Posttraumatic Stress Disorder ( PTSD ) involves a group of symptoms experienced after exposure to a potentially traumatic event that may include re-experiencing the event ; avoiding situations that trigger memories of the event ; experiencing negative feelings and beliefs ; and/ or experiencing feelings of hype-arousal such as irritability , agitation , anger of being on the alert ( American Psychiatric Association 2013 ).
How common ? PTSD is a major mental illness and is becoming a serious public health challenge – the diagnosis came into being as a formal diagnosis in 1980 when the American Psychiatric Association ( APA ) included PTSD within the 3rd edition of its standard diagnostic tome – DSM -III PTSD is the most frequent psychopathological consequence of traumatic events Currently more than 2 % of the US population is known to suffer with PTSD 8 to 9 % of the US population reports experiencing lifetime PTSD It is estimated that on-month prevalence of PTSD in the general UK population was 4.4 % Approximately 1 in 3 people in the UK report exposure to a significant traumatic event during the course of their life- most people recover but a minority may of cases traumatic will experience will lead to psychological injuries which may manifest as adjustment disorders ,PTSD or depression Young women ( 16-24 ) are more likely to meet the PTSD criteria although this declines with age The rate also varies among occupational groups for e.g ambulance workers up to 20 % war reporters up to 20 % combat troops up 7-30 % security contractors 33 % Research has also shown that in the UK PTSD rates are highest in veterans who has recently deployed in a combat role in Iraq or Afghanistan.
Risk Factors-Incidence increases with trauma severity female gender younger age prior interpersonal trauma previous psychiatric disorder subsequent life stress post-trauma h/o childhood adversity low educational attainment appraisals of work in operational theater as being above an individuals trade or experience low unit / organization morale or poor social support.
Co-morbidities-PTSD is also highly co-morbid with other mental health conditions ie people with PTSD also suffer with conditions as depression , anxiety and substance misuse , suicidality.
Why important –Significant social , personal and economic costs As mentioned above people with PTSD have a high rate of associated psychiatric co-morbidities Problems with functioning – family , work , social Consequences like difficulties in education , work earnings , marriage and child rearing Almost half ( 42.6 % ) of adults with PTSD do not get mental health treatment , among those who do only 40.4 % get minimally adequate treatment Studies have shown that about 92 % of adults with PTSD with lifetime PTSD eventually remit , the median time to remission is 14 yrs.
DSM V criteria –A traumatic event as in criteria A followed by four core symptoms as in criterion B-E- and the symptoms must have been experience for atleast a month or more. The symptoms should not be due to substance misuse , medications or other illness. A traumatic event as per DSM V is defined as an
event or series of events in which the individual has been personally or indirectly exposed to actual or threatened death , serious injury , or sexual violence.
A1-Direct exposure to traumatic events such as actual or threatened death serious injury e.g military combat physical attack torture man made / natural disasters accidents incarceration exposure to war zone / urban/ domestic violence sexual violence or assault.
A2-Is witnessing such events and includes people who directly observed such events but were not harmed themselves.
A3-Indirect exposure such as learning that a loved one was exposed to a traumatic event ; if the loved one died during such an event. Criterion A3 is only met if the death was violent or accidental.
A4-Applies to exposure to repeated or extreme details of trauma , such as seeing dead body parts or severely injured people as part of one’s profession for e.g medical , law enforcement , mortuary affairs and journalism.
Criteria B-Intrusive re-experiencing of the event ( such as traumatic nightmares or flashbacks ).Alterations in arousal and reactivity ( such as hypervigilance , exaggerated startle response , or irritability ).Negative alterations in mood and cognition ( such as persistent negative affect or self – perception , or amnesia for key parts of the trauma not caused by alcohol , head injury and / or drugs ).
Assessment –Following an initial c/o possibility of PTSD you may ask about
trauma exposure associated symptoms sensitivity impact that the trauma had on patients daily functioning.
NICE informs that patients with PTSD including complex PTSD may present with range of symptoms associated with functional impairment including re-experiencing avoidance hyper-arousal negative alterations in mood and thinking emotional numbing dissociation emotional dysregulation interpersonal difficulties or problems with relationships negative self- perception.
Trauma Screening Questionnaire-If you suspect a possibility of PTSD following initial questioning, you may consider using further screening questionnaires. CKS suggests using the Trauma Screening questionnaire in Primary care as this can be done quickly and is freely available. TSQ is a 10 item symptom screen it has based on items from the PTSD symptom scale self report ( PSS-SR Foa et al 1993 ) It has 5 experiencing item and 5 arousal items Respondents are asked to report the items that they have experienced atleast twice in the last week TSQ should be used 3 weeks or more after a traumatic event A score of 6 or more puts people at risk of PTSD and these people should be referred for further assessment .
Other tools PC-PTSD- primary care PTSD Screen PTSD brief screen Short Screening Scale for DSM IV PTSD PTSD checklist.
