Stress and Post-traumatic Stress Disorder

Stress is a feature of everyday life. Definitions vary but, in essence, it is the autonomic 'alarm' response to perceived threat in the environment, involving heightened arousal, adrenaline production facilitating short-term 'fight-or-flight' resistance, followed by physical and mental exhaustion. Stress is commonly understood as a mismatch between the external demands on an individual and their ability to cope. Many attribute their physical illness to it, from headache to cancer.

Individuals vary in their resilience to stress: some actively seek and thrive in stressful environments, seeking out extreme sports or highly demanding careers. Others shun it, and "stress" at work often means an inability to cope, leading to unhappiness, absenteeism and actual illness. Life events such as bereavement, divorce and unemployment are all important 'stressors' and may have consequences for mental health but it is important not to "medicalise" normal adjustment reactions to these types of events. Post-traumatic stress disorder (PSTD) has a different magnitude and develops in response to stress of a severe and abnormal nature.

NICE highlights the difference:¹

25 to 30% of people experiencing a traumatic event may go on to develop PTSD.¹ An American survey found that, after a traumatic event, the incidence of PTSD is 8.1% for men and 20.4% for women.³ These figures are obviously highly dependent upon the severity of the stressful event and the resilience of the individuals. They also highlight the fact that the majority of exposed individuals do not develop PTSD.
PTSD can develop at any age.

Risk factors

• Usually the precipitating event is, or is perceived as, life-threatening. Examples include serious accidents, hostage taking, natural disasters, terrorist incidents and violent assault . However it can also result from sexual assault, following rape or child sexual abuse or after a traumatic childbirth. The trauma can also be ongoing such as domestic violence, recurring sexual abuse or systematic abuse by a rogue regime.
• Refugees and asylum seekers are likely to have suffered the sort of trauma that would predispose to PTSD and are at much higher risk than the general population in their new countries of settlement.⁴
• People in the police, emergency services and military are more likely to be exposed to such an event. The fact that they have selected such an occupation suggests some inherent resilience. Amongst the military, risk factors for PTSD include:⁵
  • Duration of combat exposure
  • Low morale
  • Poor social support
  • Lower rank
  • Unmarried
  • Low educational attainment
  • History of childhood adversity
• A history of previous psychiatric disorders increases the risk of PTSD.
• Sex differences are controversial: men are more likely to be exposed to a serious event but women appear more likely to become symptomatic. A recent prospective cohort study showed that female military personnel were almost twice as likely as male colleagues to develop new onset symptoms of PTSD.²

Recognition is often a challenge:

• Many people are denied treatment for PTSD because the condition is unrecognised. If a patient presents with PTSD symptoms, depression, drug or alcohol misuse or anger, make sensitive enquiry about traumatic experiences in the past. Make similar enquiries of frequent attenders with unexplained physical symptoms.
• Ask children directly about their experiences.
• Comorbidities are common, e.g. depression, anxiety, substance abuse.
• Although the problem starts soon after the event, in 85% it may present later so that the relationship with the event is less obvious, especially if features are less specific, such as anxiety, depression, insomnia or hypochondria with frequent attendance.
• It may be necessary to distinguish PTSD from traumatic or complicated grief reactions that may develop a year or more after a bereavement, with symptoms of intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks associated with the deceased, unusual sleep disturbances and loss of interest in personal activities.⁶

PTSD symptoms fall into 3 categories:

1. Re-experiencing
   Symptoms can be very varied but the most typical include involuntary re-experience of the traumatic event. This can be very vivid and include:
   • Flashbacks where it seems as if the event were happening again.
   • Nightmares, which are common and repetitive.
   • Distressing images or other sensory impressions from the event, which intrude during the waking day.
   • Reminders of the traumatic event provoke distress.
2. Avoidance or rumination
   Sufferers avoid reminders of the trauma, such as people, situations or circumstances resembling the event or associated with it. They may try to suppress memories or avoid thinking about the worst aspects. Many others ruminate excessively and prevent themselves from coming to terms with the experience.
   • Why did it happen to me?
   • Could it have been prevented?
   • How can I take revenge?
3. Hyperarousal or emotional numbing
   This may manifest as:
   • Hypervigilance for threat
   • Exaggerated startle responses
   • Irritability
   • Difficulty concentrating
   • Sleep problems
   • Difficulty experiencing emotions
   • Feeling of detachment from others
   • Giving up previously significant activities
   • Amnesia for salient aspects of the trauma

Children

Developmentally, children may have more limited verbal skills and different means of reacting to stress compared to adults and thus will present differently with PTSD. Alternative criteria have been suggested for the diagnosis of PTSD in children, placing more emphasis on regressive behaviours and new fears, but these have yet to be fully validated.⁷ Children may re-enact the traumatic experience with joyless repetitive play or have frightening dreams without recognisable content, sometimes presenting as sleep disturbance. They may have other behavioural problems.

Time of onset

Usually the disorder strikes soon after the event but in a small minority it may be delayed. Delayed onset greater than a year post-trauma is thought to be very rare.⁸ More commonly, patients present a considerable time after the event with symptoms that date back to it.

