ABSTRACT | PDF
Seminar I
Posttraumatic stress disorder: clinical features and management
Atmesh Kumar
Postgraduate Trainee of Psychiatry, Silchar Medical College and Hospital
Introduction Posttraumatic stress disorder (PTSD) arises as a delayed or protracted response to a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or manmade disaster, combat, serious accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape, or other crime). Predisposing factors include personality traits, neurotic illness etc. It can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme. Usually arises within six months of an event. Around 25–30% of people experiencing a traumatic event may go on to develop PTSD.
Lifetime incidence of PTSD is nine to 15% and lifetime prevalence is around eight per cent. Among high risk groups lifetime prevalence is five to 75%. It is most prevalent in young adults and women than men. Prevalence is higher in children than adults exposed to the same stressor. Men’s trauma is usually combat experience while that of women’s is most commonly assault or rape.
Beliefs that can be damaged by traumatic stress Belief in one’s basic safety, in being the master of oneself and one’s environment, in “what’s right” — moral order, that our cause is honourable, that every troop is valued, in the basic goodness of people (especially oneself).
Causes of shame or guilt in traumatic stress injuries Surviving when others did not, failing to save or protect others, killing or injuring others, helplessness, failing to act, loss of control, even just having stress symptoms of any kind.
Norepinephrine system During trauma, locus coeruleus mediates sympathetic outflow. With increase in norepinephrine (NE), amygdala mediates coupling of emotional valence to declarative memories via long term potentiation forming deeply engraved trauma memories leading to intrusive memories and emotions potentially leading to PTSD. Outflows to amygdala have rapid effect and to adrenal medulla having sustained effect.
Diagnostic guidelines According to the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), the disorder should generally arise within six months of a traumatic event of exceptional severity. According to the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), duration of symptoms lasts more than one month. Acute PTSD is of less than three months’ duration and chronic PTSD is of more than three months’ duration. Delayed onset if onset of symptoms six months after the stressor.
Clinical features The most characteristic symptoms of PTSD are re-experiencing symptoms in a very vivid and distressing way, avoidance of reminders of the trauma, symptoms of hyperarousal, emotional numbing, mental status examination (MSE) reveals feelings of guilt, rejection and humiliation. Associated symptoms are aggression, violence, poor impulse control, depression and substance related disorders. Cognitive testing reveals impaired memory and attention, elevated Sc, D, F, and Ps scores on Minnesota Multi-phasic Personality Inventory (MMPI), aggressive and violent material on Rorschach test.
Reexperiencing the trauma involves flashbacks, nightmares, repetitive and distressing intrusive images or other sensory impressions. Reminders of the traumatic event arouse intense distress and/or physiological reactions. In children, there are reenacting the experience, repetitive play or frightening dreams. An individual must exhibit at least one reexperiencing symptom to meet the criteria for PTSD.
Symptoms of avoidance include efforts to avoid related thoughts or activities, anhedonia, impaired memory of the event, blunted affect, feelings of detachment or derealisation, and sense of foreshortened future. An individual must exhibit at least three such symptoms.
Symptoms of increased arousal include insomnia, irritability, hypervigilance, exaggerated startle, and difficulty in concentration. An individual must exhibit at least two such symptoms. The duration of symptoms should be at least one month.
Symptoms of emotional numbing include lack of ability to experience feelings, feeling detached from other people, giving up previously significant activities, and amnesia for significant parts of the event.Symptoms of PTSD often develop immediately after the traumatic event but in some (less than 15% of all sufferers) the onset of symptoms may be delayed.
PTSD in children and adolescents Repetitive dreams of the event, nightmares of monsters, physical symptoms like stomachache, headache, etc., traumatic play, reenactment, higher prevalence when exposed to same trauma (up to 90%), substance abuse, delinquency, sexual acting out, regressive behaviours, etc.
Gulf War Syndrome During 1990-1991 in Persian Gulf war against Iraq about 15% soldiers exhibited irritability, chronic fatigue, shortness of breath, muscle and joint pain, migraine headache, digestive disturbances, rash, hair loss, forgetfulness and difficulty concentrating caused by environmental biological stressors, probable unidentified toxins involving right parietal lobe, basal ganglia and neurotransmitter dysfunction.
9/11/01 On September 11, 2001 terrorist attack at World Trade Centre (WTC) resulted in more than 3,500 casualties. 11.4% developed PTSD and 9.7% depression. In 2004 more than 25,000 still suffered from PTSD.
Iraq and Afghanistan In the wake of 9/11/01, there were invasion of Afghanistan on October 2001 and invasion of Iraq on March 20, 2003. About 17% of returning soldiers have PTSD where more women suffered than men.
Tsunami On 26/12/2004, Indonesia, Sri Lanka, South India, Thailand, coast of Africa and South Africa are affected with more than 300,000 deaths and turning more than 1,000,000 homeless. Many survivors continue to live with PTSD; fishermen fear going out to sea, children fear playing at beaches, families have trouble sleeping at night.
Hurricane On August 2005, category five hurricane, Katrina engulfed Gulf of Mexico, the Bahamas, South Florida, Lousiana, Mississippi and Alabama, killing more than 1,300 and tens of thousands were affected.
