Post traumatic stress disorder (PTSD)

PTSD is a specific variant of anxiety. It may require tailored and specific psychotherapy and/or pharmacological treatment. It develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. PTSD does not therefore develop following those upsetting situations that are described as 'traumatic' in everyday language, for example, divorce, loss of job, or failing an exam. (NICE)

PTSD is seen in active personnel at fairly low rates (figures vary from 1-8% from recent post conflict data). However Veterans are possibly twice as likely as the remaining civilian population to develop delayed onset PTSD. The first year after discharge is the most common time frame in which this will present. Soldiers, and in particular young, single ex-infantrymen, have the highest rates of PTSD (in common with other mental and physical health problems) related to their relatively higher rates of close combat experience.

Diagnosis of PTSD

The diagnostic and statistical manual of mental disorders (DSM) is produced by the American Psychiatric Association. It lists diagnostic criteria for mental disorders and is widely accepted across the world. 

DSM diagnostic criteria for Post Traumatic Stress Disorder

  • The person has been exposed to a traumatic event in which both of the following were present:
    • The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
    • The person’s response involved intense fear, helplessness, or horror. 
  • The traumatic event is persistently re experienced in one (or more) of the following ways.
    • Recurrent and intrusive distressing recollections of the event including images thoughts or perceptions. 
    • Recurrent distressing dreams of the event. 
    • Acting or feeling as if the traumatic event were recurring (includes a sense of relieving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). 
    • Intense psychological distress at exposure to the internal or external cues that symbolise or resemble an aspect of the traumatic event.
  • Persistent avoidance of stimuli associated with the trauma and the numbing of general responsiveness (not present before trauma), as indicated by three or more of the following:
    • Efforts to avoid thoughts, feelings or conversations associated with the trauma.
    • Efforts to avoid the activities, places or people that arouse recollections of the trauma.
    • Inability to recall important aspect of the trauma.
    • Markedly diminished interest or participation in significant activities.
    • Feelings of detachment or estrangement from others.
    • Restricted range of affect (e.g. unable to have loving feelings).
    • Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span).
  • Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
    • Difficulty falling or staying asleep
    • Irritability or outbursts of anger
    • Difficulty concentrating
    • Hyper vigilance
    • Exaggerated startle response
  • Duration of the disturbance (symptoms in criteria B, C and D) is more than one month.
  • The disturbance causes clinically significant distress or impairment in social occupational, or other important areas of functioning.

This may be summarised by:-

PTSD should be suspected/diagnosed in people who have been exposed to a significant traumatic event. At the time they experienced a feeling of intense fear helplessness or horror – and have many/all of the following
Re-experiencing  Dreams, thoughts, re-living
  Of people, places or talking in detail about the event
Arousal Poor sleep, anger, hyper vigilance, emotional numbing
Duration of symptoms > 1 month
Disturbance causes significant distress or impairment of social/occupational functioning

Combat Stress is the UK's leading military charity specialising in the care of Veterans' mental health. On its website there are a number of stories – Paul’s story sums up PTSD from the point of view of the individual.

The are further PTSD Testimonials from Veterans who have accessed the Veterans' NHS Wales.

Treatment of PTSD

Effective treatment for PTSD involves a comprehensive assessment of the individual’s physical psychological and social needs. A risk assessment should be undertaken. Presentations in the community should have the initial assessment and co-ordination of care performed by their GP. The GP should assess the duration, severity and suicide risk. PTSD will often co-exist with depression and although there may be some therapeutic crossover, the management of depression will often not alleviate the PTSD symptoms and indeed PTSD may be resistant to treatment if the co-morbid depression is not addressed. NICE  recommends that healthcare professionals consider treating PTSD first in patients with PTSD and depression, as successful treatment of PTSD will often alleviate the depression. However, NICE furthermore recommends that where severe depression (for example, as evidenced by extreme lack of energy and concentration, inactivity, or high suicide risk) is present, that the risk is managed and depression treated first.

Following an initial assessment 

Nice recommends “All PTSD sufferers should be offered a course of trauma-focused psychological treatment (trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing). These treatments should normally be provided on an individual outpatient basis.”

In the case of Veterans in the community, it is likely that the traumatic event(s) triggering the PTSD will have occurred many months or years previously. NICE recommends that the duration of the trauma focused psychological treatment should last 12 sessions or more in this situation due to often multiple traumas. For most Veterans with PTSD, treatment options that should be discussed would include referral (or self-referral) to the Veterans' NHS Wales

Pharmacological treatment of PTSD

NICE recommends that “drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy.”

The evidence base for pharmacological therapy in PTSD is weak:-

mirtazapine, amitriptyline and phenelzine – all have evidence of clinically significant benefits

Paroxitine - statistically but not clinically significant benefits on the main outcome variables. However it is the only drug with a licence for PTSD

NICE recommends that only Mirtazipine and Paroxitine are used by non-specialists

NICE further recommends that hypnotics may be used short term where sleep disturbance is a major problem.

The advice for GPs therefore, would be to offer referral to any Veteran suffering with symptoms suggestive of PTSD. Consider the Veterans' NHS Wales– the experience of users of the service can be accessed here.



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