Post-Traumatic Stress Disorder (PTSD)

In prior posts, we’ve examined how the demands of practicing render physicians and dentists uniquely susceptible to anxiety and depression.  In this post, we are going to examine Post-Traumatic Stress Disorder (PTSD), another serious condition that often affects doctors—particularly doctors who work in high stress environments and who are repeatedly exposed to trauma on a daily basis.

What is PTSD?

PTSD is a mental health disorder caused by exposure to a shocking or dangerous event.  Although most people who experience a traumatic event experience an immediate emotional response when they are experiencing the event, those who develop PTSD continue to experience the symptoms of exposure to trauma after the event, and feel stressed or panicked even when there is no danger.  While some of the symptoms are similar to other anxiety disorders, PTSD is categorized as a particular type of anxiety that is caused by a specific external catalyst.  The onset of PTSD can occur within months after a traumatic event; however, in some cases symptoms may not appear until years later.

Prevalence

PTSD is associated with those who have been exposed to a traumatic event, such as combat, violence, serious accidents, or natural disasters.   Approximately seven to eight percent of the U.S. population will have PTSD at some point in their lives, with about eight million adults suffering from PTSD in any given year.[1]

PTSD can be caused by one event, or by prolonged exposure to trauma over time.  This exposure can be experienced directly, and through indirect exposure (i.e. witnessing the event).[2]

Many physicians, depending on their specialty, interact on a daily basis with traumatic situations from early on in their careers, and sometimes encounter events where patients die or are seriously harmed in a way that is very distressing to a practitioner.  Significantly, research has shown that 13 percent of medical residents meet the diagnostic criteria for PTSD.[3]  Emergency physicians, physicians practicing in remote or under-served areas, and physicians in training (i.e. residents) are particularly prone to developing PTSD.[4]

The prevalence of PTSD is also substantially elevated in individuals who are also suffering from chronic pain.  While only 3.5% of the general population has a current PTSD diagnosis, one study found that 35% of a sample of chronic pain patients had PTSD.  Another study of patients with chronic back pain showed that 51% experienced significant PTSD symptoms.  In instances where the chronic pain is caused by the traumatic event (e.g. someone involved in a motorcycle accident or someone injured during the course of a violent crime), the pain can serve as a reminder of the event and worsen the PTSD.[5]

Symptoms

Physicians who suffer from PTSD may lose this ability to confidently react, which can impair their ability to safely practice.  Untreated, PTSD can also lead to a marked decline in quality of life, and potentially other mental health disorders or medical issues.  Some common symptoms of PTSD include:

Re-experiencing symptoms:

  • Flashbacks
  • Nightmares
  • Frightening thoughts
  • Physical reactions or emotional distress after exposure to reminders
  • Intrusive thoughts

Avoidance symptoms:

  • Staying away from places, events, or objects that are reminders to the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Arousal and reactivity symptoms:

  • Being easily startled
  • Feeling tense and “on edge”
  • Having difficulty sleeping
  • Being irritable or aggressive
  • Heightened startle reaction

Cognition and mood symptoms:

  • Trouble remembering key events of the traumatic event
  • Negative thoughts about the world, and oneself
  • Distorted feelings of guilt or blame
  • Loss of interest in previously enjoyed activities
  • Negative affect

Diagnosis

PTSD is typically diagnosed by a clinical psychiatrist or psychologist.  A diagnosis is made when an individual meets the criteria for exposure, and has at least one re-experiencing symptom, one avoidance symptom, two arousal and reactivity symptoms, and two cognition and mood symptoms.

Treatments

Some of treatments that are used, either alone or in conjunction, to treat PTSD include;

  • Cognitive Behavioral Therapy
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Prolonged Exposure Therapy
  • Antidepressants
  • Anti-anxiety medication
  • Medication for insomnia

The intensity and duration of PTSD symptoms vary.  Individuals who recognize any of the above-referenced symptoms in themselves should talk to a treatment provider right away.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

Medscape, http://emedicine.medscape.com
National Institute of Mental Health, https://www.nimh.nih.gov
WebMD, http://www/webmd.com/
[1] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, How Common Is PTSD?, https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp
[2] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, PTSD and DSM-5, https://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp
[3] Myers, Michael, MD, PTSD in Physicians, Psych Congress Network, Sept. 16, 2015, https://www.psychcongress.com/blog/ptsd-physicians
[4] Lazarus, A., Traumatized by practice: PTSD in physicians, J Med. Pract. Manage., 2014 Sept-Oct; 30(2): 131-4.
[5] DeCarvalho, Lorie T., PhD, U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers,  https://www.ptsd.va.gov/professional/co-occurring/chronic-pain-ptsd-providers.asp

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Chronic Pain and Anxiety Disorders

Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming.  As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment.  The same is true of anxiety disorders.

Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety

Like depression, anxiety is more likely to co-occur with certain conditions, such as:

It is no secret that physicians and dentists have stressful and demanding careers.  One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1]  Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.

