Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) may develop after exposure to exceptionally threatening or horrifying events. Many people show remarkable resilience and capacity to recover following exposure to trauma. However PTSD can occur after a single traumatic event or from prolonged exposure to trauma, such as sexual abuse in childhood. Predicting who will go on to develop PTSD is a challenge. PTSD should be considered in any patient exposed to a major traumatic event¹ .

PTSD can result in a disturbance to individual and family functioning, causing significant medical, financial, and social problems² .

What is post-traumatic stress disorder (PTSD)?³

The World Health Organization classification ICD-11 defines PTSD as follows:

Post-traumatic stress disorder (PTSD) may develop following exposure to an extremely threatening or horrific event or series of events. It is characterised by all of the following:

1. Re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations.

2. Avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s).

3. Persistent perceptions of heightened current threat - for example, as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises.

The symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

ICD-11 defines complex post-traumatic stress disorder as:

A disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (eg, torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

All diagnostic requirements for PTSD are met. In addition, complex PTSD is characterised by severe and persistent:

1. Problems in affect regulation.

2. Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event.

3. Difficulties in sustaining relationships and in feeling close to others.

These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Traumatic events associated with the development of PTSD can be experiencing or witnessing single, repeated or multiple events, and, for example, may include⁴ :

• Serious accidents.

• Physical and sexual assault.

• Abuse, including childhood or domestic abuse.

• Work-related exposure to trauma, including remote exposure.

• Trauma related to serious health problems or childbirth experiences - eg, intensive care admission or neonatal death.

• War and conflict.

• Torture.

PTSD epidemiology

Up to 3% of adults have PTSD at any one time. Lifetime prevalence rates are between 1.9% and 8.8%¹ .

Risk factors⁵

• Refugees and asylum seekers are likely to have experienced the sort of trauma that would predispose to PTSD and are at much higher risk than the general population in their new countries of settlement⁶ .

• First responders - eg, police, ambulance personnel - are by definition more likely to be exposed to traumatic events. The fact that they have selected such an occupation suggests some inherent resilience. Amongst the military, risk factors for PTSD include⁷ :

  • Duration of combat exposure.

  • Low morale.

  • Poor social support.

  • Lower rank.

  • Unmarried status.

  • Low educational attainment.

  • History of childhood adversity.

• A history of previous psychiatric disorders increases the risk of PTSD.

• Approximately 1-2% of women have PTSD postnatally⁸ .

Recognition of PTSD⁴

Assessment of people with PTSD should include an assessment of physical, psychological and social needs and a risk assessment.

People with PTSD, including complex PTSD, may present with a range of symptoms associated with functional impairment, including:

• Re-experiencing.

• Avoidance.

• Hyperarousal (including hypervigilance, anger and irritability).

• Negative alterations in mood and thinking.

• Emotional numbing.

• Dissociation.

• Emotional dysregulation.

• Interpersonal difficulties or problems in relationships.

• Negative self-perception (including feeling diminished, defeated or worthless).

When assessing for PTSD, ask people specific questions about re-experiencing, avoidance, hyperarousal, dissociation, negative alterations in mood and thinking, and associated functional impairment. Ask if they have experienced one or more traumatic events (which may have occurred many months or years before).

For people with unexplained physical symptoms who repeatedly attend health services, think about asking whether they have experienced one or more traumatic events and provide specific examples of traumatic events.

Specific recognition issues for children

Do not rely solely on the parent or carer for information when it is developmentally appropriate to question a child or young person directly and separately about the presence of PTSD symptoms.

Possible symptoms include nightmares, repetitive trauma-related play, intrusive thoughts, avoiding things related to the event, increased behavioural difficulties, problems concentrating, hypervigilance, and difficulties sleeping.

Screening of people involved in a major disaster, refugees and asylum seekers

For people at high risk of developing PTSD after a major disaster, the routine use of a validated, brief screening instrument for PTSD at one month after the disaster, and as part of any comprehensive physical and mental health screen, should be considered.

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. After the Vietnam War, onset of symptoms occurred within six years and onset of awareness of PTSD within 20 years in 90% of individuals⁹ .

Cultural modification

There are cultural expectations and experiences that predispose an individual's response to trauma¹⁰ . All modern wars have been associated with a syndrome characterised by medically unexplained symptoms.

