2.1.1. Traumatic stressors

The diagnosis of PTSD is restricted to people who have experienced exceptionally threatening and distressing events. The ICD–10 definition states that PTSD may develop after ‘a stressful event or situation... of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone’ (World Health Organization, 1992: p. 147). Thus, PTSD would not be diagnosed after other upsetting events that are described as ‘traumatic’ in everyday language, such as divorce, loss of a job or failing an examination. In these cases, a diagnosis of adjustment disorder may be considered.

The DSM–IV highlights that a traumatic stressor usually involves a perceived threat to life (either one’s own life or that of another person) or physical integrity, and intense fear, helplessness or horror. Other emotional responses of trauma survivors with PTSD include guilt, shame, intense anger or emotional numbing.

Whether or not people develop PTSD depends on their subjective perception of the traumatic event as well as on the objective facts. For example, people who are threatened with a replica gun and believe that they are about to be shot, or people who only contract minor injuries during a road traffic accident but believe at the time that they are about to die, may develop PTSD. Furthermore, those at risk of PTSD include not only those who are directly affected by a horrific event, but also witnesses, perpetrators and those who help PTSD sufferers (vicarious traumatisation). People at risk of PTSD include:

• victims of violent crime (e.g. physical and sexual assaults, sexual abuse, bombings, riots)
• members of the armed forces, police, journalists and prison service, fire service, ambulance and emergency personnel, including those no longer in service
• victims of war, torture, state-sanctioned violence or terrorism, and refugees
• survivors of accidents and disasters
• women following traumatic childbirth, individuals diagnosed with a life-threatening illness.

2.1.2. Symptoms of PTSD

The most characteristic symptoms of PTSD are re-experiencing symptoms. Sufferers involuntarily re-experience aspects of the traumatic event in a vivid and distressing way. This includes flashbacks in which the person acts or feels as if the event is recurring; nightmares; and repetitive and distressing intrusive images or other sensory impressions from the event. Reminders of the traumatic event arouse intense distress and/or physiological reactions.

In children, re-experiencing symptoms may take the form of re-enacting the experience, repetitive play or frightening dreams without recognisable content. Chapter 9 addresses the recognition and treatment of PTSD in children and young people.

Avoidance of reminders of the trauma is another core symptom of PTSD. These reminders include people, situations or circumstances resembling or associated with the event. Sufferers from PTSD often try to push memories of the event out of their mind and avoid thinking or talking about it in detail, particularly about its worst moments. On the other hand, many ruminate excessively about questions that prevent them from coming to terms with the event, for example about why the event happened to them, about how it could have been prevented or about how they could take revenge.

Symptoms of hyperarousal include hypervigilance for threat, exaggerated startle responses, irritability, difficulty in concentrating and sleep problems.

However, PTSD sufferers also describe symptoms of emotional numbing. These include inability to have any feelings, feeling detached from other people, giving up previously significant activities and amnesia for significant parts of the event.

Many PTSD sufferers experience other associated symptoms, including depression, generalised anxiety, shame, guilt and reduced libido, which contribute to their distress and affect their functioning.

2.1.3. Course and prognosis

The onset of symptoms is usually in the first month after the traumatic event, but in a minority (less than 15%; McNally, 2003) there may be a delay of months or years before symptoms start to appear.

Post-traumatic stress disorder shows substantial natural recovery in the initial months and years after a traumatic event. Whereas a high proportion of trauma survivors will initially develop symptoms of PTSD, a substantial proportion of these individuals recover without treatment in the following years, with a steep decline in PTSD rates occurring in the first year (e.g. Breslau et al, 1991; Kessler et al, 1995). On the other hand, at least a third of the individuals who initially develop PTSD remain symptomatic for 3 years or longer, and are at risk of secondary problems such as substance misuse (e.g. Kessler et al, 1995). This raises the important questions of when treatment should be offered after a traumatic event and how people who are unlikely to recover on their own can be identified. These questions are addressed in the guideline sections on early intervention after trauma (Chapter 7) and screening for PTSD (Chapter 8). One important indicator of treatment need appears to be the severity of PTSD symptoms from around 2–4 weeks after the trauma onwards (e.g. Shalev et al, 1997; Harvey & Bryant, 1998). However, it is important to note that symptom severity in the initial days after trauma (up to about 1 week) is not a good predictor of persistent PTSD (Shalev, 1992; Murray et al, 2002). Importantly, evidence suggests that the chances that a PTSD sufferer will benefit from treatment do not decrease with time elapsed since the traumatic event (Gillespie et al, 2002; Resick et al, 2002).

