Post-traumatic stress disorder - Clinical review

Section 1. Epidemiology and aetiology

Post-traumatic stress disorder or PTSD was first defined in 1980 when the American Psychiatric Association described the clinical features of PTSD in DSM-III. PTSD was a controversial diagnosis with some critics arguing that PTSD was no more than the medicalisation of life’s vicissitudes.

Symptoms akin to PTSD have been described through the ages: examples are shell shock associated with World War One and ‘railway spine’ associated with steam train accidents in the nineteenth century; it has been suggested that Charles Dickens had suffered from railway spine. Today, in addition to natural disasters and war, PTSD can occur following various events such as motor vehicle accidents, childhood sexual abuse and domestic violence.

Psychological trauma is common and community studies indicate a lifetime trauma exposure of 50-90% with a lifetime prevalence of PTSD of between 5% and 10%. PTSD is twice as common in women and higher rates are associated with lower socioeconomic groups.

PTSD is defined directly by its cause, that is, exposure to one or more traumatic events. Extensive research in several fields including neurobiology, neuroimaging and epidemiology provide explanatory models of PTSD such as a memory disorder with increased susceptibility if early attachment problems had occurred. The malfunction of brain structures such as the hippocampus, amygdala and pre-frontal cortex following trauma are implicated in PTSD symptomatology.

The WHO included PTSD in their 1992 International Classification of Diseases: ICD-10. There are some differences between DSM-5, implemented in 2013 and the proposed ICD-11, due in 2017, which includes a new ‘complex PTSD’ diagnosis for presentations that include interpersonal relationship and emotion regulation difficulties; harmonisation of DSM-5 and ICD-11 has not been achieved.

Acute stress disorder comprises similar symptoms to PTSD but, by definition, cannot extend beyond four weeks. Delayed-onset/expression PTSD occurs when PTSD symptoms develop more than six months after trauma and PTSD can also be chronic with remissions and relapses. Although not part of DSM or ICD classification systems, PTSD is sometimes referred to as type 1 or simple if it relates to a single event, time-limited trauma and type 2 PTSD, if it relates to protracted, multiple traumas.

Section 2: Making the diagnosis

There are no diagnostic investigations for PTSD, however there are several PTSD screening tools, such as the Trauma Screening Questionnaire, which can aid diagnosis. Although there is some divergence between DSM-5 and the proposed ICD-11, both classification systems share the core PTSD symptoms of:

• Re-experiencing past trauma through intrusive memories, dreams and experiences
• Avoidance of the re-experiencing of past trauma by avoiding triggers of trauma memory such as people and places
• Hyperarousal with excessive vigilance and exaggerated startle

Complex PTSD, as proposed in ICD-11, has the additional symptoms of:

• Emotional dysregulation
• Negative self-concepts
• Disturbed relationships

DSM-5 has included new criteria that overlap with complex PTSD and evidence suggests that DSM-5 identifies PTSD more than the proposed ICD-11.

PTSD is unique amongst mental disorders by being defined by its cause. To qualify as a traumatic event, exposure to actual or threatened death, serious injury, or sexual injury is required. The event can be experienced directly or can be witnessed in person.

Vicarious PTSD can occur when learning about an accidental or violent event happening to a close family member. Repeated exposure to extreme aversive details in the line of work (such as the fire service) can also lead to PTSD. However, adverse life events such as divorce or bullying at work do not usually qualify as being traumatic, neither does exposure to traumatic events through the media.

NICE states that up to 30% of children develop PTSD symptoms after traumatic injury. For children, PTSD symptoms can present as disturbed sleep and repetitive play and DSM-5 includes criteria for the under 6-age group.

PTSD presents with considerable clinical diversity that can make diagnosis very difficult in practice when the underlying PTSD diagnosis is neither apparent nor sought. Depression and anxiety states, medically unexplained physical symptoms and drug and alcohol misuse are common presentations and PTSD symptoms can vary in severity. PTSD is associated with increased suicidality and also with behavioural problems in young people.

Section 3: Managing the condition

Traumatic events can affect individuals, groups and populations and require an appropriate response to each situation, taking into account factors such as culture and age. For traumatised individuals and groups, early social interaction and support is essential to the recovery process. The development of a therapeutic relationship is a prerequisite for any psychological or medical intervention for PTSD.

However, stabilisation can be a challenge to achieve. Avoidance is a core PTSD symptom and the inherent lack of trust and sense of safety in those suffering from PTSD can make patient engagement and concordance with interventions difficult. When managing PTSD in children, the evidence base is not as advanced as for adults, and children require specialist paediatric psychological intervention.

Psychological first aid can be provided early following trauma, and given that most people recover from an acute stress response, NICE recommend watchful waiting for the first month after trauma. Although NICE guidance advises against early single ‘de-briefing’ interventions, it supports screening for PTSD a month after larger traumatic events.

