Post-traumatic stress disorder (PTSD)

Question 1

Define PTSD.

Answer 1

Arises as a delayed or protracted response to a stressful event or situation (either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone

e.g. sexual assault, near death experience

Question 2

How common is PTSD? Who is most affected?

Answer 2

Prevalence:

• One year = 1-3 %.
• Lifetime = 6.8%

F>M

Question 3

What are the risk factors for PTSD?

Answer 3

Social:

• severe trauma
• high degree of exposure and proximity
• continuous exposure
• hx of childhood abuse, poor early attachment

Biological:

• genetics

Psychological:

• predisposing traits e.g. neuroticism
• FHx of psych disorders
• survivor guilt

Question 4

What is the triad of PTSD? What are the other clinical features?

Answer 4

1. Reliving - flashbacks or recurrent nightmares
2. Hyperarousal/vigilance - enhanced startle reaction and insomnia
3. Avoidance - due to perceived fear of re-exposure, espeically activities or situations reminiscent of the trauma

Question 5

What are the symptoms of PTSD?

Answer 5

Symptpms must be present for >1 month

1. reliving (flashbacks, nightmares, intrusive images)
2. hyperarousal/vigilance (insomnia and enhanced startle reaction)
3. avoidance

Other:

• ‘numbness’ or emotional blunting
• feeling detached from others
• unresponsiveness to surroundings
• anhedonia
• anxiety and depression
• suicidal ideation
• substance misuse

Question 6

List the hyperarousal symptoms of PTSD.

Answer 6

• hypervigilance for threat
• exaggerated startle response
• sleep problems
• irritability
• difficulty concentrating

Question 7

What is the management of PTSD?

Answer 7

If subthreshold symptoms: watchful waiting + follow up within 1 month

Psychological (1st line)

• Trauma-focused CBT includes:
  
  • cognitive processing therapy
  • cognitive therapy for PTSD
  • narrative exposure therapy
  • prolonged exposure therapy
• EMDR (eye movement desensitization and reprocessing)
• Group therapy - speaking with others with similar experiences

Biological (2nd line, not routine)

• Paroxetine or sertraline (licensed SSRIs)
• Venlafaxine (SNRI)
• Mirtazapine (NaSSa)
• +/- Antipsychotics (e.g. risperidone)
  
  • Only if failed to respond to psychological therapied or other drug treatments or if symptoms/behaviours are disabling

Experimental

• MDMA trials = 80% cure rate at 12 weeks (MAPS)

Question 8

What does trauma-focused CBT involve?

Answer 8

• A traumatic event can shatter previous belief systems (e.g. the world is an unsafe place, I am vulnerable)
• These thoughts can be examined and tested
• Exposure therapy is important (support the patient to work through their memories)
• Warning: talking about the experience can make the patient feel re-traumatised Usually 8-12 regular session
• Can be computerised if the patients would prefer not to do it face-to-face

Question 9

What does EMDR involve?

Answer 9

Offer to adults with a diagnosis of PTSD or clinical important symptoms who have presented > 3 months after non-combat related trauma. Can also be considered earlier.

1. Original trauma is deliberately re-experienced in as much detail as possible (e.g. making the patient narrate every step of it)
2. Whilst doing this, they fix their eyes on the therapist’s finger as it quickly passes from side to side in front of them
3. Eye movements can be replaced by any alternating left-right stimulus (e.g. tapping hands)
4. This aids memory processing

Question 10

What is the course of PTSD and what is the prognosis?

Answer 10

• May last a few weeks or months
• Fluctuating course
• Recovery expected in majority of cases
• Some may have a chronic course with eventual transition to an enduring personality change

Question 11

How does complex PTSD differ from PTSD?

Answer 11

Cause: exposure to prolonged or repetitive events from which escape is difficult or impossible (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

May not be as intense a trigger but will have been prolonged.

+ meets all diagnostic requirements for PTSD

Question 12

What additional problems are present in complex PTSD?

Answer 12

Problems:

1. Affect regulation
2. Dimished beliefs about oneself + feelings of shame, guilt or failure
3. Difficulties in sustaining relationships + feeling detached –> significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Question 13

What is the diagnosis and treatment?

Answer 13

Adjustment disorder - likely to go away once stressor disappears

Background of depression

Unlikely to by psychotic - more likely rumination

Question 14

Ameena undergoes a course of Trauma Focussed CBT to help her overcome her PTSD symptoms. Together with her therapist, they identify a negative thought about the trauma that she holds: ‘I am permanently broken’. This is best described as an example of which type of thinking error?

• A. All or nothing thinking
• B. Filtering
• C. Disqualifying the positive
• D. Mind reading
• E. “Shoulds” thinking

Answer 14

A

Question 15

Abeena is a 35 year old Ghanian A&E nurse. She was sexual assaulted by a stranger at a train station 5 months ago. She attend the psychiatry clinic after her GP referred her with flashbacks and nightmares about the incident. She had a panic attack when she tried to return to the train station to go to work a week ago and has not sued the train since.

Which of the following is not a symptom of the increased arousal seen in PTSD cases such as this:

• A. Difficulty falling asleep
• B. Irritability
• C. Difficulty concentrating
• D. Panic Attacks
• E. Exaggerated startle response