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Post-traumatic stress disorder (PTSD) (Pathophysiology (Chronic stress…
Post-traumatic
stress disorder (PTSD)
Definition
Psychiatric disorder arising following a major traumatic event, with re-experiencing symptoms, avoidance of reminders, emotional numbing, negative thoughts and hyper-arousal
Epidemiology
3% UK adults, 0.3% children
Uncommon
Pathophysiology
Chronic stress reaction comprises adjustment disorder (<1m), and PTSD where symptoms start 1-6m after event,
but may be delayed by months/yrs
Major traumatic event is an event that is exceptionally threatening and distressing (e.g. serious accident, violent assault, military combat, torture, terrorist attack, natural disaster)
Complex PTSD may occur after prolonged/repeat trauma
e.g. childhood sexual abuse, captivity and torture
Acute stress reaction hrs-days, with dissociation, then mixed emotions (anxiety, fear, anger)
Risk factors
Peri-trauma
Severity of trauma
Perceived threat to life
Dissociative experiences
Adverse emotional reaction during/after
Post-trauma
Concurrent life stressors
Absent social support
Pre-trauma
Profession (armed forces, police/prison/fire services, ambulance/ emergency, nurses/medics, journalists, refugees/asylum seekers)
Previous trauma
Adverse childhood experience
Psychiatric illness
Female
Extremes of age
Lower SEC
Clinical
presentation
Avoidance
People/places that remind of event
Emotional numbing/negative thoughts
Detached from others
Negative thoughts about self
Re-experiencing symptoms
Daytime or nightime
Flashbacks, intrusive images or thoughts
Hyperarousal/hyperactivity
On guard, looking for danger
Diagnosis
Examination
Psychiatric examination (MSE)
A&B: anxious, hyper-arousal
Mood: may be low
Speech: normal flow
Thoughts: negative of self, emotional blunting
Perceptions: flashbacks
Insight: may be present/absent
Diagnostic
criteria
DSM-V
Exposure to actual/threatened death, serious injury or sexual violence
2.1+ intrusive symptom (involuntary memories, nightmares, dissociation i.e. flashbacks, intense distress, physiological reactivity)
Persistently avoid stimuli associated with the event
1+ negative mood/thought (unable to recall key parts of event, negative self image, blame others, negative mood, anhedonia, detachment)
2+ trauma-related alterations in arousal (irritability, reckless behaviour, hypervigilance, concentration problems, insomnia)
Symptoms causing functional impairment, not due to medication or other illness, and persist for >1m
ICD-10
Exposure to traumatic event of exceptional threatening/catastrophic nature
Persistent remembering e.g. flashbacks, memories, dreams
Avoidance of circumstances associated with stressor
Inability to recall some key aspects of event or persistent psychological sensitivit/arousal
Symptoms occur <6m event
History
PMH
Chronic disease
DH
Current meds, allergies
PPH
Previous psychiatric disorders
Previous psych encounters,
inpatient treatments
FH
Psychiatric illness
PC/HPC
Majot trauma, re-experiencing,
avoidance, negative thoughts,
hyperarousal, withdrawal,
mood symptoms, suicide risk
Personal history
Milestones and development
Childhood and education (abuse, bullying)
Employment (stressful job)
Relationships (abuse)
SH
Occupation, social support,
alcohol, smoking, drugs
Forensic history
Interaction with the law
Pre-morbid personality
What they are like normally
Investigations
Trauma Screening Questionnaire (TSQ)
10 Qs measuring re-experience and arousal
Use >1m after event
Management
Medical
SSRI
Indication: patient preference to psych therapy
E.g. paroxetine
SNRI
Indication: patient preference to psych therapy
E.g. mirtazepine
Psychological
CBT
Indication: 1L +/- SSRI
E.g. group, individual, computerised
Eye movement desensitisation and reprogramming (EMDR)
Indication: 1L +/- SSRI
MOA: uses voluntary eye movements to reduce anxiety associated with traumatic thoughts and images, processing emotions attached to them
Conservative
Information, advice, support
Referral/admission if severe or signs of self harm/suicide risk
Identify and manage comorbid psychiatric problems
Watchful waiting with 4wk FU (mild PTSD)
Self help advice, sleep hygeine
Complications
Employment
Loss of employment (lack of sleep and concentration, avoidance, irritable, re-experiencing symptoms)
Secondary psychiatric disorders
Depression, anxiety, substance misuse, somatisation;
also ADHD and conduct disorders in children
Social
Withdrawal, family problems,
breakups, isolation
Medical problems
Chronic pain, CVD, musculoskeletal problems
Prognosis
Symptoms peak in days/week after the event,
resolve naturally in 2/3 but may take months,
in 1/3 patients it takes much longer
Symptoms decrease most rapidly in first 1y after
In children, symptoms may persist longer
Screening
High risk patients e.g. major disaster,
refugees/asylum seekers