dreams or thoughts, avoidance or arousal when the patient encounters stimuli that symbolize the event, numbing of feelings, and avoidance of thoughts, feelings, people, and activities that symbolize the event. PTSD has been recognized as an anxiety disorder that can impact any individual, resulting in lifetime prevalence rates of 5% for men and 10% for women.1,2 Because people with PTSD suffer from multiple medical conditions3,4 and a lower subjective health rating5, PTSD rates in primary care settings are at least double the national rate.6,7 In addition, individuals with PTSD experience increased medical care costs.8 More women with PTSD seek care for these symptoms in primary care settings compared with psychiatric settings.9 Although 8% to 30% of primary care patients present with PTSD, PCPs rarely assess for it.10 The P 30 The Nurse Practitioner • Vol. 34, No. 7 objective of this review is to provide rationale and tools for PTSD assessment and treatment in primary care settings, as well as a brief overview of physiologic changes in PTSD patients. ■ Incidence In the course of a lifetime, 90% of Americans experience a traumatic event from which most recover without experiencing PTSD.1,2 However, there are important characteristics that can increase the risk of PTSD. These include assaultive trauma or trauma that occurs at an early age.11 Rates for current PTSD in the general U.S. population range from 2% to 4%.1,2,12 In primary care patients, rates for current PTSD range from 8% to 30%.6,7 Women develop PTSD at twice the rate of men.1,2,12 This vulnerability may be related to an increased risk of experiencing assaultive events. However, women are at a greater risk than men to develop PTSD, independent of event type.1 ■ Comorbid conditions Individuals with PTSD may be more prominent in primary care settings due to greater use of outpatient services.8,13 In addition, individuals with PTSD report at least one other medical condition when compared with traumatized and www.tnpj.com www.tnpj.com The Nurse Practitioner • July 2009 31 PTSD: Know the warning signs nontraumatized controls without PTSD, including chronic pain, diabetes, cardiovascular disease, autoimmune disorders, thyroid disorders, and gastrointestinal disorders.3-5,7 Therefore, PTSD is often associated with multiple medical issues that may result in complex medical complaints, some of which may be treatment-resistant. Recognizing and treating PTSD may help protect some patients from developing these health alterations. Over 80% of individuals with PTSD have another psychiatric disorder.1,2,11 Common comorbid psychiatric disorders include major depressive disorder (MDD), generalized anxiety disorder, drug and alcohol abuse and dependence, and obsessive compulsive disorder. MDD is well researched in the primary care setting and healthcare providers are now apt to recognize and intervene with MDD, however, its comorbidity with PTSD may go undiagnosed. As an example, one-third of depressed patients seen in primary care who were previously assessed and not identified as having PTSD were found to be positive for PTSD during a research screening.10 In another recent study, only 11% of primary care patients with current PTSD had a diagnosis of PTSD in their charts.14 Recognition and treatment of PTSD in primary care settings may be the most effective way to improve mental and physical health in traumatized individ- uals. If these patients are treated for medical complaints without addressing the underlying psychological response to trauma, the pattern of continued health visits without symptom improvement is likely to continue. ■ Pathophysiology Patients with PTSD exhibit multiple alterations in biologic function, including the neurologic, endocrine, and immune systems, all of which may contribute to health declines. Functioning of memory areas in the brain is altered, resulting in the development of many PTSD symptoms. Specific brain areas implicated in PTSD include the amygdala, the hippocampus, and the prefrontal cortex (see Location of the amygdala and hippocampus). There is reduced volume of the hippocampus in adults and children with PTSD;15 however, return to normal hippocampal volume has been reported with treatment and symptom remission.16 Reduced memory function has also been observed and related to functional alterations in brain activity in the amygdala, hippocampus, and other