2.1.4. Impairment, disability and secondary problems

Symptoms of PTSD cause considerable distress and can significantly interfere with social, educational and occupational functioning. It is not uncommon for PTSD sufferers to lose their jobs, either because re-experiencing symptoms, sleep and concentration problems make regular work difficult, or because they are unable to cope with reminders of the traumatic event they encounter at work. The resulting financial problems are a common source of additional stress, and may be a contributory factor leading to extreme hardship such as homelessness.

The disorder has adverse effects on the sufferer’s social relationships, leading to social withdrawal. Problems in the family and break-up of significant relationships are not uncommon. Sufferers may also develop further, secondary psychological disorders as complications of the PTSD. The most common complications are:

• substance use disorders: PTSD sufferers may use alcohol, drugs, caffeine or nicotine to cope with their symptoms, which may eventually lead to dependence
• depression, including the risk of suicide
• other anxiety disorders, such as panic disorder, which may lead to additional restrictions in the sufferer’s life (for example, inability to use public transport).

Other possible complications of PTSD include somatisation, chronic pain and poor health (Schnurr & Green, 2003). Sufferers from PTSD are at greater risk of medical problems, including circulatory and musculoskeletal disorders, and have a greater number of medical conditions than people without PTSD (Ouimette et al, 2004).

2.2.1. Prevalence

Post-traumatic stress disorder is common. In a large, representative sample in the USA, Kessler et al (1995) estimated a lifetime prevalence of PTSD of 7.8% (women 10.4%, men 5.0%), using DSM–III–R criteria. Estimates for 12-month prevalence range between 1.3% (Australia; Creamer et al, 2001) and 3.6% (USA; Narrow et al, 2002). Estimates for 1-month prevalence range between 1.5–1.8% using DSM–IV criteria (Stein et al, 1997; Andrews et al, 1999) and 3.4% using the less strict ICD–10 criteria (Andrews et al, 1999). The disorder remains common in later life, but with the suggestion of a greater proportion of sub-syndromal PTSD in the older age group (van Zelst et al, 2003).

2.2.2. Incidence

Kessler et al (1995) found that the risk of developing PTSD after a traumatic event is 8.1% for men and 20.4% for women. For young urban populations, higher risks have been reported: Breslau and colleagues found an overall risk of 23.6% (Breslau et al, 1991) and a risk of 13% for men and 30.2% for women (Breslau et al, 1997).

2.2.3. Influence of type of traumatic event

Different types of traumatic events are associated with different PTSD rates. Rape was associated with the highest PTSD rates in several studies. For example, 65% of the men and 46% of the women who had been raped met PTSD criteria in the study by Kessler et al (1995). Other traumatic events associated with high PTSD rates included combat exposure, childhood neglect and physical abuse, sexual molestation and (for women only) physical attack and being threatened with a weapon, kidnapped or held hostage. Accidents, witnessing death or injury, and fire or natural disasters were associated with lower lifetime PTSD rates (Kessler et al, 1995). Other research has shown high PTSD rates for torture victims, survivors of the Holocaust and prisoners of war.

