POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is a severe, often chronic and disabling illness, which develops in some individuals who experience or witness severe trauma that constitutes a threat to the physical integrity or life of the individual or of another person.

PTSD arises as a delayed or protracted response to a traumatic or stressful event (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

CLINICAL FEATURES:

PTSD is characterized by

  • intrusive thoughts,
  • distressing recollections of the event (e. g. flashbacks or nightmares),
  • avoidance of reminders of trauma, (e. g. apathy, emotional detachment, avoidance of places or persons connected with the trauma)
  • hyperarousal (e. g. insomnia, irritability, hyper vigilance).
  • sleep disturbance,
  • Patients can also present with symptoms of associated conditions

or behaviours, such as alcohol use or after non-fatal self-harm

  • unresponsiveness to surroundings and
  • anhedonia

If the symptoms and behavioral disturbances (The disturbance is not attributable to the physiological effects of a substance or other medical condition) persist for more than one month, lead to considerable social, occupational, and interpersonal dysfunction or significant distress to the sufferer, the patient is labeled as having post‐traumatic stress disorder.

AETIOLOGY AND RISK FACTORS:

  • Traumatic stress: trauma type (violent assault) and severity (physical injury), repeated trauma
  • Genetic vulnerability: more prevalent in monozygotic twins versus dizygotic twins (Skre et al., 1993)
  • Female gender
  • Developmental factors: such as growing up in a disadvantaged home environment
  • Previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course
  • Intense emotionality after trauma
  • Structural neuroimaging: studies reveal that there is a slight reduction in volume of hippocampus 4
  • Functional imaging: reveals failure to inhibit amaygdala activation +/-  lowered amygdala threshold to fearful stimuli.
  • Neuroendocrine abnormalities: dysregulation of testosterone, oestrogen and cortisol metabolism.

TREATMENT

PREVENTION: As PTSD follows trauma, there is a theoretical scope for intervention after adversity but before the development of post-traumatic symptoms. Trauma-focused CBT, sertraline, the b-adrenoceptor blocker propranolol and intravenous hydrocortisone can prevent post-traumatic symptoms. Morphine use at the time of injury may be protective.8,9

MANAGEMENT IN PATIENTS WITH ESTABLISHED PTSD

PHARMACOLOGICAL

  • SSRIs (fluoxetine, paroxetine, sertraline),
  • SNRI venlafaxine,
  • TCAs amitriptyline and imipramine,
  • mirtazapine
  • phenelzine
  • Atypical antipsychotic drugs can be used to augment the response to antidepressant treatment

Patients who respond to pharmacological approaches should continue with them for at least 6 months to reduce the risk of a relapse of symptoms.

NON PHARMACOLOGICAL

  • NARRATIVE EXPOSURE THERAPY: patients are asked to describe the event in great detail which causes marked distress initially but habituation ensues as more and more details are recalled
  • Trauma-focused cognitive behavioral therapy
  • eye movement desensitization and reprocessing can be helpful

The relative value of long-term psychological and pharmacological treatments is, however, unknown.

 

References

  1. Medscape
  2. Uptodate
  3. Wiley Concise Guides to Mental Health: Posttraumatic Stress Disorder By Adam Cash
  1. Robert P Gordon Emma K Brandish David S Baldwin Anxiety disorders, post-traumatic stress disorder, and obsessivee compulsive disorder
  2.  N Engl J Med. 2002 Mar 28;346(13):982‐7. Galea S. Psychological sequelae of the September 11 terrorist attacks in New York City.

http://www.ncbi.nlm.nih.gov:80/entrez/queryd.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11919308

  1. Semin Clin Neuropsychiatry. 2001 Apr;6(2):131‐45.Villarreal G. Brain imaging in posttraumatic stress disorder.

http://www.ncbi.nlm.nih.gov:80/entrez/queryd.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11296313

  1. Encyclopedia of public health
  2. Oxford handbook of clinical specialities
  3. killology.com