Post-Traumatic Stress Disorder Flashcards
Define
ICD-10: arises as a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone
o Must last >1 month
o Often begins within 6 months of trauma (often within the 1st month of the trauma)
Epidemiology
Women are at higher risk of developing PTSD than men in civilian life
Only 10% of those who experience extreme trauma develop PTSD
Aetiology
Caused by exposure to traumatic events, such as:
- Serious/ life-threatening accident
- Physical or sexual assault
- Abuse (including childhood or domestic)
- Work-related exposure to trauma, including remote exposure
- Trauma related to serious health problems or childbirth experiences (e.g. ICU admission or neonatal death)
- War and conflict
- Torture
Symptoms persist for several weeks (AT LEAST 1 MONTH)
Complex PTSD events may include torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse
PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations. During traumatic experiences, the high levels of stress hormones secreted
suppress hypothalamic activity that may be a major factor toward the development of PTSD
Risk factros
- Severity of incident
- Female sex
- Younger age
- Previous experience of trauma
- Presence of multiple major life stressors
- Low social support
- Social disadvantage, history of mental health disorder
- History of anxiety disorder
- Refugee population
- Military population (survivor guilt)
Predisposing traits: neuroticism, FHx of psych disorders, childhood abuse, poor early attachment
In children: the risk of PTSD is reduced by good family support and when there is less parental distress
Symptoms
NOTE: symptoms should manifest within 6 months (can be delayed sometimes but usually within the first month)
MAIN SYMP TO SCREEN FOR:
Re-experiencing the event(s)
- Can occur in daytime when awake (flashbacks, or intrusive images or thoughts)
- Can occur as nightmares when asleep
Avoidance of external reminders, and/or thoughts and memories of the event
E.g., if car accident - have they stopped driving
Hyperarousal (including hypervigilance, enhanced startle reflex, anger, irritability, difficulty concentrating)
Other:
- Negative alterations in mood and thinking
- Emotional numbing (detachment)
- Dissociation
- Emotional dysregulation
- Interpersonal difficulties or problems in relationships
- Negative self-perception (including feeling diminished, defeated or worthless)
- Can interfere with memory –> Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor
Children with PTSD
- Dreams of trauma, which can turn into nightmares of monsters
- Re-living the trauma in their play
- Losing interest in things they previously enjoyed
- Expressing the belief that they will not live long enough to grow up
- Stomach aches and headaches
Signs O/E
Mild PTSD
- Distress caused by the symptoms is MANAGEABLE
- Person’s social and occupational functioning are NOT significantly impaired.
Moderate PTSD
- Distress and impact on functioning lie somewhere between mild and severe
- There is NOT considered to be a significant risk of suicide, harm to self, or harm to others.
Severe PTSD
- Distress caused by the symptoms is felt to be UNMANAGEABLE
AND/OR
- There is significant impairment in social and/or occupational functioning
AND/OR
- There is considered to be significant risk of suicide, harm to self, or harm to others
Investigations
- Trauma Screening Questionnaire
- GAD7 and Urine Drug screen
- Physical exam
- Bloods: TFTs, FBC
Referral to Mental Health Service (if in Primary Care)
DDx
- Acute stress disorder
- GAD
- Adjustment disorder
- Depression
- Panic Disorder
- Dissociative Disorder
Management
If patient found to be at high risk- refer urgently (same day) to crisis resolution and home treatment team
If symptoms are mild and occurring within 4 weeks of the trauma, watchful waiting is the most appropriate course of action and treat comorbid conditions (i.e. depression)
1st Line: Psychological Therapies
- CBT (Trauma-Focused)
- Exposure therapy
Person confronts their memories (by recounting the event) and is repeatedly exposed to situations which they have been avoiding (as it elicits fear)
Trauma-focused cognitive therapy
Identifies and modifies misrepresentations of the trauma and its aftermath that lead the person to overestimate the threat
Eye Movement Desensitisation and Reprocessing (EMDR)
- Not offered until CBT is done
- Original trauma is deliberately re-experienced in as much detail as possible
- While doing this, fix their eyes on the therapist’s finger as it quickly passes from side to side in front of them
- Thought to aid memory processing
2nd Line: Biological Treatment
Antidepressants
- Venlafaxine (SNRI) or SSRIs (e.g. Paroxetine) and Mirtazapine
NOTE: these can cause increased risk of suicidal thinking and self-harm in < 30 years so should be followed up within a week of starting medication
- Risk assess weekly in the first month of starting medication
- Pharmacological interventions may be given first to those who express a preference
Antipsychotics (may be considered if SEVERE)
- Risperidone
Social Interventions
- Sleep hygiene
- Support groups: Mental Health Foundation, Mind, Rethink
Complications / Prognosis
Complications
- Symptoms can cause significant impairment on personal, family, social, educational, occupational, or other important areas of functioning
- Can have depression, anxiety disorders occurring alongside
Prognosis
- The majority recover from PTSD
- Some suffer for many years
- Chronicity can lead to enduring personality change
- Symptoms can resurface on anniversaries associated with trauma
PTSD PACES
We think you are experiencing a type of anxiety disorder called post-traumatic stress disorder.
PTSD is a condition that occurs after someone has experienced a traumatic event. You might feel like you’re reliving the trauma and might feel on high alert and anxious. It might also affect your behaviour and make you avoid things that can trigger the emotions.
We first recommend something called CBT- it’s a type of therapy where a therapist examines and tests your beliefs about the world. It doesn’t require you to vividly recall the trauma but can help you understand the link between your current feelings and the trauma. It will take 12 weekly sessions.
We can also consider something called EMDR where you recall the experience while doing some actions to help you process the event, though that’s something to talk about later.
I’d like to catch-up in 4 weeks to see how you’re getting on with CBT and whether there has been any difference in your symptoms.