2.3.1. Diagnostic criteria

The ICD–10 diagnosis of PTSD requires that the patient, first, has been exposed to a traumatic event, and second, suffers from distressing re-experiencing symptoms. Patients will usually also show avoidance of reminders of the event, and some symptoms of hyperarousal and/or emotional numbing. The ICD–10 research diagnostic criteria for PTSD are as follows (reproduced with permission from World Health Organization, 1993: pp. 99–100):

1. The patient must have been exposed to a stressful event or situation (either short or long-lasting) of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.
2. There must be persistent remembering or ‘reliving’ of the stressor in intrusive ‘flashbacks’, vivid memories, or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor.
3. The patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor, which was not present before exposure to the stressor.
4. Either of the following must be present:
   1. inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor
   2. persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor), shown by any two of the following:
      1. difficulty in falling or staying asleep
      2. irritability or outbursts of anger
      3. difficulty in concentrating
      4. hypervigilance
      5. exaggerated startle response.
5. Criteria B, C, and D must all be met within 6 months of the stressful event or the end of a period of stress. (For some purposes, onset delayed more than by 6 months may be included, but this should be clearly specified.)

The DSM–IV diagnosis of PTSD is stricter, in that it puts more emphasis on avoidance and emotional numbing symptoms. It requires a particular combination of symptoms (at least one re-experiencing symptom, three symptoms of avoidance and emotional numbing, and two hyperarousal symptoms). In addition, DSM–IV requires that the symptoms cause significant distress or interference with social or occupational functioning. Several studies have found that trauma survivors who experience most, but not all, DSM–IV symptoms of PTSD show significant distress and need treatment (e.g. Blanchard et al, 2003b).

In contrast to the ICD–10 definition, a DSM–IV diagnosis of PTSD further requires that the symptoms have persisted for at least 1 month. In the first month after trauma, trauma survivors may be diagnosed as having acute stress disorder according to DSM–IV, which is characterised by symptoms of PTSD and dissociative symptoms such as depersonalisation, derealisation and emotional numbing. The ICD–10 diagnosis does not require a minimum duration. For the purposes of this guideline, we include PTSD symptoms that occur in the first month after trauma. A special section on early intervention (Chapter 7) is dedicated to the management of these early PTSD reactions.

Appendix 13 (source: Ehlers, 2000) compares the diagnostic criteria for post-traumatic stress disorder in ICD–10 and DSM–IV.

2.3.2. Assessment instruments

Well-validated, structured clinical interviews that facilitate the diagnosis of PTSD include the Structured Clinical Interview for DSM–IV (SCID; First et al, 1995), the Clinician-Administered PTSD Scale (CAPS; Blake et al, 1995) and the PTSD Symptom Scale – Interview version (PSS–I; Foa et al, 1993). All these instruments are based on the DSM–IV definition of PTSD.

There is a range of useful self-report instruments of PTSD symptoms; these include:

• Impact of Event Scale (IES; Horowitz et al, 1979) and Impact of Event Scale – Revised (IES–R; Weiss & Marmar, 1997);
• Post-traumatic Diagnostic Scale (PDS; Foa et al, 1997)
• Davidson Trauma Scale (Davidson et al, 1997)
• PTSD Checklist (Weathers & Ford, 1996).

2.3.3. Clinical aspects of the diagnostic interview

When establishing the diagnosis of PTSD it is important to bear in mind that people with this disorder find talking about the traumatic experience very upsetting. They may find it hard to disclose the exact nature of the event and the associated re-experiencing symptoms and feelings, and may initially not be able to talk about the most distressing aspects of their experience. This may particularly be the case for people who experienced the trauma many years ago or have a delayed onset of their symptoms.

2.3.3.1.

For PTSD sufferers presenting in primary care, GPs should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment. [C]

2.3.3.2.

Assessment of PTSD sufferers should be conducted by competent individuals and be comprehensive, including physical, psychological and social needs and a risk assessment. [GPP]

2.3.3.3.

When developing and agreeing a treatment plan with a PTSD sufferer, healthcare professionals should ensure that sufferers receive information about common reactions to traumatic events, including the symptoms of PTSD and its course and treatment. [GPP]

2.3.3.4.

