Post-Traumatic Stress Disorder (PTSD)

Mental and behavioral disorder that can develop because of exposure to a traumatic event

Aetiology

Trauma-related risk factors

  • Man-made rather than natural events
  • Prolonged exposure
  • Perceived threat to life

Patient-related risk factors

  • Family or personal history of mental disorder
  • Serious physical injury (patient's perception)
  • Past experience of trauma, especially childhood/developmental trauma

Environmental risk factors

  • Lack of a support network
  • Lack of economic resources
  • Disadvantage
  • Ongoing life stresses

Pathophysiology

Traumatic events

  • Trauma can be intentional (e.g. assualt) or unintentional (e.g. car accident)
  • Type I trauma involves a single incident - sudden, unexpected
  • Type 2 trauma (complex trauma) involves repetative trauma e.g. ongoing abuse, betrayal of trust in primary caregiving relationship, developmental trauma (attachment/attunement issues)

Neurobiology of trauma

  • Fear and anxiety are genetically ingrained functions of the nervous system
  • NOT a sign of weakness - has adaptive evolutionary significance
  • Emotion arises from neural processes that prompt us to freeze or to flee
  • Much more to the range of responses than 'fight or flight' - fight, flight, freeze, hide, seek, avoid, attach, submit, despair and uncontrolled activation states
    • All originate in PAG or ventral tegmental area
  • When under threat, activity shifts from the cortex (PFC) to brainstem (SC and PAG)
  • Neurobiological changes following trauma include:
    • Hippocampal atrophy
    • Increased activation of the amygdala and other limbic areas
    • Deactivation of Broca's area - difficult for person to explain trauma verbally to others
    • Right-hemispheric lateralisation - may explain the 'timeless' quality of traumatic memory

Clinical presentation

Intrusive phenomena

  • Recurrent distressing recollections
  • Nightmares
  • Flashbacks
  • Distress accompanying reminders
  • Physiological reactions

Avoidance symptoms

  • Avoidance of thoughts or feelings about the event - don't want to talk about it
  • Avoidance of external reminders e.g. people, places

Negative alterations in cognitions and mood symptoms

  • Amnesia for important aspects of trauma
  • Loss of interest in activities
  • Negative affect (fear, horror, anger, guilt, or shame)
  • Overly negative thoughts and assumptions about self/world
  • Exaggerated blame (self or others) for causing traumatic event(s)
  • Feeling isolated/detached
  • Difficulty experiencing positive emotion (including numbing)

Alterations in arousal and reactivity

  • Sleep disturbance
  • Irritability/aggression
  • Concentration difficulties
  • Hypervigilance
  • Exaggerated startle response
  • Risky and destructive behaviour

Investigations

Diagnostic criteria

  • ≳ 1 intrisive symptoms
  • 1 or both avoidance symptoms
  • ≳ 1 negative alterations in cognitions and mood
  • ≳ 2 increased arousal and activity
  • Functional impairment (social or occupational)
  • Symptoms for 1 month

Complex PTSD

Diagnosis consists of core PTSD symptoms PLUS
  • Negative self-concept - low self-esteem, self-blame, hopelessness, helplessness, pre-occupation with threat, pervasive shame or guilt
  • Emotional dysregulation - violent or emotional outbursts, reckless or self-destructive behaviour, dissociation
    • Includes tension reduction activities e.g. binge-purging, self-mutilation
  • Chronic interpersonal difficulties - issues with trust, maintaining relationships etc.

Management

Psychological treatment

  • Mild and < 4 weeks from trauma - watchful waiting
  • Within 3 months from trauma:
      1. Brief psychological intervention - trauma-focussed CBT
      1. Hypnotic medication for sleep disturbance
  • More than 3 months after trauma - trauma-focussed CBT or EMDR
Complex CBT
A phase-based approach is recommended for complex PTSD:
  • Stabilisation and safety - resourcing
  • Trauma treatment - reprocessing
  • Reintegration/rehabilitation

Pharmacological treatment

  • Consider symptomatic treatment for acute phase
  • Consider medication second, and for augmentation of trauma-focused psychological treatment for chronic PTSD
  • Antidepressants - venlafaxine or an SSRI
  • Antipsychotics - risperidone (for severe hyperarousal)
  • Alternatives: prazosin, mood stabilisers