brain structures, indicating that multiple neurologic alterations may be related to PTSD symptoms.17 The hypothalamic-pituitary-adrenal (HPA) axis produces hormones in basal and stressed states that regulate immune, neural, and other bodily functions. Alterations in this complex Location of the amygdala and hippocampus set of hormonal feedback loops of the HPA axis alterations have been observed in PTSD patients.18 The hallmark of PTSD among combat veterans is low cortisol levels and a greater negative feedback system for cortisol as tested with pharmacologic and nonpharmacologic stimulation, indicating alterations in HPA axis function. These findings were surprising considering patients with PTSD reported high levels of stress.18 Recent studies have reported contrasting findings, suggesting that sex, duration of PTSD, and other factors may contribute to alterations in HPA axis function.19 However, independent of the direction of the observed alterAmygdala Brain stem and cerebellum ation, any disruption in function of the (beneath overlying cortex) removed and brain rotated slightly HPA axis may result in the development Hippocampus of additional health conditions.20 (beneath overlying cortex) PTSD studies have reported evidence of increased inflammatory activSource: Bear MF, Connors BW, Parasido MA. Neuroscience - Exploring the Brain. 2nd ed. Philadelphia, ity in the immune system, including PA: Lippincott Williams & Wilkins; 2001. higher levels of stimulated and non- 32 The Nurse Practitioner • Vol. 34, No. 7 www.tnpj.com PTSD: Know the warning signs stimulated inflammatory cytokines,21-25 and a greater response to antigens.26 These higher levels of inflammatory activity have been linked to HPA axis abnormalities.21,25 A chronically activated inflammatory response has been shown to exert adverse reactions on many body systems. Specifically, elevations of interleukin-6 (IL-6) have been associated with reports of chronic pain, arthritis, diabetes, cardiovascular disease, and other medical conditions that have been associated with PTSD.3,4,7,13 ■ Development and progression of PTSD To qualify for a PTSD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the precipitating traumatic event must have occurred at least 3 months prior to assessment.27 If the precipitating event occurred less than 3 months prior, and the patient displays PTSD symptoms that cause distress, then the diagnosis of acute stress disorder may be appropriate. Traumatic events can be classified as an experienced event, a witnessed event, or an event that was learned of, and can range from being raped to learning that a family member or close friend was injured (see Traumatic events). Assaultive events are most Traumatic events27 Episodic assaultive violence: • Raped • Other sexual assault • Shot or stabbed • Mugged or threatened with a weapon • Badly beaten up Repeated assaultive violence: • Combat exposure • Intimate partner violence • Child physical abuse • Child sexual abuse Other injury or shocking experience: • Serious car or motor vehicle accident • Any other kind of serious accident/injury • Fire, hurricanes, or other natural disasters • Diagnosed with a life-threatening illness • A child diagnosed with a life-threatening illness Witnessed events: • Saw someone get killed or seriously injured • Discovered a dead body Learned events of a close friend/relative: • Raped or sexually assaulted • Serious physical attack • Seriously injured in a car or other accident • Unexpected death www.tnpj.com predictive of PTSD development, especially if events are ongoing (such as child abuse) or occurred in childhood.11 The patient must have at least one symptom of re-experiencing the trauma, three symptoms of avoidance or numbing related to the traumatic event, and at least two symptoms of hyperarousal when reminded of the trauma (see Symptoms of PTSD). These symptoms must have been present for at least 1 month, cause significant distress, and affect the patient’s ability to function socially, occupationally, or domestically. If symptoms last for more than 3 months, a diagnosis of chronic PTSD is established.27 Common signs and symptoms PCPs should assess for PTSD if the patient reports an experience of a traumatic event. State-mandated regulations for reporting incidents of abuse should be followed. A patient who divulges a recent event provides the PCP with an Symptoms of PTSD27 