When seeking to identify PTSD, members of the primary care team should consider asking adults specific questions about re-experiencing (including flashbacks and nightmares) or hyperarousal (including an exaggerated startle response or sleep disturbance). For children, particularly younger children, consideration should be given to asking the child and/or the parents about sleep disturbance or significant changes in sleeping patterns. [C]

2.3.3.5.

Healthcare professionals should be aware that many PTSD sufferers are anxious about and can avoid engaging in treatment. Healthcare professionals should also recognise the challenges that this presents and respond appropriately, for example by following up PTSD sufferers who miss scheduled appointments. [C]

2.3.3.6.

Patient preference should be an important determinant of the choice among effective treatments. PTSD sufferers should be given sufficient information about the nature of these treatments to make an informed choice. [C]

2.3.3.7.

Where management is shared between primary and secondary care, there should be clear agreement among individual healthcare professionals about the responsibility for monitoring patients with PTSD. This agreement should be in writing (where appropriate, using the Care Programme Approach) and should be shared with the patient and, where appropriate, their family and carers. [C]

2.3.4. Identification of PTSD in primary care

The main presenting complaint of sufferers does not necessarily include intrusive memories of the traumatic event. Patients may present with depression and general anxiety, fear of leaving their home, somatic complaints, irritability, inability to work or sleep problems. They may not relate their symptoms to the traumatic event, especially if significant time has elapsed since that event. Older adults report more frequently somatic and physical complaints (Gray & Acierno, 2002) and are often reluctant to report traumatic events or admit to emotional or psychological difficulties (Comijs et al, 1999). Practitioners may also need to distinguish PTSD from traumatic or complicated grief reactions that may develop a year or more following a bereavement, with symptoms including intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks reminiscent of the deceased, unusual sleep disturbances and maladaptive levels of loss of interest in personal activities (Horowitz et al, 1997).

Epidemiological research has shown that the diagnosis of PTSD is greatly underestimated if the interviewer does not directly ask about the occurrence of specific traumatic events (Solomon & Davidson, 1997).

2.3.4.1.

For patients with unexplained physical symptoms who are repeated attendees to primary care, members of the primary care team should consider asking whether or not they have experienced a traumatic event, and provide specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth). [GPP]

Checklists of common traumatic experiences and symptoms may be helpful for some patients who find it hard to name them. Both the CAPS (Blake et al, 1995) and the PDS (Foa et al, 1997) include checklists.

2.3.5. Trauma and families

2.3.5.1.

People who have lost a close friend or relative due to an unnatural or sudden death should be assessed for PTSD and traumatic grief. In most cases, healthcare professionals should treat the PTSD first without avoiding discussion of the grief. [C]

2.3.5.2.

In all cases of PTSD, healthcare professionals should consider the impact of the traumatic event on all family members and, when appropriate, assess this impact and consider providing appropriate support. [GPP]

2.3.5.3.

Healthcare professionals should ensure, where appropriate and with the consent of the PTSD sufferer where necessary, that the families of PTSD sufferers are fully informed about common reactions to traumatic events, including the symptoms of PTSD and its course and treatment. [GPP]

2.3.5.4.

When a family is affected by a traumatic event, more than one family member may suffer from PTSD. If this is the case, healthcare professionals should ensure that the treatment of all family members is effectively coordinated. [GPP]

Please see also the special section on the assessment of children (Chapter 9).

2.3.6. Differential diagnoses

Post-traumatic stress disorder is not the only disorder that may be triggered by a traumatic event. Differential disorders (and indicators) to be considered are:

• depression (predominance of low mood, lack of energy, loss of interest, suicidal ideation)
• specific phobias (fear and avoidance restricted to certain situations)
• adjustment disorders (less severe stressor, different pattern of symptoms; see below)
• enduring personality changes after catastrophic experience (prolonged extreme stressor, different pattern of symptoms; see below)
• dissociative disorders
• neurological damage due to injuries sustained during the event
• psychosis (hallucinations, delusions).

Of course, PTSD may also exist comorbidly with many of the above disorders, in particular depression and anxiety disorders.

