[9] Post-Traumatic Stress Disorder

Question 1

What is PTSD?

Answer 1

PTSD is an intense, delayed reaction following exposure to exceptionally traumatic events. Examples of events include severe assault, major natural disaster, serious RTA, or involvement in wars

Question 2

What can the risk factors for PTSD be divided into?

Answer 2

• Risk factors for exposure
• Pre-trauma risk factors
• Peri-trauma
• Post-trauma

Question 3

What are the risk factors for exposure in PTSD?

Answer 3

• Member of an at risk profession, e.g. armed forces, police, fire service, journalists, doctor
• Refugees or asylum seekers

Question 4

What are the pre-trauma risk factors for PTSD?

Answer 4

• Previous trauma
• History of mental illness
• Female gender
• Low socio-economic background

Question 5

What are the peri-trauma risk factors for PTSD?

Answer 5

• High severity of trauma
• Trauma with perceived threat to life

Question 6

What are the post-trauma risk factors for PTSD?

Answer 6

• Concurrent life stressors
• Absence of social support

Question 7

When must the symptoms of PTSD occur?

Answer 7

Within 6 months of the event

Question 8

What categories can the symptoms of PTSD be divided into?

Answer 8

• Reliving the situation
• Avoidance
• Hyperarousal
• Emotional numbing

Question 9

What are the ‘reliving the situation’ symptoms of PTSD

Answer 9

• Flashbacks
• Vivid memories
• Nightmares
• Distress when exposed to similar circumstances as the stressor

These symptoms are persistent, involuntary, and intrusive

Question 10

What are the avoidance symptoms of PTSD?

Answer 10

• Avoiding reminders of the trauma, e.g. associated people or locations
• Excessive rumination about the trauma
• Inability to recall aspects of the trauma

Question 11

What are the hyperarousal symptoms of PTSD?

Answer 11

• Irritability or outbursts
• Difficulty with concentration
• Difficulty with sleep
• Hypervigilance
• Exaggerated startle response

Question 12

What are the emotional numbing symptoms of PTSD?

Answer 12

• Negative thoughts about oneself
• Difficulty experiencing emotions
• Feeling of detatchment from others
• Giving up previously enjoyed activities

Question 13

What are the ICD-10 criteria for diagnosis of PTSD?

Answer 13

There must have been an exposure to a stressful event, or situation of an extremely threatening or catastrophic nature. The patient must have persistent remembering (reliving) of the situation, actual or preferred avoidance of similar situations resembling or associated with the stressor, and either an inability to recall some of the important aspects of period of exposure to stressor, or persistent symptoms of increased psychological sensitivity and arousal. All these things must occur within 6 months of the stressful event, or the end of a period of stress.

Question 14

How is PTSD investigated?

Answer 14

• History
• MSE
• Questionnaires - Trauma Screening Questionnaire, Post-traumatic diagnostic scale

Question 15

What are the differential diagnoses of PTSD?

Answer 15

• Adjustment disorder
• Acute stress reaction
• Bereavement
• Dissociative disorder
• Mood or anxiety disorder
• Personality disorder
• Head injury (may result from the traumatic event)
• Alcohol/substance misuse

Question 16

How is PTSD managed when symptoms are present within 3 month of the trauma?

Answer 16

• Watchful waiting can be used for mild symptoms lasting for <4 weeks
• Trauma focused CBT
• Short-term drug treatment can be considered for acute phase management of sleep disturbance, e.g. zopiclone
• Risk assessment - risk for neglect or suicide

Question 17

How much trauma focused CBT should be given in PTSD when symptoms have been present for <3 months?

Answer 17

Should be given at least once a week for 8-12 sessions

Question 18

How is PTSD managed when symptoms have been present for >3 months after trauma?

Answer 18

• All sufferers should be offered a course of trauma-focused psychological intervention
• Drug treatment

Question 19

What trauma-based psychological interventions can be offered in PTSD when symptoms persist for over 3 months after trauma?

Answer 19

• CBT
• Eye movement desensitisation and reprocessing (EMDR)

Question 20

What is EMDR?

Answer 20

A technique that involves eye movements to help the brain process traumatic events. It is aimed at reducing distress in the shortest period of time.

Question 21

When should drug treatment be offered in PTSD?

Answer 21

• When little benefit from psychological therapy
• When the patient doesn’t want to engage in psychological therapy
• If there is co-morbid depression or severe hyperarousal which would benefit from pharmacological interventions

Question 22

What drugs are used in the treatment of PTSD?

Answer 22

• Paroxetine
• Mirtazapine
• Amitriptyline
• Phenylzine

Mirtazapine is probably the best option

Question 23

What is the mechanism of action of mirtazapine?

Answer 23

It acts as a 5HT-2 and 5HT-3 antagonist.

Question 24

What are the side effects of mirtazapine?

Answer 24

• Sedation
• Weight gain

Question 25

How does mirtazapine cause sedation?

Answer 25

It is a strong H1 antagonist (antihistamine) activity

Question 26

What is good about the side effects of mirtazapine?

Answer 26

They can be used to therapeutic advantage