Re-experiencing symptoms (must have at least 1): • Recurring memories of the event • Nightmares of the event • Intense fear, anxiety, or physical discomfort when patient is reminded of the event • Flashbacks; feeling or acting as if the event is reoccurring while awake Avoidance of things that remind the patient of the event, and feelings of numbing (must have 3) • Avoiding people, places, or things that remind the patient of the event • Avoiding thoughts or feelings that remind the patient of the event • Inability to recall certain things about the event • Decreased activity in things previously enjoyed • Patient feels detached from other people; no one understands • Sense of foreshortened future • Restricted range of feelings Hyperarousal (must have 2) • Problems falling or staying asleep • Problems concentrating • Irritability or outbursts of anger • Hypervigilance: The feeling of always having to be ready to react. The patient may also report that he or she is more attentive to sounds • Exaggerated startle response: Sounds, being touched or surprised in any way can cause the patient to jump or be startled. These symptoms must have been present for 1 month, cause significant distress or impaired functioning, and cannot be due to a medical condition or use of drugs or alcohol. The Nurse Practitioner • July 2009 33 PTSD: Know the warning signs Short screening scale for PTSD28,29 In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month... 1. you have avoided being reminded of this experience by staying away from certain places, people, or activities? 2. you have lost interest in activities that were once important or enjoyable? 3. you have begun to feel more isolated or distant from other people? 4. you have found it hard to feel love or affection for other people? 5. you have begun to feel that there was no point in planning for the future? 6. you have had more trouble than usual falling asleep or staying asleep? 7. you have become jumpy or get easily startled by ordinary noises or movements? opportunity to intervene early and possibly prevent PTSD development. Commonly reported PTSD-related psychological symptoms include irritability, anger, problems sleeping, inability to relate to others, and physical restlessness. In addition, if the patient is not responding to pharmacologic treatment of depression or anxiety, an assessment of PTSD is advised. Focused assessment Patients who have experienced a traumatic event may be guarded, defensive, and unwilling to talk about it at the first meeting. If PCPs create a supportive and trusting relationship, patients may be more likely to disclose their traumatic experience. A PCP asking about the patient’s traumatic experiences should acknowledge that this is a life-altering experience. The patient may feel better understood and more willing to provide information that can help improve care. Ways in which traumatic events can be assessed include asking the following questions: 1. “At some point in life, most people experience something that may be traumatic or stressful. Has something like this ever happened to you?” 2. “Have you ever witnessed an event that happened to another person that made you feel frightened, shocked, or helpless?” 3. “Have you ever been sexually, physically, or emotionally harmed by another person?” Following any disclosure of a traumatic event, patients may feel vulnerable and need reassurance and support. Providing information on resources and treatment options may give the patient hope. It is equally important to assess for suicidal feelings in those who are distressed and provide immediate help and referral. 34 The Nurse Practitioner • Vol. 34, No. 7 To determine if the patient has symptoms of PTSD, the PCP can either question the patient about these symptoms or use a standard instrument. The Short Screening Scale, developed by Breslau et al.28 and evaluated by Kimerling et al.,29 is a 7-question tool designed specifically for PTSD diagnosis in the primary care setting (see Short screening scale for PTSD). Patients respond with a “yes” or “no” to each question. A sum score of 6 or greater predicts a PTSD diagnosis.29 Although this instrument predicts a PTSD diagnosis, it does not provide information on all PTSD symptoms. In contrast, the PTSD symptom scale developed by Foa et al.30 can be filled out by the patient or PCP, and provides information on all PTSD symptoms