While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder.  Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]

Chronic Pain and Anxiety—Worse Together

Facing a long-term or permanent disability can be anxiety provoking for a physician or dentist, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life.  Conversely, chronic pain is also common in people with anxiety disorders,[3]  with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]

Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5]  In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD).  Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]

Symptoms of Anxiety[7]

There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:

Generalized Anxiety Disorder

  • Difficulty controlling worry
  • Restlessness, feeling wound-up or on edge, irritability, muscle tension
  • Being easily fatigued and problems with sleep
  • Difficulty concentrating or having their minds go blank

Panic Disorder

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

  • Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
  • Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
  • Worrying before an event and/or avoiding places where there are other people
  • Having a hard time making and keeping friends

Post-Traumatic Stress Disorder

  • Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
  • Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
  • Being easily startled and feeling tense or “on edge”
  • Negative feelings about oneself or the world, and distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Obsessive Compulsive Disorder

  • Fear of germs or contamination
  • Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
  • Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting

Treatments for Anxiety

Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Support groups
  • Relaxation or meditation training
  • Alternative treatments, such as acupuncture and hypnosis
  • Exercise
  • Medication

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all

[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders

[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain

[4] Global Medical Education, Supra.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection

[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm

[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

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New Genetic Testing Predicts Most Effective Medications

In today’s pharmaceutical market there are countless prescription drugs marketed to people suffering from disabling conditions, and many of these drugs promise breakthrough relief not offered by their competitors. Individuals suffering from chronic pain and mental health disorders such as anxiety, PTSD, depression and bipolar must often take potent drugs for prolonged periods of time to get relief from their symptoms. But the search for relief can be incredibly frustrating – every person responds differently to the same drugs, and oftentimes powerful side effects can overshadow any relief.

For an individual suffering from the chronic and disabling pain brought on by severe spinal stenosis, there are several forms of treatment available – many of which are non-invasive. If other non-invasive treatments are unsuccessful, suffering through the side effects of several drugs in search of relief can be demoralizing. Powerful opioids can cause severe nausea, vomiting, dizziness, and/or constipation in certain individuals. The compounding effects of trying several different drugs can have a significant effect on one’s physical and mental health.

Recently, however, a genetic testing company has developed a simple test that will help countless individuals avoid dealing with unwanted side effects while cycling through different medications in their quest for relief.

Genesight has developed breakthrough genetic tests for both narcotic analgesics (pain medications) and psychotropic medications (treating mental health disorders). By taking a simple cheek swab, the company is able to analyze your DNA and determine which medications are match for your specific genetic profile. A clinical study of Gensight’s testing and analysis showed that patients were twice as likely to respond to the recommended medication.

This testing will likely be welcome news among those for whom relief is elusive. For many individuals suffering from disabling conditions, medications are very rarely the magic bullet that brings complete relief.  Symptoms may be so severe that no drug will ever be one hundred percent effective. More often, relief means alleviation of one’s symptoms just enough to get through the day without interminable pain or crippling anxiety while suffering only the more mild side effects. Genesight’s testing may offer hope for these individuals – people who will likely never be able to return to their previous career or their own occupation, but are in search of just enough relief from their symptoms to lead and enjoy a normal life.

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Disability Insurer Profiles: MetLife

Today we’re profiling another popular insurer that issues private disability policies to dentists and physicians: MetLife.

Company: Metropolitan Life Insurance Company, a.k.a. MetLife.

Location: New York, NY.

Associated Entities: MetLife, Inc. (parent company), General American Life Insurance Company, New England Life Insurance Company.

Assets: MetLife, Inc. held over $885 billion in assets as of May 2014, according to Forbes.

Notable Policy Features:  One thing to watch out for in MetLife disability insurance policies is a limitation on benefits for mental disorders and/or substance use disorder.  Under the Limited Monthly Disorders and/or Substance Use Disorders provision of some MetLife policies, policyholders are only entitled to a total of 24 months of benefits for any mental or substance abuse disorder, such as depression, panic disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and alcohol abuse or dependency.  The 24 month limitation is cumulative.  So, for example, if you have depression that disables you for 23 months, then start suffering from disabling alcohol dependency later in your life, you would only have one month of benefits still available to you.

Claims Management Approach: In its 2013 Annual Report, MetLife, Inc. reported that “unfavorable morbidity experience in our individual income disability business resulted in a $6 million decrease in operating earnings.”  In other words, in 2013, more private disability insurance policyholders experienced disabling illnesses or injuries than in years before, and that hurt MetLife’s profits.  In these situations, where an insurer is facing increased liability for disability benefit payments, we often see that insurer put additional resources towards managing disability claims.  In this way, the insurer can spend extra time and effort looking for ways to deny or terminate disability claims, with the goal of limiting its liability.

In our experience, one way that MetLife attempts to dispose of claims as quickly as possible is by ordering surveillance early on in the claim.  While some companies will wait until they have received more information before starting surveillance, MetLife has started following and videotaping claimants within weeks of the claim being filed.

With respect to its medical investigation, we have found that MetLife often follows a similar strategy to MassMutual’s.  The insurer will often attempt to have its own medical personnel schedule “peer-to-peer” telephone consultations with claimants’ treating physicians, with the aim of catching the treating physician off guard and persuading them into saying their patient isn’t disabled.  However, we have found that, in certain circumstances, MetLife can be amenable to submitting medical questions to the treating doctor in writing instead.  That way, the treating doctor can more carefully consider the issues, without feeling pressured or put on the spot.

 

These profiles are based on our opinions and experience. Additional source(s): MetLife’s 2013 Annual Report; Forbes.com