Cultural modification

There are cultural expectations that predispose an individual's response to trauma. All modern wars have been associated with a syndrome characterised by medically unexplained symptoms. The form that these assume, the terms used to describe them and the explanations offered by servicemen and doctors seem to be influenced by advances in medical science, changes in the nature of warfare and underlying cultural forces.⁹

Screening

Screening for PTSD is of value. There are many different tests but results are generally good with an overall diagnostic efficiency of 86.5%.¹⁰ Only those at high risk should be screened; for example:

• After a major disaster, consideration should be given to the routine use of a brief screening instrument for PTSD at 1 month after the disaster to identify those most at risk of PTSD.¹
• Refugees and asylum seekers at high risk of developing PTSD should be given a brief screening instrument for PTSD as part of the initial refugee healthcare assessment. This should be a part of any comprehensive physical and mental health screen.

• Depression
• Specific phobias
• Acute stress reaction
• Adjustment disorders
• Personality disorders
• Enduring personality change after catastrophic experience
• Dissociative disorders
• Neurological injury or disease
• Psychosis
• Complicated grief reaction
• Malingering

Much more detail about the nature of various types of management, including psychological therapies can be found in the NICE full guidelines.¹

General principles

• Single-session interventions, often referred to as debriefing, immediately after the event are not recommended as effective.¹¹
• If symptoms are mild and the event was less than a month ago, watchful waiting is appropriate.
• For those with severe symptoms in the first month, trauma-focused cognitive behavioural therapy (TF-CBT) should be offered.
• Alternative psychological treatments to TF-CBT include eye movement desensitisation and reprocessing (EMDR) and stress management.¹²
• Non-trauma-focused interventions such as relaxation or non-directive therapy, that do not address traumatic memories, should not routinely be offered to people who present with PTSD symptoms within 3 months of a traumatic event.
• Co-morbid conditions such as depression, general anxiety or alcohol or substance misuse are often secondary to the PTSD. The PTSD should be treated first and then the co-morbid condition, especially depression, will usually improve. However, if the co-morbid condition is sufficiently severe to interfere with treatment of the PTSD, it should take precedence in treatment.

Eye movement desensitisation and reprocessing

CBT has been discussed in its own article but EMDR requires more explanation. It is a technique which uses eye movements to help the brain to process flashbacks and to make sense of the traumatic experience. It is a simple procedure, amenable for use in a General Practice consultation:

• Ask the patient to visualise their flashback and at the same time to be aware of the emotion associated with it.
• Ask them to centre this emotion/physical feeling (give examples such as "some people feel tight in the chest, others in the stomach") and concentrate on it while they focus their eyes on your finger or other object held in front of them.
• Move the object slowly from side to side, in silence, for a minimum of 20 times but usually more, depending upon sensory feedback.
• It is common to elicit emotion and occasionally the patient will be unable to continue for a full session.
• The sessions should be repeated at intervals of a few days to a week until the patient is no longer socially inconvenienced by uncontrollable emotional outpouring when confronted by a cue associated with the original event.

Children

• Older children with severe PTSD should be offered TF-CBT in the first month after the traumatic event.
• Children and young people with PTSD, including those who have been sexually abused, should be offered a course of TF-CBT adjusted to suit their age and maturity.
• EMDR may also be used with children.
• NICE conclude there is currently no good evidence for widely used treatments such as play therapy, art therapy, or family therapy for PTSD.

Drug treatment

• Drug treatment is considered second-line and should not be used in preference to psychological therapy.
• If patients refuse psychological therapy but want drug treatment, or where psychological treatment has not relieved symptoms, NICE suggests the use of paroxetine or mirtazapine (primary care) and amitriptyline or phenelzine (to be initiated only by a psychiatrist). A Cochrane review supported the use of SSRIs in the treatment of PTSD.¹³ NICE reiterates the need for vigilance for suicidal ideations in young people prescribed SSRIs and care with sudden withdrawal.
• Hypnotics may be considered to help insomnia but they should not be used for more than a month and, if required for longer, should be replaced by an antidepressant.

Sufferers from PTSD are more likely to abuse drugs or alcohol³ and to have medical problems including musculoskeletal and circulatory problems. They are also more likely to suffer somatisation, chronic pain and poor health.

• A substantial proportion of those who experience serious trauma will develop some features of PTSD but most will recover spontaneously without intervention over the next year.¹⁴
• At least a third will remain symptomatic after 3 years and have increased risk of substance abuse.³
• One important indicator of the need for treatment appears to be the severity of symptoms from around 2 to 4 weeks after the trauma and beyond.¹⁵
• The severity of symptoms in the initial days or the first week after trauma is not a good predictor of persistent PTSD.^16,17
• Symptoms may still be present many years after the event. A study based 33 years after the slagheap of a coal tip engulfed a school in Aberfan found that 29% of those traced and interviewed still met criteria for PTSD.¹⁸ In the absence of effective therapy, the long-term effects of life-threatening, traumatic events in childhood can be severe.
• The benefit from treatment does not decline with the elapse of time since the traumatic event.

No routine intervention has been shown to prevent this disorder.

We cannot eliminate risk, fear and unpleasant events and most of us will experience at least one major trauma in our life. Traditional 'Health and Safety' approaches to risk management, which attempt to reduce exposure, have not been successful, and may actually increase risk aversion and reduce resilience. People are not intrinsically risk-averse, provided they can see purpose in accepting risk.¹⁹ Exposure to risk is not inevitably harmful. Claims for compensation delay recovery.²⁰ Culturally, we need to respect courage and resilience but not to stigmatize breakdown. PTSD is not just a medical but a social and political issue too.²¹