Post Traumatic Stress Disorder

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Post-traumatic Stress Disorder

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Article

PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Stress is a feature of everyday life. Definitions vary but, in essence, it is the autonomic ‘alarm’ response to perceived threat in the environment, involving heightened arousal, adrenaline production facilitating short-term ‘fight-or-flight’ resistance, followed by physical and mental exhaustion. Stress is commonly understood as a mismatch between the external demands on an individual and their ability to cope. Many attribute their physical illness to it, from headache to cancer.

Individuals vary in their resilience to stress. Some actively seek and thrive in stressful environments, seeking out extreme sports or highly demanding careers. Others shun it and ‘stress’ at work often means an inability to cope, leading to unhappiness, absenteeism and actual illness. Life events such as bereavement, divorce and unemployment are all important ‘stressors’ and may have consequences for mental health but it is important not to ‘medicalise’ normal adjustment reactions to these types of events. Post-traumatic stress disorder (PTSD) has a different magnitude and develops in response to stress of a severe and abnormal nature.

The National Institute for Health and Clinical Excellence (NICE) highlights the difference:[1]

PTSD develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. PTSD does not therefore develop following those upsetting situations that are described as ‘traumatic’ in everyday language – for example, divorce, loss of job or failing an exam.
PTSD was recognised in the First World War in men who had been subjected to prolonged and intensive bombardment including gas attacks. It was called ‘shell shock’ and many soldiers on both sides were discharged to a pitiful existence with severe psychiatric problems. It was poorly managed and misunderstood and, in some instances, afflicted soldiers were executed as ‘deserters’.

It was not until 1980, following the traumas of the Vietnam War, that the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) recognised PTSD formally as a medical entity. Combat exposure increases the risk of PTSD by approximately three-fold compared to non-deployed troops[2] but PTSD is not exclusive to military or civilian populations exposed to warfare and can be caused by a multiplicity of traumatic events.

Recent research suggests that the neurobiology of PTSD involves the autonomic system and the hypothalamic-pituitary-adrenal axis and that adrenaline is the main neurotransmitter involved in this pathway.[3] Reconsolidation – the means by which the brain reconstructs memories and associated emotional responses – appears to be an important process in the development of PTSD.[4] An understanding in the underlying neurophysiology of PTSD opens up possibilities for novel treatments of this condition.

Epidemiology
One study of UK armed forces personnel deployed to Afghanistan found that of 1,431 participants, 2.7% were classified as having probable PTSD.[5] . A household survey of UK adults estimated a prevalence of 2.6% in men and 3.3% in women.[6]

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Risk factors
Usually the precipitating event is, or is perceived as, life-threatening. Examples include serious accidents, hostage taking, natural disasters, terrorist incidents and violent assault.[7] However, it can also result from sexual assault, following rape or child sexual abuse. The trauma can also be ongoing such as domestic violence, recurring sexual abuse or systematic abuse by a rogue regime.
Refugees and asylum seekers are likely to have suffered the sort of trauma that would predispose to PTSD and are at much higher risk than the general population in their new countries of settlement.[8]
First responders – eg, police, ambulance personnel – are by definition more likely to be exposed to traumatic events..[9] The fact that they have selected such an occupation suggests some inherent resilience. Amongst the military, risk factors for PTSD include:[10]
Duration of combat exposure.
Low morale.
Poor social support.
Lower rank.
Unmarried.
Low educational attainment.
History of childhood adversity.
A history of previous psychiatric disorders increases the risk of PTSD.
One study found that females were as much as twice as likely to develop PTSD as men were – the degree of gender difference, however, depending on the circumstances. Women were more vulnerable to PTSD after disasters and accidents, followed by loss and non-malignant diseases. In violence and chronic disease, the gender differences were smallest.[11]
Approximately 1-2% of women suffer from PTSD postnatally.[12]
History
Recognition is often a challenge:

Many people are denied treatment for PTSD because the condition is unrecognised. If a patient presents with PTSD symptoms, depression, drug or alcohol misuse or anger, make sensitive enquiry about traumatic experiences in the past. Make similar enquiries of frequent attenders with unexplained physical symptoms.
Ask children directly about their experiences.
Comorbidities are common – eg, depression, anxiety, substance abuse.
Although the problem starts soon after the event, in 85% it may present later so that the relationship with the event is less obvious, especially if features are less specific, such as anxiety, depression, insomnia or hypochondria with frequent attendance.
It may be necessary to distinguish PTSD from traumatic or complicated grief reactions that may develop a year or more after a bereavement, with symptoms of intense, intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks associated with the deceased, unusual sleep disturbances and loss of interest in personal activities. The two conditions can, of course, co-exist.[13]
PTSD symptoms fall into three categories:[1]

Re-experiencing

Flashbacks where it seems as if the event were happening again.
Nightmares, which are common and repetitive.
Distressing images or other sensory impressions from the event, which intrude during the waking day.
Reminders of the traumatic event provoke distress.
Avoidance or rumination

Sufferers avoid reminders of the trauma, such as people, situations or circumstances resembling the event or associated with it. They may try to suppress memories or avoid thinking about the worst aspects. Many others ruminate excessively and prevent themselves from coming to terms with the experience.

Why did it happen to me?
Could it have been prevented?
How can I take revenge?
Hyperarousal or emotional numbing

This may manifest as:

Hypervigilance for threat.
Exaggerated startle responses.
Irritability.
Difficulty concentrating.
Sleep problems.
Difficulty experiencing emotions.
Feeling of detachment from others.
Giving up previously significant activities.
Amnesia for salient aspects of the trauma.
Children
Developmentally, children may have more limited verbal skills and different means of reacting to stress compared to adults and thus will present differently with PTSD. Alternative criteria have been suggested for the diagnosis of PTSD in children. In children and adolescents, it has been suggested that Avoidance symptoms are more diagnostically significant than Re-experience and Arousal. Guilt may be a significant symptom associated with trauma-exposed youth.[14] Children may re-enact the traumatic experience with joyless repetitive play or have frightening dreams without recognisable content, sometimes presenting as sleep disturbance. They may have other behavioural problems.

Time of onset
Usually the disorder strikes soon after the event but in a small minority it may be delayed. Delayed onset greater than a year post-trauma is thought to be very rare.[15] More commonly, patients present a considerable time after the event with symptoms that date back to it.

Cultural modification
There are cultural expectations that predispose an individual’s response to trauma. All modern wars have been associated with a syndrome characterised by medically unexplained symptoms. The form that these assume, the terms used to describe them and the explanations offered by servicemen and doctors seem to be influenced by advances in medical science, changes in the nature of warfare and underlying cultural forces.[16]

Screening
Screening for PTSD is of value. A voice-based automated system has been developed with a detection accuracy of 95.88%.[17] Only those at high risk should be screened; for example:

After a major disaster, consideration should be given to the routine use of a brief screening instrument for PTSD, at one month after the disaster, to identify those most at risk of PTSD.[1]
Refugees and asylum seekers at high risk of developing PTSD should be given a brief screening instrument for PTSD as part of the initial refugee healthcare assessment. This should be a part of any comprehensive physical and mental health screen.
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Differential diagnosis
Depression.
Specific phobias.
Acute stress reaction.
Adjustment disorders.
Personality disorders.
Enduring personality change after catastrophic experience.
Dissociative disorders.
Neurological injury or disease.
Psychosis.
Complicated grief reaction.
Malingering.
Management
Much more detail about the nature of various types of management, including psychological therapies, can be found in the NICE full guidelines.[1]