to track response to treatment. Both tools are valuable, however a clinical interview to determine symptoms and develop a rapport with the patient is necessary. Mandatory reporting of trauma Reporting current abuse is mandatory for child abuse and may be mandatory even if the patient is an adult. Each state has different regulations that need to be determined and discussed with the patient prior to assessing traumatic events. Information can be obtained at the National Domestic Violence Hotline: 1-800-799-SAFE and the National Child Abuse Hotline (1-800-4-A-CHILD), or a state department that provides services for children. ■ PTSD intervention Treating patients with PTSD in primary care can include prescribing medication, referral for short-term individual or group psychotherapy, or both. Referral to a psychotherapist or psychiatrist is required if the patient reports any suicidal or homicidal ideation, is in acute crisis, or requires more intense treatment than the primary care setting can provide. In addition, referral to a psychiatrist is required if medication management is not successful, if there are multiple psychiatric comorbidities, or if the patient needs more intensive care due to disability or safety risk.31 Early intervention In patients who recently experienced a traumatic event, recognizing symptoms and providing immediate treatment may prevent the development of PTSD. In addition to pharmacologic and psychological therapy, PCPs may also take the following actions: educate PTSD patients that their response is normal, provide information regarding acute stress disorder and PTSD symptoms, encourage patients to talk with supportive family and friends about their symptoms, and provide emotional support and referral to support groups.32 www.tnpj.com PTSD: Know the warning signs ■ Pharmacologic options First-line treatment for PTSD is a serotonin reuptake inhibitor (SSRI); however the FDA has only approved the SSRIs paroxetine (Paxil) and sertraline (Zoloft) for use in treating PTSD (see Psychotropic medication for the treatment of PTSD). Non-SSRI antidepressants may also be effective (such as venlafaxine, mirtazapine), although fewer studies have supported their use and efficacy.33 In addition, mood stabilizers, antianxiety medications, adrenergics, and atypical psychotics can be used to treat patients who do not respond to antidepressants, and should be selected based on the patient’s presenting symptoms. These medications can also be used as an adjunct to antidepressants if the patient reports incomplete reduction of symptoms following treatment with the antidepressant. A lower dose would then be required if the medication is prescribed as an adjunct.34 Medication to promote nighttime sleeping may also be effective and includes zolpidem, zaleplon, and diphenhydramine.35 Prescribing multiple psychotropic medications is often required, especially in patients who have chronic PTSD, those who have not responded to previously prescribed medications, or have other psychiatric comorbidities. The following combinations have been recommended: 1. antidepressant + mood stabilizer 2. antidepressant (SSRI) + other class of antidepressant 3. antidepressant + antipsychotic 4. antidepressant + sleeping medication 5. antidepressant + short-term antianxiety medication.33-36 ■ Psychological therapy Short-term supportive therapy may be available in a primary care setting. Some primary care offices have a counselor or therapist onsite. If therapy is not available in the primary care office, referral to a trained therapist is advised. Therapy using cognitive behavioral methods or exposure therapy, which is a specific psychological method used to treat PTSD, are the most effective modalities. Psychological therapy in conjunction with medication results in higher remission and symptom reduction rates than either method alone.33 ■ Case study 1 Rose is a 50-year-old patient who has had multiple appointments in the last month for headaches, back www.tnpj.com pain, and insomnia. Medical causes for these symptoms have been ruled out. She appears in your primary care office tearful and anxious. When you ask her if anything has changed in her life, she reports that her husband has become increasingly angry and explosive and has been hitting and pushing her over the past year. She says that she does not feel safe in her house. She describes nightmares about the