2.3.7. Is PTSD the main problem?

This guideline applies to patients for whom PTSD is the main problem. Whether or not PTSD is the problem that should be the focus of treatment depends on the severity and urgency of other disorders and problems, such as social problems, health problems and safety issues. This may include practical problems such as safe housing, support in court cases, and a range of psychological symptoms. In order to establish whether or not PTSD is the main psychological problem, it is useful to ask trauma survivors:

• what symptoms or problems bother them the most
• whether they think that they would need help with their other symptoms or problems if the PTSD symptoms could be taken away
• whether or not the other problems were present before the traumatic event.

Individuals should be fully assessed before a management plan is devised. Other factors, for example suicide risk, may determine what the most important focus should be in the first instance. Simply because there is a trauma history, it should not be assumed that there is PTSD.

Epidemiological studies give further insight into common patterns of comorbidity.

2.4.1. The traumatic event

It is now recognised that the traumatic event is a major cause of the symptoms of PTSD. Historically, this has been the subject of considerable debate. Charcot, Janet, Freud and Breuer suggested that hysterical symptoms were caused by psychological trauma, but their views were not widely accepted (see reviews by Gersons & Carlier, 1992; Kinzie & Goetz, 1996; van der Kolk et al, 1996). The dominant view was that a traumatic event in itself was not a sufficient cause of these symptoms, and experts searched for other explanations. Many suspected an organic cause. For example, damage to the spinal cord was suggested as the cause of the ‘railway spine syndrome’, micro-sections of exploded bombs entering the brain as the cause of ‘shell shock’ and starvation and brain damage as causes of the chronic psychological difficulties of concentration camp survivors. Others doubted the validity of the symptom reports and suggested that malingering and compensation-seeking (‘compensation neurosis’) were the major cause in most cases. Finally, the psychological symptoms were attributed to pre-existing psychological dysfunction. The predominant view was that reactions to traumatic events were transient, and that therefore only people with unstable personalities, pre-existing neurotic conflicts or mental illness would develop chronic symptoms (Gersons & Carlier, 1992; Kinzie & Goetz, 1996; van der Kolk et al, 1996).

It was the recognition of the long-standing psychological problems of many war veterans, especially Vietnam veterans, and of rape survivors that changed this view and convinced clinicians and researchers that even people with sound personalities could develop clinically significant psychological symptoms if they were exposed to horrific stressors. This prompted the introduction of post-traumatic stress disorder as a diagnostic category in DSM– III (American Psychiatric Association, 1980). It was thus recognised that traumatic events such as combat, rape and man-made or natural disasters give rise to a characteristic pattern of psychological symptoms. The ICD–10 classification emphasised the causal role of traumatic stressors in producing psychological dysfunction even more clearly, in that a specific group of disorders, ‘reaction to severe stress, and adjustment disorders’, was created. These disorders are ‘thought to arise always as a direct consequence of the acute severe stress or continued trauma. The stressful event... is the primary and overriding causal factor, and the disorder would not have occurred without its impact’ (World Health Organization, 1992: p. 145).

The criteria of what constitutes a traumatic stressor have been modified since the diagnosis of PTSD was introduced. Initially PTSD was thought to occur only following an event ‘outside the range of usual human experience’. However, epidemiological data showed that PTSD may develop in response to traumatic events such as road traffic accidents or assault, which are so widespread that they are not ‘outside the range of usual human experience’. The criteria for what constitutes a traumatic stressor have therefore been modified over the years (reviewed by McNally et al, 2003). The DSM–IV now emphasises threat to physical integrity as a common element of trauma, and takes into account that the person’s subjective response to the event is crucial in determining whether the event is experienced as traumatic, by specifying that the person must experience extreme fear, helplessness or horror during the event. The ICD–10 emphasises that the event must be of an ‘exceptionally threatening or catastrophic nature’.

