Patients with Post-Traumatic Stress Disorder

The lasting effects of combat could surface in the hygiene operatory

BY Lisa Dowst-Mayo, RDH, BSDH

I vividly remember my grandfather discussing World War II when I was a child. He was a prisoner of war for two years in a Japanese camp in the early 1940s, and was awarded a Purple Heart. I remember him discussing politics and war with a fervent opinion. Until the day he died, he remained a loyal soldier and American patriot. As a child, I never truly understood what war was or what it really meant to serve in the United States military during wartime. War was such an intangible subject for my generation-that is, until September 11, 2001. This was the first time generation X experienced first-hand what attacks and war really felt like. Now, thinking back on my grandfather's wartime stories, I understand and feel differently about them. Had I known then what I know now, I would have a deeper appreciation for what he was trying to teach me.

Life in America changed after September 11, 2001. The Iraq war began and still rages on today. As a practicing dental hygienist, I had grown accustomed to seeing post-traumatic stress disorder (PTSD) written on a medical history for people my grandfather's age-people who had served in a warzone so many years ago, years before I was even born.

Now, I am beginning to see PTSD written on medical history forms for people my age, or even younger. As you read this article, Generation Xers (born 1965-1979) and millennials (born 1980-2000) are fighting for America's freedoms abroad. As they return home, many are experiencing PTSD. It is imperative dental hygienists revisit their knowledge of PTSD and the dental management of patients who may suffer from this disorder. Gone are the days when you saw PTSD on a medical history only once in a blue moon. This disorder will begin presenting in your practices more frequently than ever before due to the military climate set in motion on 9/11.

PTSD is caused by directly experiencing any number of traumatic life events (e.g., war, both as a civilian and combatant; physical assault; sexual violence; abduction; being taken prisoner; terrorist attacks; torture; incarceration; domestic violence; child abuse; severe vehicular accidents; environmental disasters).¹ Medical conditions do not qualify as traumatic events for a diagnosis of PTSD under the defined parameters in the fifth edition of Diagnostic and Statistical Manual (DSM-5).¹ However, if a patient was to wake during surgery or experience anaphylactic shock, these could be considered exceptions in the PTSD diagnosis.¹

Prevalence of PTSD

The DSM-5 is the newest edition; it replaced the DSM-4 in January 2014. According to the DSM-5, the prevalence of PTSD among U.S. adults is 3.5%.¹ The highest rates are among veterans and professionals in high-risk vocations (e.g., police, firefighters, emergency personnel).¹ The prevalence is higher among female patients than male patients, and female patients tend to have a longer duration.¹ Eighty percent of individuals with PTSD will also suffer from varying comorbid disorders (e.g., depression; bipolar, anxiety, and substance abuse disorders).¹ According to the DSM-5, "among U.S. military personnel who have been deployed to Afghanistan and Iraq, co-occurrence of PTSD and mild traumatic brain injury is 48%."¹

A 2014 published research report reviewed 5,927 surveys on file with the Department of Defense and found that suicide rates within the U.S. Army have risen considerably within the last decade.² According to the report's authors, "with the advent of Operation Iraqi Freedom and Operation Enduring Freedom, suicide rates have increased, surpassing civilian rates for the first time."² PTSD has been shown to be a risk factor for suicidality in civilian and military samples,^3,4 and the incidence of PTSD has nearly doubled.² Respondents with PTSD were five times more likely to report suicidality in the past year compared to those military personnel without PTSD.²

Clinical Representations

According to the DSM-5, "the essential feature of PTSD is the development of characteristic symptoms following exposure to one or more traumatic events." The first symptoms will usually develop within the first three months after the traumatic event; however, this is variable as some do not experience symptoms until one to fifty years after the event.¹ The clinical presentations of PTSD vary dramatically from one person to another.¹

Patients with PTSD may be quick-tempered and become physically or verbally aggressive with little to no provocation.¹ They have an increased risk of engaging in high-risk behaviors (e.g., drug and alcohol abuse) or self-injurious behaviors (e.g., self-mutilation or suicidal thoughts).¹

The following list summarizes the varying presentations as reported by the DSM-5:

1. Fear-based re-experiencing; emotional and behavioral symptoms predominate. Patients will often say "I can't trust anybody ever again."¹
2. Anhedonic (lack of pleasure) or dysphoric (state of unease) mood states and negative emotions predominate. The individual may no longer find pleasure in activities once enjoyed. Patients may put themselves down and say, "I have always had bad judgement" or "Everything's always my fault." Feelings of horror, anger, guilt, and shame may worsen.¹
3. Arousal and reactive-externalizing symptoms predominate. A patient may have altered thoughts in the cause of the traumatic event (e.g., "It's all my fault my uncle abused me").¹
4. Dissociative symptoms predominate. This could present as amnesia of the details of the event not otherwise associated with any physical injury (e.g., head injury).¹
5. Combinations of all four presentation states.¹

Dental management of PTSD

Individuals with PTSD commonly have recurrent, involuntary recollections or dreams of the event.¹ They can enter into dissociative states for minutes or hours where they think they are reliving the event.¹ These states can be "triggered" by varying physical or psychological sensations that are not always known to the individual.¹ It is important for a dental professional to question a patient who reports PTSD on their medical history to find out if they have any known triggers so they can be avoided. For example, I had a patient tell me his last "episode" was triggered by someone coming up behind him and startling him. I made a special alert in his chart that anyone who enters the dental operatory must do so quietly and not speak to the patient until he can see them to avoid "startling" him.

