Depression, Men's Health, Mental Health, Women's Health | May 2, 2015 | Author: The Super Pharmacist
Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that is caused by stressful, frightening and distressing events. It was first recognised following the First World War, with many returning soldiers described as suffering from ‘shell shock’. However, the condition was poorly understood and managed, with many returning servicemen and women placed in psychiatric institutions with no appropriate care. It was only in 1980, after the cessation of the Vietnam War and a large number of mental health problems in returning US soldiers, that PTSD was formally recognised and classified by the medical community. Although military personnel are more likely to suffer PTSD than the general population, it can affect anybody who has had a particularly traumatic experience.
The events that precede PTSD are often life threatening, or perceived as life threatening. Individuals are more likely to be affected by PTSD if they have been involved in a combat situation, a serious accident, natural disasters, terrorist incidents or violent assaults. PTSD can also result from sexual assaults, domestic violence or persistent and systematic abuse from rogue regimes or corrupt institutions (1). Refugees and asylum seekers fleeing persecution are also at high risk of PTSD.
PTSD can have a significant impact on the day to day lives of those who suffer from it. Symptoms typically start to manifest around a month after the traumatic event has taken place, with the most common being a ‘re-experiencing’ of traumatic events through flashbacks, nightmares, or repetitive and distressing images. This mental distress can also manifest physically as sweating, trembling and general pain (2).
Many individuals with PTSD also have constant negative thoughts that arise from their experience, asking questions that prevent them from coming to terms with the event itself. People may fixate on whether they could have done anything to prevent the incident from happening which can also lead to feelings of shame and guilt. Many PTSD sufferers will also try to avoid being reminded of the traumatic event. This can manifest as avoiding particular places or people associated with the event, or withdrawing from social circles and not talking about what has happened to them. Conversely, some individuals may throw themselves into work or hobbies to remain distracted. Avoidance can also lead to further complications: co-morbidities such as depression, anxiety and substance misuse are common (3).
Another common symptom of PTSD is ‘hyperarousal’ in which individuals are very anxious and find it difficult to relax. This can also lead to irritability, difficulty concentrating, being constantly on guard for potential threats and sleeping problems (4). For children with PTSD, additional symptoms include bedwetting and being unusually anxious about being separated from their parents (5). Some individuals may also develop Obsessive Compulsive Disorder (OCD) alongside their PTSD (6).
The predominant treatment for PTSD is psychotherapy. All patients should receive a detailed assessment before any form of therapy begins to determine the most appropriate course of action that is tailored to their specific needs. Depending on the assessment, patients will be referred to either a community mental health nurse, a psychologist or a psychiatrist. The first treatment usually offered is a period of watchful waiting in which patients symptoms are observed following a traumatic event. Over two thirds of people who experience a traumatic event will get better without treatment (7), so a follow up appointment is usually scheduled for a month to see how patients are progressing.
Historically, single-session interventions (known as ‘psychological debriefing’) with a mental health professional were offered to patients whose work exposed them to stressful incidents. However, the evidence base for such brief interventions shows them to be at best ineffective and at worst causing further harm to vulnerable patients.
A study analysing brief interventions with military personnel, conducted in the UK in 2011, concluded that a large number of patients who had been through debriefing experienced adverse effects as a result (8).
Trauma-based Cognitive Behavioural Therapy (TBCBT) has a firm evidence base in both group and individual settings (9, 10) and is often the preferred first line treatment for many individuals with PTSD. This typically involves 8-10 sessions with a trained CBT Therapist addressing some of the historical factors that have contributed to PTSD and finding sustainable ways of addressing and coping with them.
Eye Movement Desensitization and Reprocessing (EMDR). The goal of EMDR is to help patients come to terms with unresolved trauma through processing their memories and helping them to develop coping mechanisms. A 2007 systematic review of 33 RCTs involving EMDR found it to be an effective method as measured by both patient outcome and patient self-reporting (11). A more recent meta-analysis of a range of studies found EMDR’s effect size in a laboratory setting to be large and significant, and its effect size in a therapeutic context to be moderate and significant (12).
There is a limited evidence base for PTSD treatments delivered in conjunction with other treatment services for co-morbidities such as depression and substance misuse. The majority of clinical guidelines recommend treating PTSD first and co-morbidities later, unless co-morbidities negatively interfere with a patient’s ability to complete treatment. Medication for PTSD is generally recommended as a second line treatment, with a range of antidepressants such as paroxetine, mirtazapine, amitryptyline and phenelzine being the most commonly prescribed. Medication will typically only be used if patients do not want to have psychological treatment, psychological treatment would not be effective as a result of ongoing trauma (such as exposure to domestic violence), or the patient has an underlying co-morbidity (such as depression) that affects their ability to benefit from psychological treatment. Paroxetine is the only drug licensed specifically for PTSD, although the evidence base for most antidepressants in the specific treatment of PTSD is limited. Fluoxetine, paroxetine and venlafaxine have all been shown to have limited effect and there remains a need for more research (13).
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