abuse and says that, on most nights, she feels “on edge and jumpy,” and is unable to calm down. She also says she has insomnia, reduced appetite, and feels that she is no longer a useful person, is depressed every day, and that she avoids family and friends who want to talk about her relationship with her husband. She denies suicidal feelings. Rose reports that she experienced depression about 5 years ago, and that the current anxiety and nightmares started immediately after the physical abuse began. After questioning her further regarding PTSD symptoms, you determine that she has PTSD and comorbid depression. You prescribe paroxetine (Paxil) 20 mg per day, which is the medication that resolved her depression symptoms during her previous episode. She is willing to see a trained therapist and to return to the clinic for medication management. In addition, you provide information about local resources for domestic violence shelters, support groups for abused women, and hotline numbers to access 24 hours a day. Furthermore, you advise Rose to keep this information in a place where her husband will not find it. You encourage Rose to use all the resources available. Psychotropic medication for the treatment of PTSD Medication class Specific medications Symptom reductions SSRIs (FDA-approved) • Sertraline • Paroxetine • Overall PTSD symptoms • Improved sleep • Comorbid depression Dual serotonin and noradrenergic reuptake inhibitors (off-label use) • Venlafaxine • Mirtazapine • Overall PTSD symptoms • Comorbid depression Mood stabilizers and anticonvulsants (off-label use) • • • • • Overall PTSD symptoms • Mood lability Atypical antipsychotics (off-label use) • Olanzapine • Risperidone • Psychotic symptoms that present with PTSD • PTSD symptoms when used as an adjunct Antiadrenergics (off-label use) • Prazosin • Clonidine • Propranolol • Nightmares • Hyperarousal symptoms Valproic acid Lamotrigine Topiramate Gabapentin The Nurse Practitioner • July 2009 35 PTSD: Know the warning signs When she returns to the clinic a week later, she reports no troubling adverse reactions from the medication, and depression symptom reduction, which you do not attribute to the medication, but to the hope that her situation can improve. She says, however, that she still feels nervous. You encourage her to continue the medication and advise her that if her PTSD symptoms are not better in 4 weeks, additional medication can be considered. She continues medication management at your primary care clinic and sees a psychotherapist. ■ Case study 2 Roger is a 24-year-old male who presents at your primary care clinic with anxiety and anger. He reports that he has been using marijuana once or twice a week and over-thecounter sleeping medications to alleviate these symptoms. He is guarded and “just wants the right medicine.” You reassure him that a comprehensive assessment and the proper diagnosis will provide him with the best medication for the symptoms he is experiencing. Upon further questioning, he reports that he has “always been negative.” He says that he experienced physical abuse from his stepfather from the ages of 2 to 8, and the abuse ended when his stepfather and mother divorced. He tells you that he thinks about this abuse often, has dreams about it, and often avoids being with his family, because they remind him of the abuse, which makes him feel angry, anxious, and useless. He also reports that he is unable to make friends or connect with others and has isolated himself. The marijuana use began when he was 15 years old, and he occasionally also uses alcohol when he is reminded of the abuse “as a way to calm myself.” He took fluoxetine (Prozac) at the age of 17 and reported no reduction in symptoms. From what he says, you conclude that he has PTSD, and that the marijuana and alcohol use are secondary to his issues. You prescribe him zolpidem (Ambien) 10 mg nightly to help him sleep and venlafaxine (Effexor) that is increased over 1 week to a dose of 225 mg daily. He takes the medication for 4 weeks and reports some symptom reduction, but that he still is “jumpy,” anxious, and that he needs to avoid people that remind him of the abuse. You prescribe topiramate (Topamax, an off-label medication for PTSD) and increase the dose as tolerated to 75 mg twice daily. You also encourage him to begin psychological therapy. He says he will consider it, but does not follow