2.4.2. Trauma memories

The characteristic re-experiencing symptoms in PTSD appear to be the result of the way the traumatic event is laid down in memory. Trauma is overwhelming, and exceeds people’s resources for information processing. The resulting memory for the event appears to be different from ordinary autobiographical memories. This has the effect that aspects of the memory can be easily triggered, and are re-experienced as if they were happening right now, rather than as memories of a past event. The exact mechanisms of the memory abnormalities are currently being investigated (Brewin et al, 1996; McNally, 2003; Brewin, 2005; Ehlers et al, 2004).

2.4.3. Fear conditioning

Classical conditioning theory suggests that stimuli experienced at the time of trauma become associated with fear. Consequently, stimuli resembling those present during the traumatic event trigger severe distress, and are avoided (see, for example, Keane et al, 1985).

2.4.4. Individual interpretations of the traumatic event and its consequences

The degree of threat that people perceive during a traumatic event depends on their interpretation of what is happening. For example, whether or not people perceive that their life is in danger during the traumatic event has a large impact on the likelihood of developing PTSD. Similarly, the conclusions they draw from the event are important factors in maintaining PTSD; for example, if PTSD sufferers feel guilty or ashamed about what happened, and blame themselves for things they think they are responsible for, they are unlikely to come to terms with the event and resume their former lives. If PTSD sufferers interpret the trauma as meaning that they are at great risk of further trauma, they continue to feel threatened in their everyday life. The interpretations characteristic of PTSD not only concern the traumatic event, but also its consequences, including responses of others in the aftermath of the event, initial PTSD symptoms and physical injuries (e.g. Foa et al, 1999; Ehlers & Clark, 2000).

2.4.5. Unhelpful coping strategies

Trauma memories are painful and PTSD symptoms are distressing. In their efforts to cope with the event and the symptoms they are experiencing, trauma survivors may resort to a range of coping strategies that appear to be helpful at the time, but prolong or exacerbate symptoms. These include effortful suppression of trauma memories and emotions, rumination about the event, dissociation, social withdrawal, avoidance and substance use (e.g. Ehlers & Clark, 2000).

2.4.6. Social support and relationships with significant others

Lack of social support in the aftermath of trauma is associated with greater risk of chronic PTSD (Brewin et al, 2000; Ozer et al, 2003). The experience of a traumatic event often has a negative impact on survivors’ ability to trust other people and engage in close relationships, in particular if the event involved intentional harm by others. Sufferers may feel alienated from others and withdraw from previously significant relationships. This may contribute to the maintenance of the problem, and interfere with a trusting relationship with health professionals (e.g. Ehlers et al, 2000).

2.4.7. Litigation

The hypothesis that reports of PTSD symptoms are mainly due to malingering and compensation-seeking (‘compensation neurosis’) has not been supported by systematic research. On the other hand, protracted legal proceedings may exacerbate the distress of PTSD sufferers and make it difficult for them to put the event in the past (Blanchard et al, 1996; Ehlers et al, 1998). This may well explain much of the association between PTSD symptoms and litigation, but the relationship is a complex one and is more fully considered in Chapter 8.

2.4.8. Hypothalamic–pituitary–adrenal axis abnormalities

People with current PTSD may show abnormally low levels of cortisol compared with normal controls and with traumatised individuals without current PTSD (e.g. Yehuda et al, 1995). In addition, PTSD sufferers may also have an increased number of lymphocyte glucocorticoid receptors. When given a low dose of dexamethasone, PTSD sufferers exhibit hypersuppression of cortisol. Thus, PTSD sufferers tend to show a very different pattern of hypothalamic–pituitary–adrenal (HPA) axis response from patients with major depression. The pattern of findings suggests that the HPA axis in PTSD is characterised by enhanced negative feedback (Yehuda et al, 1995). There may also be a downregulation of corticotrophin-releasing factor receptors at the anterior pituitary due to chronic increases in corticotrophin-releasing factor (Bremner et al, 1997). Overall, the pattern of findings suggests that the HPA axis in PTSD is set to produce large responses to further stressors.