According to the DSM-5, "individuals with PTSD may be very reactive to unexpected stimuli, display heightened startle responses, or jumpiness to loud noises and unexpected movements."¹ Physically touching a patient with PTSD without permission could trigger an unpleasant reaction. I worked with a student who could not stand to be touched on the shoulder or the arm. This action was a trigger for her. For most people, a gentle touch on the shoulder during a dental appointment is reassuring and allows the dental hygienist to show compassion. However, for patients with PTSD, this may send them into a state of anxiety and stress. The dental office has many loud noises and varying smells. When treating a patient with PTSD, the dental hygienist should be sure to explain the use of any instrument that elicits noise (e.g., polishers; X-ray units; ultrasonic, low-, and high-speed handpieces) prior to use of the equipment. The dental hygienist should also explain what he or she is doing in detail prior to performing the action and gain the patient's approval to proceed. This will help the patient feel in better control during the appointment and allow them the opportunity to stop a situation they know to be a "trigger" for them.

Maintaining a calm and relaxing environment is important since many patients with PTSD also suffer from anxiety. Speak clearly and in a soft and reassuring tone to communicate compassion and understanding.⁵ Be extra attentive to a patient's nonverbal and verbal communication. Even coming into the dental office can very difficult for a patient with PTSD. According to a 2014 article in Nursing, "the experience may be enough to induce frightening psychological responses."⁵ If possible, provide extra time in your schedule for these patients so you can be more relaxed and work on establishing a safe and trusting relationship with the patient. The paper also states, "patients with a history of trauma may respond better to having multiple visits for more complex needs or procedures. Scheduling multiple visits with the healthcare provider breaks the process down into smaller steps that may be more manageable for the patient."

Schedule a patient's appointment at a time that works best for them. They may do better in the morning after having taken their prescribed medications. Anniversaries of traumatic events are a "trigger" for many patients with PTSD, so avoiding that date would be important.⁵ Patients with PTSD may continuously scan your room and have difficulty concentrating on what you are saying.⁵ They will instinctively choose a place to sit where they are facing a door because it makes them feel like they have an escape route.⁵ If your operatory has a private door, do not close it without asking the patient first.

Since depression, anxiety, and drug and alcohol abuse rates are higher in this population, the dental hygienist should be utilizing risk assessments for caries and periodontal disease and inquiring about current tobacco use. Medications prescribed for depression, anxiety, and PTSD will be in the antipsychotic, antianxiety, and antidepressant classes. These medications have many anticholinergic side effects, including xerostomia. Xerostomia and drug, alcohol, and tobacco use are major risk factors for caries and periodontal disease. The dental hygienist should educate their patients on dry mouth substitutes and management, as well as recommend topical fluoride treatments depending on a patient's risk assessment outcome.

A new generation of war has now set in motion an increasing percentage of individuals who may present to your office with PTSD. Understanding the disorder etiology, prevalence, clinical manifestations, and needed dental office management will assist the hygienist in establishing a trusting relationship with their patients. Once trust is built, clinical care can be provided without causing undue stress for patients suffering with PTSD. RDH

Lisa Dowst-Mayo, RDH, BSDH, graduated magna cum laude with a degree in dental hygiene sciences from Baylor College of Dentistry in 2002. She is currently pursuing a master's in health administration from Ohio University. She is a full-time professor at Concorde Career College in the dental hygiene department where she teaches clinical sciences, board review, special needs, and pharmacology. She is a published author and national speaker and can be contacted through her website at www.lisamayordh.com.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Virginia: American Psychiatric Association; 2013.

2. Ramsawh HJ, Fullerton CS, Mash HB, et al. Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army. J Affect Disord. 2014;161:116-122.

3. Bryan CJ, Corso KA. Depression, PTSD, and suicidal ideation among active duty veterans in an integrated primary care clinic. Psychol Serv. 2011;8:94-103.

4. Nock MK, Hwang I, Sampson NA, Kessler RC. Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15:868-876.

5. Heavey E. Female refugees: Sensitive care needed. Nursing. 2014;44:28-34. doi:10.1097/01.NURSE.0000445731.62016.58.