Differentials-Acute stress disorder-symptoms happen within a month of the traumatic event and come to an end within that month. If the symptoms continue and follow other patterns typical of PTSD – the diagnosis may change to PTSD Depression Adjustment disorder- both are linked to anxiety that happens following a stressor but in PTSD the stressor has to be a traumatic event , whereas in adjustment disorder stressor does not have to be severe or outside the range of normal human experience and the symptom intensity is less severe. Panic disorder – PTSD typically lacks the arousal and dissociative symptoms of panic disorder Generalised anxiety disorder -in PTSD avoidance , irritability and anxiety is directly associated with a traumatic event ( it is not in GAD ) Obsessive -compulsive disorder – thoughts in OCD are generally not related to a pas traumatic event unlike PTSD.
Referral –PTSD diagnosis and management is established and led by secondary care as a GP our role is to determine the need for emergency physical and mental health assessment and to co-ordinate care.
Severity-Based on impact of PTSD ( look for scores using tools as TSQ ) it can be mild , moderate or severe. Use clinical judgement to determine the urgency of care needed.
Co-morbidities-As discussed previously PTSD often co-exists with other psychiatric conditions as depression , anxiety and substance misuse- manage as appropriate
Suicide risk-If significant mental illness suspected and the patient is at risk of harming themselves – assess and refer same day to the crisis/ home-treatment team.
NICE recommends active monitoring of distressed trauma-exposed personnel in the 1st month after the incident. Psychological interventions for PTSD include Trauma focused CBT and eye movement desensitisation and reprocessing ( EMDR ) these are 1st line treatments
Medications –Not recommended as routine 1st line treatment strategy it can often have a role in treating symptoms and co-morbid depression or severe hyper-arousal. NICE recommends Venlafaxine or a SSRI like sertraline if the patient has preference for drug treatment
Veterans-Can be referred rapidly under the veteran’s priority scheme
Support-Provide information and support -see under links and resources
LINKS AND RESOURCES
PATIENT SUPPORT RESOURCES
Veterans UK- part of the ministry of defence UK https://psychcentral.com/lib/differential-diagnosis-of-ptsd-symptoms/
Combat Stress UK https://www.combatstress.org.uk/
For patients in the US Pilot database https://www.ptsd.va.gov/
Royal College of Psychiatrists on PTSD https://www.rcpsych.ac.uk/mental-health/problems-disorders/post-traumatic-stress-disorder
PTSD factsheet from Rethink Mental Illnesses https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/post-traumatic-stress-disorder-ptsd/
Mind on PTSD with a helpful video https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/
American Psychiatric Association on PTSD https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
PTSD Counsellor in UK https://www.counselling-directory.org.uk/ptsd.html
INFORMATION FOR CLINICIANS
Trauma Screening Questionnaire http://www.sadag.org/images/pdf/trauma_screening.pdf
A collection of PTSD questionnaires used by the American Psychology Association https://www.apa.org/ptsd-guideline/assessment/
Brief Trauma Questionnaire -free access https://www.ptsd.va.gov/professional/assessment/te-measures/brief_trauma_questionnaire_btq.asp
NICE guideline https://www.nice.org.uk/guidance/ng116
Phoenix Australia PTSD guideline https://www.phoenixaustralia.org/resources/ptsd-guidelines/
American Psychology Association guideline on PTSD https://www.apa.org/ptsd-guideline/
- Post-traumatic stress disorder : diagnosis and management Victoria Williamson , Neil Greenberg Trials in Urology & Men’s Health July/ August 2019 https://www.researchgate.net/publication/337570454_Post-Traumatic_Stress_Disorder_Diagnosis_and_Management
- The management of Post-Traumatic Stress Guideline Summary The management of POs-Traumatic Stress Working Group via healthquality.va.gov 2010
Post Traumatic Stress Disorder NICE guideline 116 December 2018
- Agency for Healthcare Research and Quality Evidence-based Practice Center Systemic Review protocol Psychological and Pharmacological Treatments for Adults with Posttraumatic Stress Disorder ( PTSD ) : Systemic Review May 2017
- International Society for Traumatic Stress Studies-Posttraumatic Stress Disorder Prevention and Treatment Guidelines via www.istss.org
- Latest developments in post-traumatic stress disorder: diagnosis and treatment Neil Greenberg et al British Medical Bulletin Advance Access published April 2015
- VA/ VOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder Departments of Veteran Affairs Version 3 , 2017
- CKS NHS Post-traumatic Stress Disorder https://cks.nice.org.uk/post-traumatic-stress-disorder
- American Psychiatric Association Posttraumatic Stress Disorder
Differential Diagnosis of PTSD Symptoms by Harol Cohen PhD via https://psychcentral.com/lib/differential-diagnosis-of-ptsd-symptoms/