2.4.9. Neurochemical abnormalities

Several neurotransmitter systems may be dysregulated in PTSD. Research suggests a sensitisation of the noradrenergic system. Another subgroup of PTSD sufferers seems to be characterised by a sensitised serotonergic system. Endogenous opiates have been suspected to mediate the symptoms of emotional numbing and amnesia. The dopaminergic, gamma-aminobutyric acid (GABA) and N-methyl-D-aspartate systems have also been implicated in PTSD, but the evidence for these hypotheses is sparse at this stage (Charney et al, 1993).

2.4.10. Hippocampal size

People with long-standing PTSD may have a smaller hippocampus than controls. Latest findings suggest that small hippocampus size may be a vulnerability factor, rather than a consequence of trauma (Gilbertson et al, 2002; see McNally, 2003, for a review).

2.4.11. Vulnerability factors

A range of vulnerability factors for PTSD have been identified (Brewin et al, 2000; Ozer et al, 2003). These include a previous personal or family history of anxiety disorders or affective disorders, neuroticism, lower intelligence, female gender and a history of previous trauma. Genetic factors and the impact of early trauma on the neurobiological system may also have a role (Heim & Nemeroff, 2001). Overall, the amount of variance explained by these factors is small. Chapter 8 is dedicated to a systematic review of factors that may be useful in screening for people at risk for PTSD after traumatic events.

2.6.1. First presentations

Many individuals will consult their general practitioner shortly after experiencing a traumatic event, but will not present a complaint or request for help specifically related to the psychological aspects of the trauma; for example, an individual who has been physically assaulted or involved in a road traffic accident or an accident at work might present requiring attention to the physical injuries sustained. This provides an opportunity for an assessment of the patient’s psychological state. Similarly, individuals who have been involved in such events often present at local emergency departments, notification of which is sent to general practitioners. Others suffering from a potentially adverse psychological reaction to trauma include people who might have been traumatised as a result of domestic violence or childhood sexual abuse and might not necessarily have presented with complaints related to this previously. The key point here is that primary care staff should consider that PTSD can arise not simply from single events such as an assault or a road traffic accident but also from the repeated trauma associated with childhood sexual abuse, domestic violence or the repeated trauma associated with being a refugee.

A small proportion of PTSD cases have delayed onset (probably less than 15%; McNally, 2003). The assessment of such presentations is essentially the same as for non-delayed presentations. There is evidence to suggest that delayed presentations of PTSD, even those that occur some years after the traumatic event, are likely to respond to treatment (Foa et al, 1991; Gillespie et al, 2002; Resick et al, 2002). A long period between the trauma and the onset and presentation of symptoms should therefore not be a disincentive to the identification and referral for treatment.

2.6.1.1.

PTSD may present with a range of symptoms (including re-experiencing, avoidance, hyperarousal, depression, emotional numbing, drug or alcohol misuse and anger) and therefore when assessing for PTSD, members of the primary care team should ask in a sensitive manner whether or not patients with such symptoms have suffered a traumatic experience (which might have occurred many months or years before), giving specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth). [GPP]

2.6.1.2.

General practitioners and other members of the primary care team should be aware of traumas associated with the development of PTSD. These include single events such as assaults or road traffic accidents, and domestic violence or childhood sexual abuse. [GPP]

2.6.2. Repeated presentations

A number of people may previously have presented with PTSD and received treatment for it. Although the response to effective interventions for the treatment of PTSD is now generally good, a small but significant number do not respond to such treatment. It is important to reassess individuals who have not responded and to consider other diagnoses and comorbidity. There is some evidence to suggest that returning for a second period of treatment may be beneficial and it is important therefore not to assume that failure of a previous treatment means that a person will not respond well to treatment in the future. For example, the presence of a continuing threat might have impaired an individual’s ability to benefit from previous treatment, the treatment provided might have been inadequate, or the patient might not have been able to tolerate the treatment offered at the time.

