Post-traumatic stress disorder

Summary
Post-traumatic stress disorder (PTSD) has been the focus of considerable attention, and some controversy, since it was formally recognised in 1980. It is a common anxiety disorder in Australia with a 12-month prevalence of 3.3%. In its more serious forms, it is a chronic and disabling psychiatric disorder associated with high comorbidity and impairment of functioning. The possible existence of the disorder can be ascertained with a few simple questions. Several strategies may be adopted by primary health care providers to assist patients with both acute and chronic forms of the disorder. Referral for intensive treatment should be made in more severe cases.

Introduction
The history of reactions to trauma goes back for many hundreds of years. References appear as far back as Homer's Iliad. Historically, terms such as shell shock, battle fatigue and compensation neurosis have been used to describe the psychological effects of trauma. It was not until 1980, however, with the advent of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III),¹ that the disorder was formally recognised. The term post-traumatic stress disorder (PTSD) emphasised that a single disorder accounted for the psychopathological consequences of all traumatic events such as combat, rape and life-threatening accidents. The definition of specific diagnostic criteria has prompted considerable empirical research and theoretical debate.

Clinical presentation
Psychological distress is part of a normal human response to overwhelming experiences. Only when symptoms are severe, or last too long, is the response considered pathological. In the majority of people, symptoms progressively resolve over the first few months. There is a return of a sense of safety and the soothing of disturbed patterns of reactivity.

In a minority of cases, there is a progressive recruitment of symptoms and disability in the period following traumatic exposure. This represents PTSD. Research suggests that around 10% of women and 5% of men will meet criteria for PTSD at some stage in their lives.² Of these, around 60% will recover, even without the benefit of treatment.^2,3 Other life stressors, and environmental triggers reminiscent of the trauma, play a central role in determining the severity of current symptoms. The symptoms commonly vary in intensity over time and occasionally present years after the trauma.

An essential requirement for a diagnosis of PTSD is experience of a traumatic event. DSM-IV (summarised in Table 1) emphasises a physical threat, as well as the presence of subjective distress. This latter feature is a matter of controversy because the variability of perception between people exposed to the same event can introduce a person's premorbid stress reactivity into the aetiological equation. This is in some conflict with the notion of the stress having the primary role in the diagnosis.

A second group of diagnostic criteria relates to re-experiencing the trauma. Individuals with PTSD remain so captured by the memory of past horror that they have difficulty paying attention to the present. In an attempt to prevent the occurrence of these distressing re-experiencing phenomena, the person is likely to avoid any reminders of the trauma. In more severe cases, there is a pervasive numbing of general responsiveness to a variety of current life experiences. The numbing symptoms are proposed as being central to the diagnosis of PTSD, differentiating it from an uncomplicated distress response.⁴

The final cluster of symptoms is those of persistently increased arousal. This may include sleep disorders.

The DSM-IV requires that symptoms have been present for at least one month, highlighting the fact that such a symptom constellation may be common in the first few weeks. There is a delayed category in which the onset of symptoms is at least 6 months post-trauma. Comorbidity (notably alcohol abuse and depression) is common - around 44% of women and 59% of men with chronic PTSD will meet criteria for at least 3 other psychiatric disorders.²

A new category of acute stress disorder (ASD) is included in the DSM-IV and the International Classification of Diseases, 10th revision. It describes a post-trauma reaction that has been present for less than the 4 weeks required for PTSD. ASD is also differentiated from PTSD by symptoms of dissociation (such as feeling in a daze, derealisation and depersonalisation), which are particularly disruptive to functioning. Some, but not all, patients with PTSD will have suffered from ASD.

Assessment
PTSD is easily overlooked. Individuals may present with vague complaints, little or no account of the traumatic experience and emotional numbing. Avoidance further contributes to problems in diagnosis. If PTSD is suspected, a few key screening questions may be useful:

• Do you have vivid memories of a traumatic event?
• Do you avoid things that remind you of the trauma?
• Do you feel emotionally numb?
• Are you irritable or constantly on edge?

A history should establish the nature and course not only of core PTSD symptoms, but also of likely comorbid conditions such as depression, anxiety and substance abuse. In order to understand the patient's reaction to the experience, information must be collected regarding the broader context, including current social supports.

