22nd February 2024

Post-Traumatic Stress Disorder

Background

Post-traumatic stress disorder (PTSD) usually occurs following one or more traumatic life events. Whilst the symptoms described in the presentation section below can develop following any traumatic event, in those with PTSD, these symptoms are persistent and have a significant impact on the lives of patients and their loved ones. Those at risk of PTSD include victims of war, torture, abuse, sexual assault and survivors of disasters, serious illness, or traumatic childbirth. It also affects those who serve in the army, the police force and emergency services. It is often comorbid with depression and anxiety. Other risk factors for developing PTSD include a family or personal history of mental health disorders, abuse as a child, the presence of survivors’ guilt or persisting trauma. PTSD sufferers will often relive the traumatic event rather than just simply remember the event due to disruption in the storing and processing of the traumatic event in their memory. The hypervigilance and exaggerated startle response is thought to be due to the hypertrophy of the amygdala, the emotional processing centre of the brain. Despite flashbacks of the event and constant reminders of the trauma, the sufferers may not completely remember all the details relating to the trauma (an atrophied hippocampus, the memory centre, is thought to be a factor).

Presentation

PTSD usually presents within 6 months of the traumatic event occurring. 

Symptoms of PTSD usually fall into 3 categories, see table below.

The three categories of PTSD, BMJ best practice. Post-traumatic stress disorder [Internet]. BMJ ; 2023 [cited 2023 Jul 11]. Available from: https://bestpractice.bmj.com/topics/en-gb/430/management-approach 

Physical symptoms of gastrointestinal upset, joint pains and headaches can also be present.  Symptoms can be debilitating and distressing and have a substantial effect on day-to-day functioning.  

Diagnosis

PTSD consists of 4 types of symptoms: intrusive symptoms, avoidant behaviours, negative thinking patterns and mood, and changes in arousal and reactivity. The symptoms should be present for over a month and need to have an impact on the functioning of the sufferer for a diagnosis of PTSD to be made. On diagnosis, there is often a comorbidity of anxiety disorders, mood disorders such as depression or substance misuse disorders. 

Diagnostic factors 

The event triggering PTSD could be a threat to life, serious injury or a violent event. It could have involved the sufferer directly, they may have been a witness to the event or found out about the trauma occurring to a close friend or family. Trauma can also include repeated exposure to details of a traumatic event as part of their occupation, e.g. law enforcement.  

Exposure to trauma followed by each of the four symptoms (below) for over 1 month, which affects day to day functioning. 

Image Source: Wikimedia Commons (2018). NG116, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/ng116/informationforpublic (Accessed: 7 May 2023).

A diagnosis can be made in primary care, but referral to specialist services is often required for further management options.  Diagnosis can be made using the DSM–5 or ICD-10.

Investigation

• PTSD Symptom Scale-Interview Version for DSM-5 (PSS-I-5) – A 20-item questionnaire based on DSM-5 description of PTSD symptoms 
• Trauma Screening Questionnaire (TSQ) – 10-item questionnaire which focuses on arousal and flashback symptoms. 
• Posttraumatic Diagnostic Scale (PDS-5) – Looks at the severity of PTSD symptoms 

Management

Non- pharmacological therapies 

• Exposure therapy: the patient is encouraged to remember and describe the traumatic event. By doing so, they repeatedly encounter the trauma that they have been avoiding and which has been causing them distress. 
• Trauma-focused cognitive therapy: helps the patient identify misconceptions and thoughts that are associated with a particular trauma, helping them confront and overcome the things that elicit fear and distress. 
• Eye movement desensitisation and reprocessing (EMDR). An effective therapy where the patient is encouraged to describe or reimagine the original trauma in detail. Whilst doing this, their therapist will move their finger / an object from side to side and patients are encouraged to follow the movement of the stimuli with their eyes. The repetitive movement of the eyes is thought to stimulate the brain and helps with reprogramming the patients’ traumatic memories and the negative emotions attached to them.

Pharmacological therapies:

These are commenced in patients who have not responded to psychological therapies, who do not want to engage in psychological therapies or who cannot undergo psychological therapies yet due to ongoing trauma. It is also started in combination with other therapies, particularly in those with co-morbid depression.  

• SSRIs: Firstline, for example, Fluoxetine, Paroxetine and Sertraline. 
• SNRIs: Venlafaxine is thought to reduce PTSD symptoms and improve functionality. Used in those who don’t tolerate SSRIs.
• Atypical Antipsychotics: If the above fail, Quetiapine and Risperidone are recommended
• TCA: Amitriptyline or mirtazapine can be used as a last resort if the other drug therapies are ineffective 

If drug therapy is successful, it should be continued for at least 12 months. 

References

• NICE Guidelines. Information for the public: Post-traumatic stress disorder: Guidance [Internet]. NICE. 2018 [cited 2023May7]. Available from: https://www.nice.org.uk/guidance/ng116/informationforpublic 
• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 158–9. 
• BMJ best practice. Post-traumatic stress disorder [Internet]. BMJ ; 2023 [cited 2023 Jul 11]. Available from: https://bestpractice.bmj.com/topics/en-gb/430/management-approach