Earthquake On October 8, 2005, 7.6 magnitude earthquake hit Pakistan, Afghanistan and Northern India resulting in more than 85,000 casualties. Up to 3,000,000 were left homeless and many still suffer from PTSD.
Torture As defined by United Nations, torture is any deliberate infliction of severe mental pain or suffering, usually through cruel, inhuman or degrading treatment or punishment. It is common in most of the 150 countries worldwide. Five to 35% of the world’s 14 million are refugees. Torture is distinct from other trauma because its human inflicted and intentional. It can be either physical or psychological. PTSD is seen in about 36%. There are comorbid depression, anxiety disorders, somatisation, etc.
Management The National Institute for Health and Clinical Excellence (NICE) guidelines for PTSD –
1. Brief single session intervention (debriefing) should not be a routine practice.
2. Watchful waiting.
3. Trauma focused psychological intervention on outdoor patients’ department (OPD) basis (cognitive behavioural therapy [CBT], eye motion desensitization and reprocessing [EMDR]).
4. Trauma focused CBT for children and young people.
5. Drug treatment for PTSD is not routinely used, exceptions are:
i) those that refuse psychological treatment,
ii) those who do not respond to psychological treatment.
6. Disaster screening is carried out one month after disaster.
What is the natural course of PTSD? Usual onset of symptoms is a few days after the event. Many recover without treatment within months/years of event (50% natural remission by two years), but some may have significant impairment of social and occupational functioning. Treatment means that about 20% more people with PTSD recover. Generally 33% remain symptomatic for three years or longer with greater risk of secondary problems.
How to treat PTSD: key messages Increased awareness and greater recognition of PTSD especially in primary care should be generated. Increased provision of trauma focused psychological treatments. Shift away from inappropriate use of medications and brief single session psychological treatments (debriefing).
Immediate management of PTSD Psychological first aid is to be provided. Give information and social support as soon as possible. Avoid brief single session debriefing given to individuals alone following an event. Watchful waiting if symptoms are moderate – assess whether natural recovery occurs, review at one month. Screen at risk groups following disaster, refugees and asylum seekers.
Interventions for PTSD over time: within three months of trauma Treat PTSD within one month if symptoms are severe. Introduce trauma focused CBT by first month if symptoms persist.
Interventions for PTSD over time: beyond three months of trauma Trauma-focused CBT or EMDR is used as first line treatment for people with more than a three month history of symptoms. Drug treatments should not be used in routine care in preference to a trauma focused psychological therapy.
Where drug treatments are used General use: paroxetine or mirtazapine. Specialist use: amitriptyline or phenelzine.
Psychological treatments Interventions need to be focused on the trauma and structured. Trauma-focused CBT-therapist helps the PTSD sufferer to confront traumatic memories with less fear, modify misinterpretations which overestimate threat, and develop skills to cope with stress.
EMDR is a structured trauma-focused psychological intervention. PTSD sufferer is asked to recall an important aspect of the traumatic event. The sufferer follows repetitive side to side movements, sounds or taps as the image is being focused on.
Challenges in treating PTSD In the management of ongoing trauma e.g. domestic violence, ensure safety before starting treatment. If comorbid drug and alcohol misuse is severe, treat it first. In case of severe depression, treat the depression first but most depression will get better. Be aware of possible increased risk in some of ex-military personnel. In presence of personality disorder, can still treat PTSD but may need to extend sessions. Traumatic bereavement may complicate treatment.
What special issues are there for children and young people? Diagnostic categories are same as adult. Important to talk to children directly and not rely solely on information from parents for diagnosis. Symptoms may differ in younger children (e.g. reenacting, repetitive play, emotional and behavioural disturbances). Offer trauma focused-CBT for children with PTSD. Drug treatments should not be routinely prescribed.
Pharmacotherapy In PTSD, randomised trials have shown effectiveness of selective serotonin reuptake inhibitors (SSRTs), tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). SSRIs are first line treatment. They are safer and better tolerated. Sertraline and paroxetine are the only ones approved by Food and Drug Association (FDA). β-blockers may reduce peripheral sympathetic tone. It perhaps has potential to worsen depression. Once a drug seems effective, continue for at least 12 months.
Recent updates
1. Guided self help
2. Multicomponent CBT packages
3. Augmentation strategy
4. PTSD diagnosis could appear on driver’s license
5. Local anaesthetics may relieve PTSD symptoms
6. Complex PTSD
References
1. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th and 9th editions
2. Kaplan and Sadock’s Synopsis of Psychiatry, 10th edition
3. Kaplan and Sadock’s Concise Textbook of Psychiatry, 3rd edition
4. Shorter Oxford Textbook of Psychiatry. Gelder, Harrison, Cowen, 5th edition
5. Text revision of fourth edition of Diagnostic and Statistical Manual Of Mental Disorders (DSM-IV-TR)
6. Tenth edition of International Statistical Classification of Diseases and Related Health Problems (ICD-10)
7. Worldwideweb
8. Clinical Guideline 26, Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. ISBN: 1-84257-922-3. Published by the National Institute for Clinical Excellence March 2005
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