08.c.ix • Consequences of trauma (PTSD)

Chronic mental health problems including post traumatic stress disorder (PTSD)

Over the course of the year following major trauma, mental health problems are common, with almost a third suffering from a mental disorder. The four most prevalent disorders being a major depressive episode, generalised anxiety disorder, substance misuse and post traumatic stress disorder. (Bryant et al. (2010)). When quality of life is considered, psychiatric illness has a greater impact at one year than either injury or pain (O'Donnell et al. (2013)).

Therefore, a comprehensive rehabilitation programme should be sensitive to the mental health needs of its patients.

The bulk of new psychiatric diagnoses following trauma involve depression and the anxiety disorders. Most new diagnoses are not present initially and evolve over the course of the year and in this setting mental illness comorbidity is common. When it is considered that many cases will have ongoing physical disabilities, pain and possibly cognitive problems following the trauma careful assessment of patients’ mental health requirements is necessary. It should be noted that mental illnesses arising within this group remain treatable and should not be dismissed as 'understandable'.


Post traumatic stress disorder

Post traumatic stress disorder (PSTD) can develop in response to one or more traumatic events in individuals who have directly experienced or witnessed a traumatic event that includes actual or threatened death. It can lead to significant distress and functional impairment.


Symptoms

Typically develop soon after the event. Involuntary re-experiencing of the traumatic event is a key feature. This includes: intrusive recollections, nightmares and flashbacks, in which the individual subjectively feels back within the traumatic event. Reminders of the traumatic event could trigger psychological distress and physiological reactions. This often leads to avoidance of these, which is another core feature of the disorder. A common strategy of avoidance is to push memories of the trauma to the back of their mind, forcing themselves not think about it.

Other symptoms include hyper vigilance and hyper arousal symptoms including:

  • anger outbursts
  • exaggerated startled response
  • difficulty concentrating
  • scanning for threat
  • emotional numbing
  • sleep disturbances
  • substance misuse

Risk factors for development of PTSD

Some individuals may be more at risk than others of developing psychological difficulties following a traumatic event. People who may be at increased risk of this include:

  • women
  • previous experience of psychological difficulties
  • experiencing an interpersonal trauma
  • individuals with an acute stress reaction (similar symptoms to PTSD but less than a month after the event)
  • having experienced a previous trauma
  • high level of perceived threat during trauma.

Screening for PTSD

People with symptoms of PTSD may find it distressing to talk about the traumatic event. This could cause them to have difficulties in describing the nature of the event and in reporting any associated symptoms. If you feel the individual would benefit from being screened for PTSD, or any mental health problems, discuss this with a mental health professional, such as a clinical psychologist or your local liaison psychiatry service.


Clinical management considerations

  • Assess for risk, eg. suicide ideation, thoughts of wishing to harm themselves or others. If there are any risk issues, manage these first.
  • Do not offer a single session of psychological debriefing shortly after the event; this can be harmful.
  • Take into account any potential triggers on the ward/assessment environment which may inhibit symptoms of PTSD, eg. loud noises, flashing lights, sudden movements etc. Adapt assessment environment to suit needs of the individual, eg. if loud noises trigger flashbacks, treat in a quiet room.
  • Provide empathy and normalise the patient’s trauma symptoms.
  • Provide psycho-education to the patient their friends and family about PTSD
  • Screen for PTSD and refer onto a clinical psychologist if the individual meets criteria.

Family/visitors

  • Assess the impact of the traumatic event on all family members.
  • Provide the family and close friends with psycho-education on the symptoms of PTSD and the type of treatments available.
  • Encourage the family/friends to allow the person with trauma to talk about their experiences as opposed to pushing it to the back of their mind.
  • Try to encourage the family/visitors to normalise the person’s symptoms.
  • Remind the family/friends that certain things may trigger the person’s symptoms, such as flash backs or re-living experiences (see above under ‘symptoms’). Explain that there may be good days and bad days for the person, depending on where they are and how they are feeling.

Management

  • Guidelines by the National Institute for Clinical Health and Excellence (NICE; 2005) suggest that trauma-focused psychological therapy should be the first treatment of choice offered to individuals with PTSD.
  • All people who present with symptoms of PTSD should be offered an evidence based trauma-focused psychological intervention. These should either be traumafocused cognitive behaviour therapy (CBT) or eye movement desensitisation
    • and reprocessing (EMDR). Other evidence based trauma focused interventions include prolonged exposure therapy and cognitive processing therapy. Individuals can access these therapies via referral to a Clinical Psychologist or to their local Improving Access to Psychological Therapies (IAPT) service or Secondary Care Service. These referrals can also be made through contacting the individual’s GP.
  • Evidenced based pharmacological options are available where trauma-focussed therapies are refused, unavailable or otherwise inappropriate. Such medications include: sertraline, paroxetine and venlafaxine. Treatment should be continued for 12 months in those who have responded

Time lines for treatment

  • If symptoms are mild, offer a routine follow-up appointment at least four weeks from your initial assessment to explore any further development of symptoms. This is also referred to as ‘watchful waiting’.
  • The NICE (2005) guidelines recommend for trauma-focused cognitive behavioural therapy (CBT) to be offered to those with severe symptomatology in the first month following the traumatic event.

Further sources of information

  • Post traumatic stress disorder. National Institute for Health and Care Excellence: www.nice.org.uk/CG26
  • Information leaflets on PTSD are available from the Royal College of Psychiatrist’s website: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/ posttraumaticstressdisorder.aspx