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.

• Prolonged grief disorder.

Prolonged grief disorder is defined in ICD-11 as:

• A disturbance in which, following the death of a partner, parent, child, or other person close to the bereaved, there is persistent and pervasive grief response characterised by longing for the deceased or persistent preoccupation with the deceased, accompanied by intense emotional pain (eg, sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one's 'self', an inability to experience positive mood, emotional numbness, difficulty in engaging with social or other activities).

• The grief response has persisted for an atypically long period of time following the loss (more than six months at a minimum) and clearly exceeds expected social, cultural or religious norms for the individual's culture and context.

• The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

PTSD treatment and management⁴

Much more detail about the nature of various types of management, including psychological therapies, can be found in the National Institute for Health and Care Excellence (NICE) full guidelines (see reference link).

Supporting people with PTSD

• Provide information and support, covering:

  • Common reactions to traumatic events, including the symptoms of PTSD and its course.

  • Assessment, treatment and support options.

• Tell people about, and help them access, peer support groups if they want to and could benefit.

• Provide information and help to access services.

• Be aware of the risk of continued exposure to trauma-inducing environments. Avoid exposing people to triggers that could worsen their symptoms or stop them from engaging with treatment - for example, assessing or treating people in noisy or restricted environments, placing them in a noisy inpatient ward, or restraining them.

• Consider providing information and support to family members and carers of people with PTSD.

• Involve family members and carers, if appropriate, in treatment for people with PTSD as a way to inform and improve the care of the person with PTSD, and identify and meet their own needs as carers.

• Consider providing practical and emotional support and advice to family members and carers - for example, directing them to health or social services or peer support groups.

• Think about the impact of the traumatic event on other family members because more than one family member might have PTSD. Consider further assessment, support and intervention for any family member suspected to have PTSD.

• For members of the same family who have PTSD after experiencing the same traumatic event, think about what aspects of treatment might be usefully provided together (such as psychoeducation), alongside individual treatments.

Management of PTSD in children, young people and adults

People with PTSD may be apprehensive, anxious, or ashamed. They may avoid treatment, believe that PTSD is untreatable, or have difficulty developing trust. Engagement strategies could include following up when people miss appointments and allowing flexibility in service attendance policies.

For people with PTSD whose assessment identifies a significant risk of harm to themselves or others, establish a risk management and safety plan (involving family members and carers if appropriate) as part of initial treatment planning.

Consider active monitoring for people with subthreshold symptoms of PTSD within one month of a traumatic event. Arrange follow-up contact to take place within one month.

Psychological interventions for the prevention and treatment of PTSD in children and young people

• Do not offer psychologically-focused debriefing for the prevention or treatment of PTSD.

• Consider active monitoring or individual trauma-focused cognitive behavioural therapy (CBT) within one month of a traumatic event for children and young people aged under 18 years with a diagnosis of acute stress disorder or clinically important symptoms of PTSD.

• Consider a group trauma-focused CBT intervention for children and young people aged 7-17 years if there has been an event within the last month leading to large-scale shared trauma.

Treatment for children and young people

• Consider an individual trauma-focused CBT intervention for children aged 5-6 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than one month after a traumatic event.

• Consider an individual trauma-focused CBT intervention for children and young people aged 7-17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between one and three months after a traumatic event.

• Offer an individual trauma-focused CBT intervention to children and young people aged 7-17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than three months after a traumatic event.

• Include planning booster sessions if needed, particularly in relation to significant dates (for example, trauma anniversaries).

• Consider eye movement desensitisation and reprocessing (EMDR) for children and young people aged 7-17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than three months after a traumatic event only if they do not respond to or engage with trauma-focused CBT.

• Do not offer drug treatments for the prevention or treatment of PTSD in children and young people aged under 18 years.

Psychological interventions for the prevention and treatment of PTSD in adults

Prevention for adults
Offer an individual trauma-focused CBT intervention to adults who have acute stress disorder or clinically important symptoms of PTSD and have been exposed to one or more traumatic events within the preceding month. These interventions include:

• Cognitive processing therapy.

• Cognitive therapy for PTSD.

• Narrative exposure therapy.

• Prolonged exposure therapy.