through. Roger receives some additional benefit from the topiramate, and over the next 2 months is able to initiate some friendships and starts taking classes at a local college. He continues to experience some residual 36 The Nurse Practitioner • Vol. 34, No. 7 symptoms, but overall feels that the medication has been helpful. ■ An opportunity for improvement PTSD is a condition that impacts the physical and psychological health of those individuals who develop it. PTSD is often underrecognized and undertreated, especially in the primary care setting. Primary care patients may have rates of PTSD that are three times the national rate, and may be more likely to report their PTSD symptoms to their PCPs, as opposed to seeking a referral to a psychiatric care provider. Thus, there is a great opportunity for PCPs to improve the health of traumatized individuals by assessing for symptoms of PTSD and providing early treatment for PTSD. By intervening and acknowledging the impact of traumatic events on the psychological and physical health of individuals, PCPs may be able to reduce the negative impact of PTSD in those who experience trauma. REFERENCE 1. Breslau N, Kessler RC, Chilcoat HD. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry. 1998; 55(7): 626-32. 2. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995; 52(12): 1048-60. 3. Kimerling R. An investigation of sex differences in nonpsychiatric morbidity associated with posttraumatic stress disorder. J Am Med Womens Assoc. 2004; 59(1): 43-7. 4. Boscarino JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosom Med. 2008; 70(6): 668-76. 5. Frayne SM, Seaver MR, Loveland S, et al. Burden of medical illness in women with depression and posttraumatic stress disorder. Arch Intern Med. 2004; 164(12): 1306-12. 6. Alim TN, Graves E, Mellman TA, et al. Trauma exposure, posttraumatic stress disorder and depression in an African-American primary care population. J Natl Med Assoc. 2006; 98(10): 1630-6. 7. Gill JM, Szanton S, Taylor TJ, et al. Medical conditions and symptoms associated with posttraumatic stress disorder in low-income urban women. J Womens Health (Larchmt). 2009; 18(2): 261-7. 8. Walker EA, Katon W, Russo J, et al. Health care costs associated with posttraumatic stress disorder symptoms in women. Arch Gen Psychiatry. 2003; 60(4): 369-74. 9. Butterfield MI, Becker M, Marx CE. Post-traumatic stress disorder in women: current concepts and treatments. Curr Psychiatry Rep. 2002; 4(6): 474-86. 10. Gerrity MS, Corson K, Dobscha SK. Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms. J Gen Intern Med. 2007; 22(9): 1321-4. 11. Breslau N. The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma Violence Abuse. 2009. Epub ahead of print. 12. North CS. The Oklahoma City bombing study and methodological issues in longitudinal disaster mental health research. J Trauma Dissociation. 2005; 6(2): 27-35. 13. Dobie DJ, Kivlahan DR, Maycard C, et al. Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. Arch Intern Med. 2004;164(4): 394-400. 14. Liebschutz J, Saitz R, Brower V, et al. PTSD in urban primary care: high prevalence and low physician recognition. J Gen Intern Med. 2007; 22(6): 719-26. 15. Wignall EL, Dickson JM, Vaughan P, et al. Smaller hippocampal volume in patients with recent-onset posttraumatic stress disorder. Biol Psychiatry. 2004; 56(11): 832-6. www.tnpj.com PTSD: Know the warning signs 16. Vermetten EM Vythilingam, et al. Long-term treatment with paroxetine increases verbal declarative memory and hippocampal volume in posttraumatic stress disorder.” Biol Psychiatry. 2003; 54(7): 693-702. 17. Bremner JD. Functional neuroimaging in post-traumatic stress disorder. Expert Rev Neurother. 2007; 7(4): 393-405. 18. Yehuda R. Advances in understanding neuroendocrine alterations in PTSD and their therapeutic implications. Ann N Y Acad Sci. 2006;1071: 137-66. 28. Breslau N, Peterson EL, Kessler RC, et al. Short screening scale for DSM-IV posttraumatic stress disorder. Am J Psychiatry. 2000; 156(6): 908-11. 29. Kimerling R, Ouimette P, Prins A, et al. Brief report: Utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21(1):65-7. 30. Foa EB, Cashman L, Jaycox L. The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychological Assessment. 1997; 9: 445-451. 19. Meewisse ML, Reitsma JB, de Vries GJ, et al. Cortisol and post-traumatic stress disorder in adults: systematic review and meta-analysis. Br J Psychiatry. 