General principles
Single-session interventions, often referred to as debriefing, immediately after the event, have been deemed at best ineffective and at worst harmful in the treatment of PTSD. However, some authorities argue that such sessions may be of value when used in selected groups.[18]
If symptoms are mild and the event was less than a month previously, watchful waiting is appropriate.
For those with severe symptoms in the first month, trauma-focused cognitive behavioural therapy (TF-CBT) should be offered.
The evidence from one study which reviewed the effectiveness of CBT delivered in a group setting to patients suffering from postnatal depression was equivocal.[19] However, a recent Cochrane meta-analysis looking at a wider range of patients supported its use.[20]
Alternative psychological treatments to TF-CBT include eye movement desensitisation and reprocessing (EMDR) and stress management. One study reported that EMDR reduced the vividness of memories in a student sample, suggesting perhaps some interference in the reconsolidation process.[21]
Non-trauma-focused interventions such as relaxation or non-directive therapy, that do not address traumatic memories, should not routinely be offered to people who present with PTSD symptoms within three months of a traumatic event.
Comorbid conditions such as depression, general anxiety or alcohol or substance misuse are often secondary to the PTSD. The PTSD should be treated first and then the comorbid condition, especially depression, will usually improve. However, if the comorbid condition is sufficiently severe to interfere with treatment of the PTSD, it should take precedence in treatment.
EMDR (Eye Movement Desensitisation and Reprocessing) Therapy
CBT is discussed in its own article but EMDR requires more explanation. It is an integrative psychotherapy approach with a set of standardized protocols, principles and procedures. One technique uses eye movements to help the brain process traumatic events, although this is but one part of the entire therapy. The goal of EMDR is to reduce distress in the shortest period of time. It should only be conducted by an appropriately trained therapist.

Children
Older children with severe PTSD should be offered TF-CBT in the first month after the traumatic event.[22]
Children and young people with PTSD, including those who have been sexually abused, should be offered a course of TF-CBT adjusted to suit their age and maturity.[23]
EMDR may also be used with children.
NICE concludes that there is currently no good evidence for widely used treatments such as play therapy, art therapy, or family therapy for PTSD.[24]
Drug treatment
Drug treatment is considered second-line and should not be used in preference to psychological therapy.
It should be borne in mind that patients with PTSD are known to have poor compliance with medication.[25]
If patients refuse psychological therapy but want drug treatment, or where psychological treatment has not relieved symptoms, NICE suggests the use of paroxetine or mirtazapine (primary care) and amitriptyline or phenelzine (to be initiated only by a psychiatrist). A Cochrane review supported the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of PTSD.[26] NICE reiterates the need for vigilance for suicidal ideations in young people prescribed SSRIs, and care with sudden withdrawal.
Hypnotics may be considered to help insomnia but they should not be used for more than a month and, if required for longer, should be replaced by an antidepressant.
Clonidine has recently been explored as a potential treatment. It is thought to act by blocking the reconsolidation process.[4]
Procedures
Stellate ganglion block has recently been used for the treatment of PTSD. The rationale for this treatment is a reduction in the action of adrenaline (epinephrine), the main neurotransmitter associated with fear conditioning.[3]

Decision aids
Doctors and patients can use Decision Aids together to help choose the best course of action to take.
Compare the options
Complications
Those with PTSD are more likely to abuse drugs or alcohol[27] and to have medical problems with general medical conditions, musculoskeletal pain, cardiorespiratory symptoms and their gastrointestinal health.[28] An association with cardiovascular disease is being investigated.[29]

Prognosis
A substantial proportion of those who experience serious trauma will develop some features of PTSD but 80-90% will recover spontaneously.[30]
Symptoms may still be present many years after the event. One study found that people exposed to war-related trauma were at a high risk of having PTSD symptoms a decade later if no treatment was initiated.[31]
The severity of symptoms two weeks after trauma is a good predictor of the degree of severity at six months.[32]
The benefit from treatment does not decline with the lapse of time since the traumatic event.
Prevention
We cannot eliminate risk, fear and unpleasant events and most of us will experience at least one major trauma in our life. Traditional ‘Health and Safety’ approaches to risk management, which attempt to reduce exposure, have not been successful and may actually increase risk aversion and reduce resilience. People are not intrinsically risk-averse, provided they can see purpose in accepting risk.[33] Exposure to risk is not inevitably harmful. Claims for compensation delay recovery.[34] Culturally, we need to respect courage and resilience but not to stigmatise breakdown. PTSD is not just a medical but a social and political issue too.[35]

There is some evidence that cortisol given within the first few hours after a traumatic event (the ‘golden hours’) may have a prophylactic effect on the subsequent development of PTSD.[30]

