Approaching post-traumatic stress disorder (PTSD)
Armed Forces Day takes place in June, so this month we discuss a mental health condition closely associated with the military – post-traumatic stress disorder (PTSD). We spoke with Dr Jason Taylor, Consultant Psychiatrist at Priory Hospital Chelmsford, about the causes of PTSD, signs and symptoms to look out for, and the best treatment to offer.
When the phrase PTSD was originally coined in the 1980s, it was used to describe symptoms of trauma arising primarily from combat exposure. Since then, it has been extended to encompass any group of people exposed to traumatic events. This includes:
- Victims of violent crime (e.g. physical and sexual assaults, sexual abuse, bombings, riots)
- Emergency services personnel
- Victims of war, torture, state sanctioned violence, terrorism and refugees
- Survivors of industrial or road traffic accidents and disasters
- Women following traumatic childbirth
- Individuals diagnosed with a life-threatening illness
Those in the military are particularly susceptible to this condition due the frequency of their traumatic experiences.
Why does PTSD occur?
The ICD10 classification for PTSD (F43.1) states:
- The disorder arises as a delayed response to a stressful event or situation, (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive stress in almost anyone
- Upsetting situations that are described as ‘traumatic’ in everyday language, e.g. divorce, loss of a job or failing an examination are better classified as (F43.2) adjustment disorder
Complex PTSD is said to arise where there has been repetitive, prolonged trauma involving sustained abuse or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic.
In response to acute stress, the body's sympathetic nervous system is activated due to the sudden release of hormones, triggering the release of catecholamine. This leads to a state of hyper-arousal, commonly known as the ‘fight or flight’ response. When people experience trauma, the world may then feel like a less secure place and the trauma may re-invoke earlier feelings of vulnerability.
Some people with PTSD are said to show organic and functional abnormalities of the brain. Areas implicated include the amygdala, hippocampus and pre-frontal cortex.
Spotting the signs and symptoms of PTSD
Key symptom clusters include:
- Re-living (re-experiencing) of traumas through intrusive memories such as flashbacks, nightmares or recurring images
- Emotional numbness, detachment from others, anhedonia or unresponsiveness to surroundings
- Autonomic hyper-arousal with hyper-vigilance, an enhanced startle reaction, insomnia and often irritability
- Ruminating excessively over questions that prevent them from coming to terms with the event, for example “why did it happen to me?” or “how can I get revenge?”
A small number of cases may follow a chronic course leading to enduring personality change. This latter diagnosis arose from clinical descriptions of concentration camp survivors and is characterised by:
- A distrustful attitude towards the world
- Social withdrawal
- Feelings of emptiness
- A chronic feeling of ‘being on edge’ as if constantly threatened
Many PTSD sufferers experience other associated symptoms and co-morbid conditions, including depression, generalised anxiety, shame, guilt and reduced libido, which contribute to their distress and impact on their functioning.
It is not uncommon for PTSD sufferers to lose their jobs or even, in some cases, become homeless. Re-experiencing traumatic symptoms or experiencing problems with sleep and concentration, may make regular work difficult, or they may be unable to cope with reminders of the traumatic event if this was experienced through work. The resulting financial problems are a common source of significant additional stress.
Social withdrawal, problems in the family and break-up of significant relationships are common repercussions. Irritability and the use of illicit substances to cope, can also be a contributory factor.
Approaching PTSD in primary care
A recommended approach to PTSD management in primary care would include:
- An assessment of the trauma experienced whilst recognising that this may be distressing for the patient to relay
- An exploration of the PTSD symptoms and co-morbid symptoms including suicidal thoughts
- Brief exploration of past mental health history
- Psycho-education for the patient and, if applicable, the family, including an exploration of the support networks in place
- Discussion around treatment options and, if appropriate, medication side effects
- Consideration of referral for specialist psychiatric evaluation
- Agreement of a follow-up plan after initiating medication or other treatment
- Careful documentation of the assessment
- For patients with unexplained physical symptoms who are repeat attendees to primary care, sensitively explore whether they have experienced past traumatic events, for example, assaults, rape, childhood sexual abuse or traumatic childbirth
- Assessment and evaluation in your GP surgery
A diagnosis of PTSD is made if symptoms are:
- Protracted since the initial trauma and have lasted longer than a month
- Distressing or cause significant interference in personal functioning
In general practice, it is best to focus on the three key areas:
- Re-experiencing of the trauma in the here and now - the focus should be on asking about recurrent memories of the trauma, bad dreams, flashbacks with high levels of anxiety, or somatic symptoms such as sweating
- A persistent sense of current threat that is manifested by exaggerated startle and hyper-vigilance - the GP can explore questions around over-sensitivity to noise, increased irritability and heightened aggression, an increase in arguments or actual violence to property or people, difficulties with concentration, and impaired sleep
- Avoidance of traumatic reminders - does the person avoid thinking about the trauma? After a road traffic accident, are they now a nervous passenger or do they avoid driving?
Formulating a treatment plan
Once a diagnosis is established, a detailed assessment of the symptom profile can be made, and a treatment plan formulated. I find it useful to include family members in assessments, particularly if substance misuse or increased irritability are features, as this can lead to family or relationship breakup.
This is often offered in the immediate aftermath but there is little evidence that a single one-off debriefing session is helpful for treatment or that this will reduce the incidence of PTSD.
Systematic reviews suggest that cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) are both effective in the treatment of PTSD.
National Institute for Health and Care Excellence (NICE) guidance suggests that all PTSD sufferers should be offered a course of trauma-focused psychological treatment (either trauma-focused CBT or EMDR), regardless of the time lapse since the traumatic event/series of events:
Trauma-focused CBT (individual treatment)
This is a CBT-based approach that utilises cognitive techniques as well as exposure to the trauma, either in imagination such as writing or visualising the trauma. This is carried out until the trauma ceases to evoke the same stress responses. ‘In-vivo’ exposure is also beneficial, such as getting back to driving after a road traffic accident or revisiting the site of the trauma.
EMDR was developed by Shapiro (1989). This therapy aims to help sufferers to reprocess their traumatic memory and to think more positively about their experience. EMDR involves inducing a series of rapid and rhythmic eye movements to facilitate cognitive change and decrease anxiety. Patients are instructed to focus on a trauma-related image and to bring the negative emotions, sensations and thoughts to the forefront of their minds, while visually tracking the therapist’s fingers as they move back and forth in front of the patient’s eyes.
Some other therapeutic approaches are not recommended as first line treatments but are listed below:
- Stress management (individual treatment)
- Group CBT
- Individual and group supportive therapy (for example victim support groups)
- Psychodynamic -based therapy
- Self-help books
NICE recommends psychological therapy as first line treatment but with drug treatment alongside this. This includes selective serotonin reuptake inhibitor (SSRI) antidepressants such as paroxetine, sertraline, tetracyclic antidepressants, or mirtazapine. This is recommended for where there is significant co-morbid depression or severe hyper-arousal that significantly impacts on a sufferer’s ability to benefit from psychological treatment alone. There may also be a clear patient preference for medication over psychological therapy.
Mirtazapine may be quite sedating in some patients but is potentially useful if a person is aroused, irritable or sleeping poorly.
In reality, many patients may face waiting lists for psychological therapies on the NHS and some services will only offer group-based CBT. Pharmacotherapy should be offered where patients have no access to psychological therapies and are symptomatic to the extent that this is impacting on their day-to-day functioning.
Other sources of support
The PTSD Checklist – this is a useful self-report checklist which can be provided to patients who are suffering from PTSD. Please click here to view.