post traumatic stress disorder

Last edited 04/2022 and last reviewed 04/2022

Post-traumatic stress disorder (PTSD) is a reaction which a person may develop in response to one or more traumatic events/stressors.

• a stressor which precipitates a PTSD is often of such a magnitude that the patient's coping strategies and defense mechanisms are overwhelmed
• post trauma reaction may vary greatly between individuals, it may range from highly resilient--with little or no emotional distress-- to those that are relatively mild and short-term, to those that are major, chronic, and highly debilitating (1)

Trauma can be explained as an event or experience that is shocking and overwhelming, usually  associated with a major threat to physical, emotional, or psychological safety and well-being of the individual victim(s) and loved ones and friends (as well as to others)

• these traumatic events can occur in many ways (1,2)
• direct experiencing
• witnessing, in person
• learning that the traumatic event(s) occurred to a family member, or someone else in close relationship
• experiencing repeated or extreme exposure to aversive details of the traumatic event(s) -common in first responders and emergency personnel
  
  
• traumatic event can be a one-time event or it may occur on a regular or prolonged basis such as sexual abuse in childhood (3)
  • post-traumatic stress disorder (PTSD) develops after a stressful event or situation of an exceptionally threatening or catastrophic nature
    • it is a disorder that can affect people of any age
    • around 25-30% of people experiencing a traumatic event go on to develop PTSD
      
      
• examples of traumatic events include
• military combat, acts of terror
• motor vehicle and other accidents
• natural or human-caused disasters and accidents
• sudden or violent death of loved ones
• interpersonal violence, such as mass shootings, assaults, and physical, sexual, and emotional abuse
• traumatic separations and other significant losses (including neglect and abandonment);
• hostage-taking
• torture; slavery
• certain types of disability, illness, and medical treatment, especially for life-threatening conditions
  
  
• stressors caused by “upsetting events” that are described as traumatic in everyday language e.g. - divorce, bullying, loss of a job or failing an examination, death of a pet, and learning about a diagnosis of cancer in a close family member are not deemed extreme enough to precipitate PTSD. (1,2,3)
• however symptoms similar PTSD may be seen in these instances which raise questions about the validity of the definitions for traumatic events.

In International Classification of Diseases, Injuries, and Causes of Death (ICD-10), it is classified as a neurotic stress-related and somatoform disorder while in DSM-5, PTSD was moved from a fear-based anxiety disorder to a new category entitled, “Trauma- and Stressor-Related Disorders (1).

• PTSD can present with a range of symptoms (3)
  • adults - most common of these are vivid, distressing memories of the event or flashbacks, known as intrusive symptoms
    • another prominent symptom is avoidance of trauma-related reminders or general social contact. People with PTSD often try to push memories of the event out of their mind and avoid thinking or talking about it in detail
    • on the other hand, people may also reflect excessively on questions that prevent them from coming to terms with the event - for example, why it happened to them, how it could have been prevented, or how they could take revenge
    • people with PTSD often have nightmares related to the trauma that affect their sleep
      
      
  • symptoms of PTSD often develop immediately after the traumatic event but in some people (fewer than 15%) onset is delayed
    • people may not present for treatment for months or years despite experiencing considerable distress
    • PTSD is a treatable disorder, even for people who present many years later, but assessment can be challenging because many people avoid talking about their problems even when presenting with associated complaints
      
      
  • children, particularly those aged under 8 years, may not complain directly of PTSD symptoms such as re-experiencing or avoidance
    • instead, symptoms may take the form of re-enacting the experience, repetitive play or frightening dreams with no recognisable content

Early pharmacological interventions for universal prevention of PTSD

• SSRIs improve PTSD symptoms and are first line pharmacotherapy based on moderate certainty evidence (4)
  • mirtazapine and amitriptyline may also improve PTSD symptoms but this is based on low-certainty evidence

Reference:

• (1) American Psychological Association (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults
• (2) Bisson JI et al. Post-traumatic stress disorder. BMJ. 2015;351:h6161
• (3) NICE (December 2018).Post-traumatic stress disorder (NG116)
• (4)Williams T, Phillips NJ, Stein DJ, Ipser JC. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub3.