Treatment
Not all people who experience trauma require treatment. Severe traumatic events rarely leave the individual unaffected, but the majority of survivors adapt without developing enduring symptoms. This impression can lead to trivialising the reactions of those who are more severely impaired and to underestimating the importance of early intervention. Empathic care by general practitioners (as well as teams caring for injured survivors) is critical to creating feelings of safety and to negotiating the path to more intensive treatment if required. Cases of chronic PTSD (more than 3 months' duration) should be referred to an experienced mental health professional. Early attention to comorbid disorders such as depression is strongly recommended.

To assist survivors of trauma, it is common to work through several phases of treatment in a specific order (Table 2).

Support and stabilisation
Provide advice on practical issues. This may include establishing realistic short-term goals and assisting with problem solving. Encourage a return to normal activities at a gentle pace as soon as possible. Attention should be paid to minimising alcohol and drug use.

Education
Provide information about typical traumatic stress symptoms, with reassurance that such reactions are common, and promote expectations of recovery. If appropriate, assist the person in finding out more about what happened to them and why. Attempts to make sense of the experience are an important part of recovery.

Stress management
Provide advice on simple stress management strategies such as aerobic exercise and distraction techniques. If possible, try more specific techniques such as deep muscle relaxation and breathing retraining. Practical advice around issues such as sleep and diet - especially reducing stimulants like caffeine and nicotine - will often be useful. Assisting and encouraging the individual to use relationship networks is likely to facilitate recovery.

Trauma focus work
In acute cases, provide opportunities to discuss the traumatic experience. This enables the person to confront the painful memories and their associated feelings in a safe environment, and to reflect on the meaning of the event. Equally, be aware that not everyone will be ready to talk about the trauma at the same time. Although the same process occurs in the treatment of chronic PTSD, it is more complex and may carry some associated risks. The identification of subtle triggers to traumatic memories can help minimise the repeated escalation of distress.

Relapse prevention and maintenance
Recognise that recovery from trauma is a long process. The survivor may require additional support from time to time, especially during periods of crisis. The management of irritability and numbing in the context of relationships is often critical in maintaining social networks.

Pharmacological interventions
The dearth of randomised clinical trials limits our knowledge of this area. Nevertheless, medication is an important adjunct to psychological treatment and support in those with severe symptoms. It also has an important role in the treatment of comorbidities associated with PTSD. Some authors have recommended the use of anti-adrenergic drugs (notably clonidine) in the management of acute stress reactions.⁵ Tricyclic antidepressants can be helpful if severe insomnia emerges. Benzodiazepines are not useful.⁶

The most commonly prescribed medications in chronic PTSD are antidepressants. The size of treatment effect is similar for all types of antidepressants, with adverse effect profiles often influencing the specific choice.⁷ When prescribing antidepressants in PTSD, it is important to ensure that the dose is sufficiently high to optimise the therapeutic effect. Patients should be advised that they might have to remain on the medication for some time, with progressively increasing benefit over time. Experience has shown that patients are highly vulnerable to relapse for months, even years. In a significant minority of patients, the goal of treatment should be maintenance with the minimisation of secondary disability.

Referral for specialist help
One of the major impediments to effective treatment is the reluctance of people with severe symptoms to seek help. The failure of a patient's distress to settle quickly is the main indication for referral. An eclectic, multidimensional approach is necessary to maximise outcomes. Several specialist techniques have been tried including cognitive-behavioural and brief psychodynamic approaches, hypnosis and eye movement desensitisation and reprocessing (EMDR).⁸ Foa⁹ has highlighted the importance of engagement to successful psychotherapeutic interventions in PTSD, as well as noting that anger is often a defensive barrier to confronting traumatic memories and seeking treatment.

Conclusion
PTSD is a potentially chronic and disabling psychiatric disorder, with considerable cost to the community in terms of both economics and human suffering. Primary health care providers play a central role in diagnosis, as well as in overcoming the avoidance that is often a critical barrier to effective treatment. Evidence is emerging that delayed treatment is an important risk factor for chronicity. This highlights the importance of understanding indirect manifestations such as somatic symptoms or unexpectedly prolonged disability following physical injury.