Post-traumatic stress disorder

Prevalence

PTSD in adults

3.7% of men and 5.1% of women screened positive for PTSD.
Women aged 16-24 were most likely to screen positive (12.6%).
Age 55-64 was the only category where men were more likely to screen positive than women.

PTSD in children:

0.2% for children 5–15 years of age.

Prognosis

In around two-thirds of people, symptoms resolve naturally, although this may take several months.

For around a third of people, symptoms are longer lasting, and for many, these are severe and enduring.

Complex post-traumatic stress disorder may develop after extreme prolonged or repeated trauma (such as repeated childhood sexual abuse or prolonged captivity involving torture).

Diagnosis

Traumatic event (Directly experienced the traumatic event OR Witnessed an event happening to someone else)

  • A serious/life-threatening accident.

  • Physical or 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 (for example, intensive care admission or neonatal death).

  • War and conflict.

  • Torture.

The ICD-10 describes a major traumatic event as 'a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone'.

The DSM-5 describes a major traumatic event as 'exposure to actual or threatened death, serious injury, or sexual violence'.

Diagnostic criteria:

Experienced a Traumatic Event AND

  • Re-experiencing symptoms — which may occur in the daytime when the person is awake (flashbacks, or intrusive images or thoughts) or as nightmares when asleep. This is the most characteristic symptom.

  • Avoidance of people or places that remind the person of the event.

  • Emotional dysregulation.

  • Emotional numbing/negative thoughts, where the person expresses a lack of ability to experience feelings or feels detached from other people, or has negative thoughts about themselves.

  • Hyperarousal/hyperreactivity, where the person is on guard all the time, looking for danger (hypervigilance), or the person has irritable behaviour or angry outbursts with little or no provocation.

Screening questionnaires

In primary care, the Trauma Screening-Questionnaire (TSQ) may be helpful to identify people with post-traumatic stress disorder.

Differential diagnosis

  • Depression — suggested by low mood, lack of energy, loss of interest, suicidal ideation.

  • Generalized anxiety disorder
    Anxiety and worry accompanied by at least three additional symptoms (of restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, or disturbed sleep).

  • Panic disorder — suggested by recurrent, unexpected panic attacks not triggered by stimuli that recall a specific trauma.

  • Specific phobias — suggested by fear and avoidance restricted to certain situations.

  • Adjustment disorder — suggested by variable symptoms of low mood, anxiety, worry, traumatic stress symptoms, and feelings of inability to cope, plan ahead, or carry on. Symptom intensity is usually less than with PTSD.

  • Dissociative disorders — suggested by persistent and recurrent feelings of detachment and estrangement from oneself (depersonalisation disorder), and/or gaps in recall, often related to traumatic events (dissociative amnesia). There is an absence of the re-experiencing and hyper-arousal symptoms of PTSD.

  • Psychosis — suggested by hallucinations, delusions. Flashbacks and vivid intrusive images are accompanied by perceptual and cognitive disorganisation.

Management

If the person is considered to be at high risk of suicide, refer urgently (same day) to the crisis resolution and home treatment team.

Clinically important symptoms of PTSD can be defined as those causing at least moderate functional impairment and/or those scoring above a clinical threshold on a validated scale (where this has been assessed)

Subclinical PTSD symptoms:
consider watchful waiting and arrange regular review.

For people with clinically important PTSD symptoms —> Referral to a specialist mental health service

  1. Trauma-based psychological therapies (usually considered first-line)
    Trauma-focused cognitive behavioural therapy (CBT) — up to 12 sessions are typically offered.
    Trauma-focused cognitive therapy
    Eye movement desensitization and reprocessing (EMDR)

  2. Drug treatment.
    Consider initiating venlafaxine SNRI or an SSRI in an adult, if patient expresses preference, declines psychological therapy or referral is delayed

    Be aware that in a minority of people aged under 30 years of age, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. Anyone in this age group receiving an SSRI or SNRI should therefore be seen within 1 week of first prescribing, and the risk of suicide and self-harm should be monitored weekly for the first month. 

    Only paroxetine and sertraline are licensed in the UK for the treatment of post-traumatic stress disorder (PTSD).

    Also, paroxetine, is more likely to be associated with discontinuation symptoms

    Otherwise, review the effectiveness and adverse effects of the drug every 2 to 4 weeks during the first 3 months of treatment and every 3 months thereafter

Dr Rajesh VarmaPost-traumatic stress disorder, PTSD