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Further reading & references
The ISTSS Expert Consensus Treatment Guidelines For Complex PTSD In Adults, Complex Trauma Task Force (Nov 2012)
EMDR Association UK & Ireland
Bisson JI; Post-traumatic stress disorder. BMJ. 2007 Apr 14;334(7597):789-793.
Combat Stress
Davis SM, Whitworth JD, Rickett K; Clinical inquiries. What are the most practical primary care screens for post-traumatic stress disorder? J Fam Pract. 2009 Feb;58(2):100-1.
Stergiopoulos E, Cimo A, Cheng C, et al; Interventions to improve work outcomes in work-related PTSD: a systematic review. BMC Public Health. 2011 Oct 31;11:838. doi: 10.1186/1471-2458-11-838.
Digangi J, Guffanti G, McLaughlin KA, et al; Considering trauma exposure in the context of genetics studies of posttraumatic stress disorder: a systematic review. Biol Mood Anxiety Disord. 2013 Jan 3;3(1):2.
Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care; NICE (2005)
Smith TC, Ryan MA, Wingard DL, et al; New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ. 2008 Feb 16;336(7640):366-71. Epub 2008 Jan 15.
Lipov E, Kelzenberg B, Rothfeld C, et al; Modulation of NGF by cortisol and the Stellate Ganglion Block – Is this the missing link between memory consolidation and PTSD? Med Hypotheses. 2012 Dec;79(6):750-3. doi: 10.1016/j.mehy.2012.08.019. Epub 2012 Sep 18.
Gamache K, Pitman RK, Nader K; Preclinical evaluation of reconsolidation blockade by clonidine as a potential novel treatment for posttraumatic stress disorder. Neuropsychopharmacology. 2012 Dec;37(13):2789-96. doi: 10.1038/npp.2012.145. Epub 2012 Aug 8.
Jones N, Seddon R, Fear NT, et al; Leadership, cohesion, morale, and the mental health of UK Armed Forces in Afghanistan. Psychiatry. 2012 Spring;75(1):49-59. doi: 10.1521/psyc.2012.75.1.49.
McManus S et al; Adult Psychiatric Morbidity in England, 2007 – Results of a household survey, The NHS Information Centre for health and social care
Kleim B, Ehlers A, Glucksman E; Early predictors of chronic post-traumatic stress disorder in assault survivors. Psychol Med. 2007 Oct;37(10):1457-67. Epub 2007 Jun 22.
Bogic M, Ajdukovic D, Bremner S, et al; Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012 Mar;200(3):216-23. doi: 10.1192/bjp.bp.110.084764. Epub 2012 Jan 26.
Haugen PT, Evces M, Weiss DS; Treating posttraumatic stress disorder in first responders: a systematic review. Clin Psychol Rev. 2012 Jul;32(5):370-80. doi: 10.1016/j.cpr.2012.04.001. Epub 2012 Apr 13.
Iversen AC, Fear NT, Ehlers A, et al; Risk factors for post-traumatic stress disorder among UK Armed Forces personnel. Psychol Med. 2008 Apr;38(4):511-22. Epub 2008 Jan 29.
Ditlevsen DN, Elklit A; Gender, trauma type, and PTSD prevalence: a re-analysis of 18 nordic convenience samples. Ann Gen Psychiatry. 2012 Oct 29;11(1):26. doi: 10.1186/1744-859X-11-26.
Andersen LB, Melvaer LB, Videbech P, et al; Risk factors for developing post-traumatic stress disorder following childbirth: a systematic review. Acta Obstet Gynecol Scand. 2012 Nov;91(11):1261-72. doi: 10.1111/j.1600-0412.2012.01476.x. Epub 2012 Aug 13.
Nakajima S, Ito M, Shirai A, et al; Complicated grief in those bereaved by violent death: the effects of post-traumatic stress disorder on complicated grief. Dialogues Clin Neurosci. 2012 Jun;14(2):210-4.
Blom M, Oberink R; The validity of the DSM-IV PTSD criteria in children and adolescents: a review. Clin Child Psychol Psychiatry. 2012 Oct;17(4):571-601. doi: 10.1177/1359104511426408. Epub 2012 Jan 27.
Frueh BC, Grubaugh AL, Yeager DE, et al; Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics. Br J Psychiatry. 2009 Jun;194(6):515-20.
Jones E, Hodgins-Vermaas R, McCartney H, et al; Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution. BMJ. 2002 Feb 9;324(7333):321-4.