Treatment for adults
Offer an individual trauma-focused CBT intervention to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than one month after a traumatic event. These interventions include:

• Cognitive processing therapy.

• Cognitive therapy for PTSD.

• Narrative exposure therapy.

• Prolonged exposure therapy.

Include planning booster sessions if needed, particularly in relation to significant dates (for example, trauma anniversaries).

• Consider eye movement desensitisation and reprocessing (EMDR) for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between one and three months after a non-combat-related trauma if the person has a preference for EMDR.

• Offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than three months after a non-combat-related trauma.

• Consider supported trauma-focused computerised CBT for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than three months after a traumatic event if they prefer it to face-to-face trauma-focused CBT or EMDR as long as:

  • They do not have severe PTSD symptoms, in particular dissociative symptoms; and

  • They are not at risk of harm to themselves or others.

• Consider CBT interventions targeted at specific symptoms such as sleep disturbance or anger, for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than three months after a traumatic event only if the person:

  • Is unable or unwilling to engage in a trauma-focused intervention; or

  • Has residual symptoms after a trauma-focused intervention.

Drug treatments for adults

• Do not offer drug treatments, including benzodiazepines, to prevent PTSD in adults.

• Consider venlafaxine or an SSRI, such as sertraline, for adults with a diagnosis of PTSD if the person has a preference for drug treatment.

• Consider antipsychotics such as risperidone in addition to psychological therapies to manage symptoms for adults with a diagnosis of PTSD if:

  • They have disabling symptoms and behaviours - for example, severe hyperarousal or psychotic symptoms; and

  • Their symptoms have not responded to other drug or psychological treatments.

• Antipsychotic treatment should be started and reviewed regularly by a specialist.

Care for people with PTSD and complex needs

For people presenting with PTSD and depression:

• Usually treat the PTSD first because the depression will often improve with successful PTSD treatment.

• Treat the depression first if it is severe enough to make psychological treatment of the PTSD difficult, or there is a risk of the person self-harming or harming others.

Do not exclude people with PTSD from treatment based solely on comorbid drug or alcohol misuse.

For people with additional needs, including those with complex PTSD:

• Build in extra time to develop trust with the person, by increasing the duration or the number of therapy sessions according to the person's needs.

• Take into account the safety and stability of the person's personal circumstances (for example, their housing situation) and how this might affect engagement with, and success of, treatment.

• Help the person manage any issues that might be a barrier to engaging with trauma-focused therapies, such as substance misuse, dissociation, emotional dysregulation, interpersonal difficulties or negative self-perception.

• Work with the person to plan any ongoing support they will need after the end of treatment, for example to manage any residual PTSD symptoms or comorbidities.

EMDR therapy¹¹

Cognitive behavioural therapy (CBT) is discussed in a separate article but EMDR requires more explanation. It is an integrative psychotherapy approach with a set of standardised protocols, principles and procedures. One technique uses eye movements to help the brain process traumatic events, although this is only 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

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others¹² .

Drug treatment¹³

• Drug treatment is considered second-line and should not be used in preference to psychological therapy.

• NICE says paroxetine and mirtazepine may be considered as potential treatments for PTSD but evidence for the effectiveness of other drugs is lacking.

• 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.

PTSD complications

Those with PTSD are more likely to abuse drugs or alcohol and to have medical problems with general medical conditions, musculoskeletal pain, cardiorespiratory symptoms and their gastrointestinal health^{14 15} . There is an association with cardiovascular disease and PTSD in older patients¹⁶ .

Prognosis

• A substantial proportion of those who experience serious trauma will develop some features of PTSD but 80-90% will recover spontaneously¹⁷ .

• 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 initiated¹⁸ .

• The severity of symptoms two weeks after trauma is a good predictor of the degree of severity at six months¹⁹ .

• The benefit from treatment does not decline with the lapse of time since the traumatic event.

Prevention

Studies have shown that preventative interventions, such as cognitive behavioral therapy (CBT), or stress hormone-targeted pharmacological interventions, are effective in selected samples of survivors. However, the effectiveness of early clinical interventions remains unknown, and results obtained in large groups overlook individual variability in PTSD cause and effects²⁰ .

A Cochrane review found the evidence for debriefing sessions after childbirth to be equivocal with respect to preventing psychological trauma including PTSD²¹ .