Ep 183 – Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) may develop (either immediately or delayed) following exposure to a stressful event or situation of an exceptionally threatening or catastrophic nature. It is characterised by four groups of symptoms: intrusion symptoms, avoidance, negative alterations in cognition and mood and alterations in arousal and reactivity. These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made. Its presentation is often comorbid with conditions such as depression, anxiety, anger and substance use disorder. In this episode, Dr Roger Henderson looks at the aetiology of PTSD, its assessment, treatment options and prognosis.

Key take-home points

• PTSD is a debilitating mental health condition that arises following exposure to trauma such as actual or threatened death, serious injury or sexual violence.
• Up to 3% of adults have PTSD at any one time and lifetime prevalence rates are between 1.9% and 8.8%.
• Psychological vulnerabilities, including a history of prior psychiatric illness, early life trauma or maladaptive coping strategies increase the risk.
• Development depends on an interaction between the severity and nature of the trauma, the individual’s biological predispositions, their psychological coping mechanisms and the social context in which the trauma occurs.
• Symptoms are grouped into four clusters: intrusion, avoidance, negative alterations in cognition and mood and alterations in arousal and reactivity.
• These symptoms must persist for more than 1 month and cause significant distress or impairment in social, occupational or other areas of functioning.
• If symptoms occur within the first month following trauma, the diagnosis of acute stress disorder is considered instead.
• Substance use is frequent, as individuals attempt to self-medicate intrusive memories or insomnia with alcohol, cannabis or sedatives.
• While some patients exhibit all four symptom clusters vividly, others may present primarily with sleep problems, irritability or vague somatic complaints.
• Evidence strongly supports the use of trauma-focused psychotherapies as first-line interventions. Trauma-focused cognitive behavioural therapy helps patients identify and reframe maladaptive beliefs, confront avoided trauma memories and reduce emotional distress.
• Pharmacological treatment is also important, especially when psychotherapy alone is insufficient or inaccessible, but we should not offer drug treatments, including benzodiazepines, to prevent PTSD in adults.
• Selective serotonin reuptake inhibitors such as sertraline, paroxetine and fluoxetine, as well as the serotonin–norepinephrine reuptake inhibitor venlafaxine, are the only medications with robust evidence for PTSD.
• The course of PTSD is highly variable. Many individuals can experience spontaneous remission, while others may suffer for decades.
• Factors predicting poor outcome include exposure to severe or prolonged trauma, multiple traumas, early onset, comorbid psychiatric disorders and lack of social support.
• The severity of symptoms 2 weeks after trauma is a good predictor of the degree of severity at 6 months.

Key references

1. Bisson JI, et al. BMJ. 2015:351:h6161. doi: 10.1136/bmj.h6161.
2. NICE. 2018. https://www.nice.org.uk/guidance/ng116/.
3. Warner CH, et al. Am Fam Physician. 2013;88(12):827-834.
4. Bisson BI, et al. Cochrane Database Syst Rev. 2013;2013(12):CD003388. doi: 10.1002/14651858.CD003388.pub4.
5. APA. 2022. https://www.appi.org/Products/DSM-Library/Diagnostic-and-Statistical-Manual-of-Mental-Di-(1).