CKS: Post-traumatic stress disorder

A 26-year-old mother-of-three presents with recurrent nightmares. She was recently mugged while walking back from work in the evening and sustained minor cuts and bruises which are healing.

Assess for suicide risk (Photograph: SPL)
Assess for suicide risk (Photograph: SPL)

When should I suspect post-traumatic stress disorder?
Suspect post-traumatic stress disorder (PTSD) if your patient has experienced a traumatic event and presents with re-experiencing symptoms such as flashbacks; avoids people, situations or circumstances that resemble or are associated with the traumatic event; emotional numbing (a lack of ability to experience feelings or feeling detached from people); or is hyper-vigilant for threats.

Consider the possibility of PTSD in patients with depression, generalised anxiety disorder, drug or alcohol abuse, inappropriate anger, inability to work, relationship problems, poor sleep and sexual dysfunction.

How is the diagnosis confirmed?
The diagnosis is confirmed using specific diagnostic criteria (DSM-IV1 or ICD-102). Generally the diagnosis is confirmed by a mental health specialist with expertise in managing PTSD. However, the diagnosis may also be confirmed in primary care if a healthcare professional has the appropriate training and experience to do so, or has access to a suitably qualified practice therapist.

What assessment should I make?
Assess their risk of suicide, self harm and harm to others, and consider emergency referral. If your patient does not require emergency referral, assess the severity of PTSD symptoms and depending on the degree of distress she is experiencing and the degree to which her symptoms are impairing her social and occupational functioning, classify the symptoms as mild, moderate, or severe.

Ask how long the symptoms have been present and assess your patient's social needs.
Assess for a secondary psychological disorder (depression, generalised anxiety disorder and panic disorder, and drug or alcohol abuse) and if present, establish the main problem in order to determine which condition to treat first.

How do I manage my patient with PTSD?
If your patient has mild symptoms of less than four weeks duration, consider a period of watchful waiting. Explain that symptoms improve over time and only a third of people will require specialist help.

If your patient has severe symptoms or has had symptoms for more than four weeks, refer her to a specialist mental health service with expertise in managing PTSD (see the Trauma Group website, www.uktrauma.org.uk/uklist.html).

The evidence
These recommendations are based on NICE guidance on the management of PTSD in adults and children in primary and secondary care.3

References
1. American Psychiatric Association (Ed.) Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th Ed. Washington, DC: American Psychiatric Association 2000.

2. WHO The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. World Health Organization, 1992.

3. NICE. Guidance on post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care.CG26. London, NICE, 2005. Available from www.nice.org.uk/nicemedia/live/10966/29772/29772.pdf


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