PTSD

Question 1

Describe the current DSM-V classification of PTSD

Answer 1

The person was exposed to a stressor (life threatening event etc). They must experience symptoms from four clusters:

• Re-experiencing/intrusion symptoms (flashbacks etc)
• Hyperarousal (loss of sleep etc)
• Avoidance
• Negative alterations in mood

The duration must be at least 1 month and cause functional impairement.

Question 2

Describe the symptoms of PTSD

Answer 2

According to DSM-V, PTSD involves four main cluster of symptoms:

• Re-experiencing:
  
  • Flashbacks
  • Recurring memories related to the traumatic event
  • Recurring dreams of the event.
• Hyperarousal:
  
  • Difficulty falling asleep
  • Irritability and outbursts of anger
  • Difficulty concentrating
  • Exaggerated startle response.
• Avoidance:
  
  • Efforts to avoid thoughts and feelings associated with the trauma
  • Efforts to avoid activities, places and people that around recollections of the trauma
  • Feeling detached from others
  • Reduce interest in participation in important activities.
• Negative alterations in cognition or mood:
  
  • Persistent negative cognitions about self, others, and the world
  • Persistent negative emotional state
  • Diminished interest in significant activities
  • Inability to experience positive emotions.

Question 3

Describe the aetiology of PTSD

Answer 3

It occurs after an experience of a severe traumatic event of an exceptionally threatening nature which is likely to cause distress in almost anyone. The type of trauma can be combat trauma, torture, terrorism, rape or even witnessing the violent death of others. Though the type of trauma can be categorised as:

• Type 1 trauma - a single traumatic event
• Type 2 trauma - prolonged and repeated trauma

It is not clear why some people develop PTSD and some people do not. Genes have an impact on susceptibility, as heritability is estimated to be at 30%. Also susceptibility is linked to impaired sensitivity of HPA axis and reduced hippocampal volume.

Question 4

What is the prevalence of PTSD?

Answer 4

Lifetime prevalence in the general population is estimated at 8%! And in general practise patients - 14%.

• 31% of Vietnam war veterans had PTSD in their lifetimes.
• PTSD is more prevalent in victims of interpersonal trauma than disaster victims.

Higher incidence of PTSD in America than in the UK. Thought to reflect cultural differences in emotional processing.

Question 5

What are the co-morbidities of PTSD?

Answer 5

• Alcohol abuse/dependence is more common in males (52%) than females (27%).
• Drug misuse (34%)
• MDD (Major Depressive Disorder)
• Physical health problems (stomach ulcer) more prevalent than in the general population

Question 6

Describe the management of PTSD

Answer 6

• Ongoing evaluation of risk to self and others
• Treat the PTSD itself by:
  
  • Watchful waiting in mild/moderate PTSD for first 4 weeks.
  • Pharmacotherapy - mirtazapine, paroxetine, sertaline, olanzapine.
  • Psychosocial interventions - trauma-focuded CBT and EMDR (Eye Movement Desensitisation and Reprocessing).
• Treat comorbidities such as substance misuse
• Physical health checks
• Social support
• Voluntary work/employment
• Carer’s assessment

Question 7

What is the prognosis of PTSD?

Answer 7

• 56% improve after receiving psychotherapy (no longer meeting diagnostic criteria for PTSD)
• 38% continue to have some residual symptoms
• Highest remission rates in PTSD survivors of natural disasters (60%)

Trauma severity, the lack of social support and additional post-trauma life stressors are important risk factors.

Question 8

What are the problems with current diagnostic classification of PTSD?

Answer 8

• Complex PTSD - a psychological disorder thought to occur as a result to repetitive trauma involving harm or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic. The main distinction is that PTSD distorts a person’s core identity. Many of the features of C-PTSD are not covered by the PTSD DMS-V criteria, for example, C-PTSD is also characterised by attachment disorder.
• ‘Disorders of Extreme Stress Not Otherwise Specified’ DESNOS
• ‘Enduring Personality Change After Catastrophic Event’ EPCACE. Involves:
  
  • A change of at least four years in duration, in a person’s pattern of perceiving or thinking about their environment of themselves.
  • Features such as permanent hostile and distrustful attitude, social withdrawal, a constant feeling of emptiness and/or hopelessness, feeling ‘on-edge’, permanent feeling of being changed or different.
  • May or may not be proceeded by PTSD.
  • Caused by a catastrophic trauma - defined by prolonged exposure to life-threatening circumstances with imminent possibility of being killed.