2.6.3. Comorbid presentations

Post-traumatic stress reactions are associated with significant comorbidities. Most prominent among these comorbidities is depression. Depression that does not respond to conventional treatments or that might have arisen following a traumatic event should alert the general practitioner or other primary care team member to the possibility of a post-traumatic stress reaction. The inappropriate use of prescribed drugs or the misuse of street drugs or alcohol, particularly if associated with avoidance of certain situations, to facilitate sleep or to avoid other psychological difficulties, should also alert the practitioner to the possibility of PTSD.

As detailed in the section on screening and assessment (2.3.2 and 2.3.3), a few simple questions may be required to identify patients who require further and more detailed assessment.

2.6.4. Watchful waiting

A significant number of people presenting with acute reactions or established PTSD can be expected to recover within a relatively short space of time (Rothbaum et al, 1992; Bryant, 2003). The rate of remission is higher for those with milder symptoms. For such people some element of brief education, support and advice in the context of their presentation followed by watchful waiting may be most appropriate, with the individual either encouraged to return for further assessment or offered a specific appointment time if there is sufficient concern on the part of the general practitioner or the primary care team member.

2.6.4.1.

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 sufferers, should be considered by healthcare professionals. A follow-up contact should be arranged within 1 month. [C]

2.6.5. Immediate management of PTSD

The immediate management of PTSD in part depends upon the nature of the trauma and the circumstances in which it arose. In the rare event that it arose as part of a major disaster, man-made or natural, specific resources to support individuals involved in this may be available and it will be for the general practitioner and other members of the primary care mental health team to facilitate the individual’s access to such services as may be available. More usually, however, the trauma will arise as a result of a smaller-scale incident. In the latter circumstances a number of treatment options are available. For some people relatively low-key brief interventions provided in primary care can offer the appropriate level of intervention. For others, more complex and longstanding interventions are required; inevitably some of these people will be required to wait for treatment, and this will leave the general practitioner and other members of the primary care mental health team with a potentially significant management problem. This might relate to specific PTSD symptoms, for example intrusive recollections or nightmares concerning the event, specific sleep disturbance, social withdrawal, irritability or more generalised distress. In such circumstances strategies such as advice on sleep hygiene, advice to rely on the natural support from their families and others available (including, where appropriate, support groups) and where possible pharmacological interventions (see Chapter 6) should be considered. Depending on the waiting time for appropriate psychological or other specialist interventions, the general practitioner may also consider regular reviewing of individual patients.

2.6.6. Persisting PTSD and chronic disease management

Regardless of offers of treatment or actual courses of treatment, a number of individuals with PTSD will achieve negligible or only partial recovery and will continue to suffer from PTSD symptoms for a considerable period. The degree of disability that people with chronic PTSD suffer can be significant and can considerably impair functioning in an individual’s personal, social and occupational life. This may be associated with problems such as chronic sleep disturbance and occasionally with alcohol or drug misuse. More often it is characterised by significant social avoidance. In these circumstances the focus of management in primary care may be on the disabling symptoms rather than the underlying PTSD. Advice on sleep hygiene and (where appropriate) pharmacological interventions may have some benefit in dealing with sleep-related problems. An encouragement to engage in structured and supported activities with some facilitation from primary or secondary care mental health staff may also be of value to people with the chronic social avoidance associated with PTSD, as may contact with other individuals who have undergone a similar experience. In some areas support groups exist and individuals should be made aware of these and of national organisations.

Chronic disease management models, where the practice identifies and helps individuals develop appropriate coping strategies to cope with their chronic problems, should be considered. Models such as those that have been developed for the treatment of depression (Katon et al, 2001), drawing on previous work for the treatment of chronic physical conditions such as diabetes or arthritis, offer some promise. Regular routine contact, often through members of the primary care staff other than the general practitioner, and regular if not frequent reviews with the general practitioner, offer a real opportunity.

2.6.6.1.

Chronic disease management models should be considered for the management of people with chronic PTSD who have not benefited from a number of courses of evidence-based treatment. [C]