Post Traumatic Stress Disorder - F43.1

Question 1

What is the epidemiology of PTSD?

Answer 1

The majority of people will experience at least 1 traumatic event in their lifetime - men>women women but women experience higher impact events (DA, rape) and are more likely to develop PTSD subsequently

Lifetime prevalence estimate - 7.8%

Incidence of developing following a traumatic event: 8.1% for men, 20.4% for women

Question 2

What is the aetiology of PTSD?

Answer 2

Occurs after a particularly stressful/traumatic event - war, assault, rape, DA, RTA etc

Interpersonal trauma more likely to develop PTSD than non-assault based traumas

Can also affect witnesses, perpetrators and those who help PTSD sufferers (vicarious traumatisation)

Genetics is a risk factor

Question 3

What are some groups at risk of PTSD?

Answer 3

Victims of violent crime, war, torture, terrorism and refugees

Members of armed forces, police, journalists, prison service, fire service, ambulance and emergency personnel

Survivors of accidents and disasters

Women following traumatic childbirth, individuals diagnosed with life threatening illness

Question 4

What is some hypothesised pathophysiology of PTSD?

Answer 4

Traumatic event → overactive adrenaline response → ‘deep neurological patterns in the brain’ related to fear processing (wut) i.e. depression of hypothalamic response/HPA axis dysfunction, limbic system activation, hippocampus suppression (hence flashbacks) → over-consolidation of traumatic memories → persistence of these patterns → triggering of these patterns in a stressful situation → hyperresponsivenss

Bodily changes – those affected show low cortisol secretion and high catecholamine secretion

Question 5

How does PTSD present?

Answer 5

Begins within a few months of the incident
Flashbacks
Nightmares; sleeping problems – falling/staying asleep
Hypervigilant
Features of generalised anxiety
Possible alcohol and substances to relieve anxiety
Emotional numbing

Question 6

What are flashbacks?

Answer 6

Patient feels as if they are re-experiencing the event

More vivid than a simple memory recall; intrusive, occurring at any time but often have triggers i.e. when being in a similar situation to when the trauma occurred

Likely leading to ‘avoidance’ behaviours

Inability to recall either partially or completely, some important aspects of the period of exposure to the stressor

Question 7

What is hypervigilance?

Answer 7

Watchful of danger, overly alert, ‘jumpy’, anxious, exaggerated startle response, difficulty concentrating
Irritability or outbursts of anger

Question 8

What conditions are common with PTSD?

Answer 8

Anxiety or depressive conditions - treat PTSD first and others are likely to resolve independently (or more easily dissolve with treatment)

Alcohol or substance misuse - if the problem is affecting commitment to treatment, should treat drug or alcohol problem first

Question 9

What is important with the identification of PTSD?

Answer 9

In situations like major disasters, war zones, road traffic accidents, after the disclosure of domestic violence etc - direct screening should take place

Severity of initial (2-4wks) traumatic response is an indicator for the need for early intervention; chances of benefiting from treatment do not change with time elapsed

Question 10

How should you manage early stage PTSD?

Answer 10

Debriefing where the focus of the debrief is on the traumatic incident should NOT be routine practice when delivering services – found not to be useful and even potentially harmful

Watchful waiting - mild symptoms have been present for <4wks post trauma, arrange F/U within 1/12 for further assessment of difficulties

Question 11

What psychological therapies should be used in PTSD?

Answer 11

Eye Movement Desensitisation and Reprocessing (EMDR)

Trauma focussed CBT - brief (5 session therapy) may be effective if started within 1/12 following trauma; usual course lasts 8-12 when started outside 1/12 post trauma

Treatment should be regular and continuous with the same therapist if possible

Question 12

What are SSRIs and TCAs useful for in PTSD?

Answer 12

Paroxetine, Mirtazapine or amitriptyline

Good for treating positive symptoms i.e. flashbacks, arousal, anxiety, not so good for negative i.e. avoidance

Not routine first line, typically only if: patient preference to not engage in therapy, where there is still trauma ongoing (i.e. DA), psychology not helped, comorbid severe anxiety/depression impacting on commitment to psychology

Indicated for 12 months before gradual withdrawal

Question 13

What use do hypnotics have in PTSD?

Answer 13

For use in early stages if sleep disturbance present and not for very long (as addiction)