This is a UKMLA-centred history guide about Post-Traumatic Stress Disorder.

Introduction

Post-traumatic stress disorder, a condition first recognised in war veterans, is a mental health problem that some experience following traumatic events. PTSD develops in around ⅓ of people who experience trauma; it is still unclear why some people develop this and others do not, although a few theories have been suggested. 

Definition 

A mental health condition that occurs following exposure to a major traumatic event. This may be due to direct experience, witnessing, extreme exposure (first responders) or learning of an event happening to a close family member. The event may include, but is not limited to, a serious accident, abuse, assault, trauma, torture or conflict. 

Causes 

• Car crash 
• Abuse/harassment/bullying 
• Rape/sexual assault
• Kidnap 
• Violence (whether this is taking part or being subject to)
• Natural disaster 
• Traumatic childbirth/hospital admission 
• Mental health admission 
• Losing someone suddenly/in a traumatic way 

Risk factors 

• Exposure to a traumatic event 
• A more severe event often leads to more severe PTSD
• Trauma over a long period of time 
• Involvement of physical pain 
• Female 
• Young age 
• Premorbid personality 
• Other life stressors 
• Poor social support 
• History of mental health disorders and substance abuse

Vulnerable groups 

• Military 
• Emergency services 
• Social workers 
• Refugees and asylum seekers 
• Those with physical health problems 
• Other social concerns 

Signs and symptoms 

Symptoms usually occur within 3 months of the event, but can present at any point in life and may have a delayed onset.

HARD acronym 

H – hyperarousal (hypervigilance/anger/irritability/poor concentration)

A – avoidance (thoughts/reminders/memories/people)

R – re-experiencing (flashbacks/nightmares)

D – dissociation or dysregulation 

Other symptoms 

• Negative mood and thinking 
• Feeling ‘on edge’ 
• Dissociation 
• Isolation 
• Insomnia 
• Irritability 
• Emotional numbing 
• Interpersonal difficulties
• Physical symptoms (headache/dizziness/sweating/exhaustion/chest and abdominal pain)
• Social impact (self-neglect/inability to hold down a job/poor decision making/substance abuse)
• Other mental health conditions (anxiety/depression/dissociative disorders)
• Children reenacting an event through play 

Diagnosis 

• Consider PTSD in someone experiencing the above symptoms following a traumatic event
• Consider PTSD in someone presenting with repeated unexplained physical symptoms
• Referral to mental health specialists trained in diagnosing PTSD via DSM5 or ICD11

Questionnaires 

Trauma screening questionnaire – https://www.sadag.org/images/pdf/trauma_screening.pdf

DSM5 criteria 

Exposure to actual or perceived danger

Persistently re-experiencing one intrusive symptom:

• Intrusive memories 
• Nightmares 
• Dissociation 
• Distress 
• Reactivity 

Persistently avoiding associated stimuli:

• Thoughts or feelings 
• Reminders 

Experiencing at least two negative changes in mood:

• Poor recollection of features associated with the event 
• Negative beliefs or expectations 
• Distorted blame 
• Negative emotional state 
• Reduced interest in pre-trauma activities 
• Detachment  
• Inability to experience positive emotions 

Experiencing at least two alterations in arousal and reactivity:

• Irritability/aggression 
• Recklessness/Self-destruction 
• Hypervigilance 
• Exaggerated startle response 
• Poor concentration 
• Sleep disturbance 

The above symptoms should:

1. Cause significant distress or functional impairment
2. Not be caused by medication, substance use or other illness 
3. Be persistent for over one month 

ICD11 criteria 

• Symptoms presenting within 6 months of the event
• Exposure to a traumatic event 
• Persistent remembering or reliving of the event with associated distress 
• Actual or preferred avoidance 
• Inability to recall or increased arousal

Treatment 

• Determine the need for emergency physical and mental health assessment
• Determine risk, quality of life and functional impairment
• Urgent referral to crisis or home treatment teams if high risk of suicide

Subclinical symptoms 

• Active monitoring with regular follow-up 

Self-care for PTSD 

• Understand your own triggers 
• Challenge the unhelpful thoughts 
• Open up to friends and family members 
• Look after physical health 

Psychological therapies for diagnosed PTSD

• Trauma-focused cognitive behavioural therapy
  • Cognitive processing therapy 
  • Cognitive therapy for PTSD 
  • Narrative exposure therapy 
  • Prolonged exposure therapy 
• Eye movement desensitisation and reprocessing 

Consider drug treatment (venlafaxine/paroxetine/SSRI/risperidone) in the following circumstances 

• Patient is over the age of 18 (unless recommended by a specialist)
• Personal preference 
• Declined psychological therapies or cannot engage 
• Co-morbid depression 
• Poor response to psychological therapies 
• Delayed referral 

Support groups 

• Veterans UK
• Anxiety UK 
• National Child Traumatic Stress Network 
• Combat stress 
• Rape Crisis England and Wales 
• Victim support 
• CRUSE 
• UK Psychological Trauma Society 
• PILOTS database 
• David Baldwin’s Trauma pages 

Complications 

Delayed-onset PTSD 

• When symptoms of PTSD start at least 6 months after the trauma.

Birth trauma 

• PTSD related to traumatic childbirth.

Complex Post-Traumatic Stress Disorder (CPTSD)

Causes 

Usually due to pervasive experiences of a series of threatening events. Trauma often occurs from a young age and can develop following events where rescue is impossible or very unlikely. 

Examples include, but are not limited to:

• Childhood abuse/neglect 
• Domestic violence 
• Sexual abuse 
• Slavery or torture 
• Kidnapping 
• Sex trafficking
• War and conflict  

Symptoms 

All diagnostic requirements for PTSD being met, CPTSD is additionally characterised by severe and persistent:

• Problems in affect regulation 
• Self-belief diminished, defeated or worthless
• Feelings of guilt, shame or failure 
• Difficulties sustaining relationships and feeling close to others 

These symptoms cause significant impairment in personal, family, social, educational and occupational functioning.

Treatment 

Like PTSD, treatment will likely include a combination of psychological therapies and medication. Treatment is often intense and more long-term. 

References and Resources

1. https://cks.nice.org.uk/topics/post-traumatic-stress-disorder/
2. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/overview/
3. https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/understanding-ptsd/

Written by – Dr Emily Ross (FY1) 

Reviewed by – Dr James Sandell (CT2) 

Edited by – Dr Daniel Arbide (FY2)