Mindfulness-based techniques can be useful for stabilisation and trauma-focused psychological therapies are recommended first line by NICE. Pharmacological treatments for PTSD are regarded as second line with paroxetine, fluoxetine, sertraline and venlafaxine having the best evidence. The judicious use of hypnotics for acute PTSD can also be considered, although the usual cautions about dependency apply.

Although numerous therapies and techniques have been developed for managing PTSD, NICE recommends trauma-focused CBT for cognitive re-structuring and eye movement desensitisation and reprocessing (EMDR) for trauma memory processing. An example of a new psychological intervention is guided self-help, which is an emerging technique for mild to moderate PTSD.

For more complex presentations, the management of PTSD can be divided into three phases:

• Emotional stabilisation
• PTSD management
• Social re-integration at home and work

The need for more effective management of complex PTSD has led to modification of some trauma therapies such as EMDR and the development of new techniques and therapies such as ‘skills training in affective and interpersonal regulation’ and the ‘comprehensive resource model’.

The recognition of two types of PTSD, and the diversity of PTSD presentations and co-morbidities, has recently led to questioning of a ‘one size fits all’ approach to clinical management. The notion of tailored PTSD care is currently a hot topic.

Section 4: Prognosis

The majority of patients recover from traumatic events without any intervention and full recovery can occur following trauma-focused psychological therapies. The outcomes to treatment for simple, single-event trauma PTSD are usually more successful than for chronic, multiple trauma, complex PTSD.

Evidence suggests around a third of PTSD sufferers experience an enduring chronic disorder. NICE proposes that chronic PTSD, which proves resistant to treatment, should be managed in primary care through a chronic condition model.

Conversely, traumatic experiences can lead to personal development called post-traumatic growth that would not have occurred without the traumatic experiences. Developing therapies for complex and chronic PTSD is a current challenge and is supported by advances in neuroscience and through epidemiological studies.

Section 5. Case study

John, a 38-year-old accountant, attends his GP together with his wife. They had become increasingly worried about his health and also their relationship, which was strained.

John had been involved in a minor car accident two months previously when he was bumped from the rear at low velocity. Since the accident, he had become very irritable with mood swings leading to angry outbursts directed at his wife and family on the slightest provocation.

His sleep was disturbed due to distressing dreams leaving him tired and unable to concentrate in the day. His short-term memory had declined too. He could not get the accident out of his mind and he tried very hard to distract himself to avoid the memories.

He had resumed driving for work purposes but avoided any other driving if he could. He was very anxious, jumpy and low in mood with other features of depression. He had a number of odd sensations in his body, with numbness in his face and arms, blurred vision, vertigo and tinnitus. His alcohol consumption had escalated.

He had suffered similar symptoms when, aged 22, he had helped at a car crash when he had witnessed the death and mutilation of a mother and child. However, then his symptoms had mostly resolved after about four weeks.

A diagnosis of PTSD was made by the GP. As the local NHS psychological therapies waiting list for trauma-focused CBT or EMDR was one to two years, the GP provided an explanation of the symptoms and reassured John that he would recover.

John was prescribed sertraline with review appointments every six weeks with the same GP for trauma psycho-education and symptom review until he received EMDR therapy. After eight 90-minute sessions the symptoms subsided and his alcohol consumption reduced. His relationships improved and he resumed full driving again.

Section 6. Evidence base

Guidelines

• NICE produced a PTSD guideline in 2005: Post-Traumatic Stress Disorder (PTSD): The management of PTSD in adults and children in primary and secondary care.
• Quick reference guide: www.nice.org.uk/cg026quickrefguide
• Information for the public: plain English version for sufferers, carers and the public: www.nice.org.uk/cg026publicinfoenglish

Trials

The PTSD NICE guideline update, 2013, includes references for several trials that underpin its advice and recommendations:

• Ford JD, Steinberg KL, Hawke J et al. Randomized trial comparison of emotion regulation and relational psychotherapies for PTSD with girls involved in delinquency. Journal of Clinical Child and Adolescent Psychology 2012; 41: 27-37.
• Panagioti M, Gooding PA, Tarrier N. A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression. Comprehensive Psychiatry 2012; 53: 915-30.

Textbook

There is much literature on PTSD and a good introduction to the subject can be found in:

• Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. Bessel A. van der Kolk, Alexander C. McFarlane and Lars Weisaeth, Editors. 2007. The Guilford Press. New York, London.

Online

• The UK Psychological Trauma Society, UKPTS, is a multidisciplinary professional forum to provide evidence-based comment and share best practice on PTSD-related subjects. UKPTS has links with the European Society for Traumatic Stress Studies, ESTSS. http://www.ukpts.co.uk/
• The US department of Veterans Affairs, National Centre for PTSD website has a section on PTSD with access for professionals and researchers: www.ptsd.va.gov/index.asp
• www.ptsd.va.gov/PTSD/professional/PTSD-overview/complex-ptsd.asp: An example PTSD topic: complex PTSD

• Dr Downes is a GP in Flintshire, North Wales and a GPSI in Psychological Trauma. He is a member of the Cardiff University Traumatic Stress Research Group.

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