2007; 191: 387-92. 31. Nakell L. Adult post-traumatic stress disorder: screening and treating in primary care. Prim Care. 2007;34(3): 593-610, vii. 20. Gill JM, Szanton SL, Page GG. Biological underpinnings of health alterations in women with PTSD: a sex disparity.” Biol Res Nurs. 2005; 7(1): 44-54. 32. Guess KF. Posttraumatic stress disorder: early detection is key. Nurse Pract. 2006;31(3): 26-7, 29-33; quiz 33-5. 21. Rohleder N, Joksimobvic L, Wolf JM, et al. Hypocortisolism and increased glucocorticoid sensitivity of pro-Inflammatory cytokine production in Bosnian war refugees with posttraumatic stress disorder. Biol Psychiatry. 2004; 55(7): 745-51. 33. Keane TM, Marshall AD, Taft CT. Posttraumatic stress disorder: etiology, epidemiology, and treatment outcome. Annl Rev Clin Psychol. 2006;2:161-97. 22. Baker DG, Ekhator NN, Kasckow JW, et al. Plasma and cerebrospinal fluid interleukin-6 concentrations in posttraumatic stress disorder. Neuroimmunomodulation. 2001; 9(4): 209-17. 23. Woods AB, Page GG, O’Campo P, et al. The mediation effect of posttraumatic stress disorder symptoms on the relationship of intimate partner violence and IFN-gamma levels. Am J Community Psychol. 2005; 36(1-2): 159-75. 24. Pervanidou P, Kolaitis G, Charitaki S, et al. Elevated morning serum interleukin (IL)-6 or evening salivary cortisol concentrations predict posttraumatic stress disorder in children and adolescents six months after a motor vehicle accident. Psychoneuroendocrinology. 2007; 32(8-10): 991-9. 25. Gill J, Vythilingam M, Page GG. Low cortisol, high DHEA, and high levels of stimulated TNF-alpha, and IL-6 in women with PTSD. J Trauma Stress. 2008; 21(6): 530-9. 26. Altemus M, Dhabhar FS, Yang R. Immune function in PTSD. Ann N Y Acad Sci. 2006; 1071: 167-83. 27. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. (2000). New York, NY: American Psychiatric Association. 䊳 34. Bobo WV, Warner CH Warner CM. The management of post traumatic stress disorder (PTSD) in the primary care setting. South Med J. 2007; 100(8): 797-802. 35. Davis M, Barad M, Otto M, et al. Combining pharmacotherapy with cognitive behavioral therapy: traditional and new approaches. J Trauma Stress. 2006; 19(5): 571-81. 36. National Academies of Medicine. I.0.M. Report. Post-traumatic stress disorder (PTSD): Diagnosis and assessment; 2008. The authors have disclosed that they have no significant relationship or financial interest in any commercial companies that pertain to this educational activity. At the National Institutes of Health, National Institute of Nursing Research, Bethesda, Md., Dr. Jessica Gill is a clinical investigator, Dr. Leorey Saligan is a nurse scientist, and Dr. Wendy Henderson is a staff scientist. Dr. Sarah Szanton is an assistant professor at Johns Hopkins University School of Nursing, Baltimore, Md. For more than 87 additional continuing education articles related to Advanced Nursing Practice topics, go to Nursingcenter.com\CE. 䊴 Earn CE credit online: Go to http://www.nursingcenter.com/CE/NP and receive a certificate within minutes. INSTRUCTIONS PTSD: Know the warning signs TEST INSTRUCTIONS • To take the test online, go to our secure Web site at http://www.nursingcenter.com/ce/NP. • On the print form, record your answers in the test answer section of the CE enrollment form on page 38. Each question has only one correct answer. You may make copies of these forms. • Complete the registration information and course evaluation. Mail the completed form and registration fee of $24.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. • You will receive your CE certificate of earned contact hours and an answer key to review your results.There is no minimum passing grade. • Registration deadline is July 31, 2011. www.tnpj.com DISCOUNTS and CUSTOMER SERVICE • Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together and deduct $0.95 from the price of each test. • We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter.com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of The Nurse Practitioner journal, will award 2.6 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.6 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia and Florida #FBN2454. LWW home study activities are classified for Texas nursing continuing education requirements as Type I. Your certificate is valid in all states. The Nurse Practitioner • July 2009 37