According to the ICD-10 (WHO, 1992), PTSD arises as a delayed response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
Typical symptoms include repeated reliving of the trauma in intrusive memories (“flashbacks”) or dreams, occurring against the background of a sense of “numbness” and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma. Rarely, there may be dramatic, acute bursts of fear, panic or aggression triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of the original reaction to it. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia.
The onset follows the trauma by a few weeks to months (but rarely exceeds 6 months).
NICE (CG26, April 2005) guidelines for Post traumatic stress Disorder (PTSD)
If you believe your patient is presenting with PTSD, then NICE (CG26) recommends the following approach:
Initial response to trauma
• For individuals who have experienced a traumatic event the systematic provision to that individual alone of brief, single-session interventions (often referred to as debriefing) that focus on the traumatic incident should not be routine practice when delivering services.
• Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by individual people with post-traumatic stress disorder (PTSD), should be considered. A follow-up contact should be arranged within 1 month.
Trauma-focused psychological treatment
• Trauma-focused cognitive behavioural therapy should be offered to those with severe post-traumatic symptoms or with severe PTSD in the first month after the traumatic event. These treatments should normally be provided on an individual outpatient basis.
• All people with PTSD should be offered a course of trauma-focused psychological treatment (trauma-focused cognitive behavioural therapy [CBT] or eye movement desensitisation and reprocessing [EMDR]). These treatments should normally be provided on an individual outpatient basis.
Drug treatments for adults
• 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.
• Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by mental health specialists) should be considered for the treatment of PTSD in adults who express a preference not to engage in trauma-focused psychological treatment.
Screening for PTSD
• For individuals at high risk of developing PTSD following a major disaster, consideration should be given (by those responsible for coordination of the disaster plan) to the routine use of a brief screening instrument for PTSD at 1 month after the disaster.
Click here for the full NICE CG26 (April 2005) guidelines.