Xu R, Mei G, Zhang G, et al; A voice-based automated system for PTSD screening and monitoring. Stud Health Technol Inform. 2012;173:552-8.
Hawker DM, Durkin J, Hawker DS; To debrief or not to debrief our heroes: that is the question. Clin Psychol Psychother. 2011 Nov-Dec;18(6):453-63. doi: 10.1002/cpp.730. Epub 2010 Dec 19.
Stevenson MD, Scope A, Sutcliffe PA, et al; Group cognitive behavioural therapy for postnatal depression: a systematic review of clinical effectiveness, cost-effectiveness and value of information analyses. Health Technol Assess. 2010 Sep;14(44):1-107, iii-iv. doi: 10.3310/hta14440.
Barrera TL, Mott JM, Hofstein RF, et al; A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clin Psychol Rev. 2013 Feb;33(1):24-32. doi: 10.1016/j.cpr.2012.09.005. Epub 2012 Oct 6.
van den Hout MA, Bartelski N, Engelhard IM; On EMDR: Eye movements during retrieval reduce subjective vividness and objective memory accessibility during future recall. Cogn Emot. 2013 Jan;27(1):177-83. doi: 10.1080/02699931.2012.691087. Epub 2012 Jul 6.
Gillies D, Taylor F, Gray C, et al; Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database Syst Rev. 2012 Dec 12;12:CD006726. doi: 10.1002/14651858.CD006726.pub2.
Macdonald G, Higgins JP, Ramchandani P, et al; Cognitive-behavioural interventions for children who have been sexually abused. Cochrane Database Syst Rev. 2012 May 16;5:CD001930. doi: 10.1002/14651858.CD001930.pub3.
Dorsey S, Briggs EC, Woods BA; Cognitive-behavioral treatment for posttraumatic stress disorder in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2011 Apr;20(2):255-69. doi: 10.1016/j.chc.2011.01.006.
Kronish IM, Edmondson D, Li Y, et al; Post-traumatic stress disorder and medication adherence: results from the Mind Your Heart Study. J Psychiatr Res. 2012 Dec;46(12):1595-9. doi: 10.1016/j.jpsychires.2012.06.011. Epub 2012 Jul 16.
Ipser JC, Stein DJ; Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD). Int J Neuropsychopharmacol. 2012 Jul;15(6):825-40. doi: 10.1017/S1461145711001209. Epub 2011 Jul 29.
Leeies M, Pagura J, Sareen J, et al; The use of alcohol and drugs to self-medicate symptoms of posttraumatic stress disorder. Depress Anxiety. 2010 Aug;27(8):731-6. doi: 10.1002/da.20677.
Pacella ML, Hruska B, Delahanty DL; The physical health consequences of PTSD and PTSD symptoms: A meta-analytic review. J Anxiety Disord. 2012 Sep 13;27(1):33-46. doi: 10.1016/j.janxdis.2012.08.004.
Wentworth BA, Stein MB, Redwine LS, et al; Post-traumatic stress disorder: a fast track to premature cardiovascular disease? Cardiol Rev. 2013 Jan;21(1):16-22. doi: 10.1097/CRD.0b013e318265343b.
Zohar J, Juven-Wetzler A, Sonnino R, et al; New insights into secondary prevention in post-traumatic stress disorder. Dialogues Clin Neurosci. 2011;13(3):301-9.
Priebe S, Matanov A, Jankovic Gavrilovic J, et al; Consequences of untreated posttraumatic stress disorder following war in former Yugoslavia: morbidity, subjective quality of life, and care costs. Croat Med J. 2009 Oct;50(5):465-75.
Kleim B, Ehlers A, Glucksman E; Investigating Cognitive Pathways to Psychopathology: Predicting Depression and Posttraumatic Stress Disorder From Early Responses After Assault. Psychol Trauma. 2012 Sep;4(5):527-537. Epub 2012 Jan 23.
Wessely S; Risk, psychiatry and the military. Br J Psychiatry. 2005 Jun;186:459-66.
Frueh BC, Elhai JD, Gold PB, et al; Disability compensation seeking among veterans evaluated for posttraumatic stress disorder. Psychiatr Serv. 2003 Jan;54(1):84-91.
Stein DJ, Seedat S, Iversen A, et al; Post-traumatic stress disorder: medicine and politics. Lancet. 2007 Jan 13;369(9556):139-44.

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