20th November 2023

Post-Traumatic Stress Disorder

This is another disorder where the clue is in the name. Post-traumatic stress disorder (PTSD, ICD-10 F43.1) occurs in response to a particularly traumatic life event or even multiple life events. Patients describe reliving the experience, understandably avoiding events that remind them of it and heightened reactions to stimulus or hypervigilance.

Predisposition, onset and maintenance

It is more common in patients of lower social or educational status, from Afro-Caribbean or Hispanic backgrounds, previous psychiatric comorbidities or traumas and low self-esteem. More common in females with a ratio of 1:2, men have an 8-13% chance of developing PTSD following an event compared with 20-30% for females. There may be psychological and biological roles in developing PTSD. Psychologically, reliving the experience, keeping the experience as an active memory until it has been dealt with or dissociating from it play a role. There are neurophysical changes in response to stress caused, which may lead to neuronal changes. Stress hormones like glucocorticoids and catecholamines, alongside serotonin, GABA and opioids, are associated.

Focused history

Firstly, it would be critical to identify the stressful event and then move on to assessing the impact. The patient may experience flashbacks in day-to-day life or nightmares; this can be coupled with strong sensations and intense emotions. They may be actively avoiding thinking about the event, which would cause setbacks in coming to terms with what has happened or avoiding places, situations or people that were there. The patient may perceive that they are constantly under threat.

Assessment of physical factors and investigations

Similarly to OCD, imaging is not used in the diagnosis, but there may be changes seen, for example, reduced volume of the hippocampus. The fear response may be heightened due to irregular functioning of the amygdala, hippocampus, prefrontal cortex and septum. Whereas the anterior cingulate, medial prefrontal cortex and thalamus may play a role in hyperarousal. The occipital, parietal and temporal cortices mediate dissociative phenomena.

Diagnosis

Symptoms are seen within 6 months of the initial traumatic stressor, present for 1 month, with a negative impact on functioning. Symptoms should not be present before the event, and patients must experience two or more of the following: flashbacks, remembering, reliving, hypervigilance, exaggerated response to stimulus, irritability or anger, sleep disturbance, reckless behaviour, avoidance of the stressor, inability to recall all or parts of the event.

Treatment

Biological – Again, SSRIs are most effective, namely paroxetine, sertraline or fluoxetine. Next, venlafaxine can be trialled. Second line treatments include antipsychotics, MAOIs and tricyclic antidepressants, even IV ketamine.

Psychological – Recommended as first line by NICE are trauma focussed CBT and EMDR. These should be used before moving on to pharmacological treatments.

Social – Education of family and carers (it is possible they were also exposed to the same traumatic event and may require support themselves). Awareness of maintaining environments the patient feels safe in. Continuity of care by professionals.

References

• Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• National Institute for Health and Care Excellence. (2018). Post-traumatic stress disorder. NICE guideline [NG116]. https://www.nice.org.uk/guidance/ng116
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F40-F48
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f2070699808
• Taylor DM; Barnes TRE; Young AH. (2021). The Maudsley Prescribing Guidelines in Psychiatry, fourteenth edition.