Stress and PTSD

Stress is a feature of everyday life. Some people seek it for the exhilaration of extreme sports or enjoy the satisfaction of a demanding job. Others shun it, and "stress" at work often means an inability to cope leading to unhappiness, absenteeism and actual illness. Bereavement, divorce and unemployment are all stresses. It is important not to "medicalise" normal responses but post traumatic stress disorder is of a rather different magnitude and in response to stress of a severe and abnormal nature. It should not be confused with anxiety neurosis.

The definition by NICE is:

NICE suggests that 25 to 30% of people experiencing a traumatic event may go on to develop PTSD. An American survey found that after a traumatic event the incidence of PTSD is 8.1% for men and 20.4% for women.² These figures are obviously highly dependent upon the severity of the stressful event and the resilience of the individuals.

• It is usually a life threatening event that precipitates the condition such as a serious accident or hostage taking although it can also result from sexual assault, as after rape or child sexual abuse or after a traumatic childbirth.
• It may not be immediately obvious that the person has suffered such an event and direct questioning may be required.
• Refugees and asylum seekers are likely to have suffered the sort of trauma that would predispose to PTSD.
• People in the police, emergency services and military are more likely to be exposed to such an event but the fact that they have selected such an occupation would suggest some inherent resilience.
• It may be an isolated event such as an accident or assault or an ongoing problem such as domestic violence, recurring sexual abuse or systematic abuse by a rogue regime.
• Men are more likely to be exposed to a serious event but women are more likely to become symptomatic.

The condition can strike at any age and especially in young children the presentation may be atypical.

Re-experiencing Symptoms

Symptoms can be very varied but the most typical include involuntarily re-experiencing features of the traumatic event. This can be very vivid and distressing. There are flashbacks where it seems as if it is happening again. Nightmares are common and repetitive and distressing images or other sensory impressions from the event intrude during the waking day. Reminders of the traumatic event are most distressing.

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 happened to me?
• Could it have been prevented?
• How can I take revenge?

Hyperarousal or Emotional Numbing

They may show hypervigilance for threat, exaggerated startle responses, irritability and difficulty concentrating, and sleep problems. Alternatively they may show lack of ability to experience feelings, feeling detached from other people, giving up previously significant activities, and amnesia for significant parts of the event.

Associated features include depression, anxiety, shame, guilt and reduced libido.

Children

Children may re-enact the experience with repetitive play or frightening dreams without recognisable content. The last may present simply as disturbance of sleep and direct questioning about nightmares may be required. There may be other behavioural problems in children.

Time of Onset

Usually the disorder strikes soon after the event but in up to 15% it may be delayed.³ However, it is not uncommon for the patient to present a considerable time after the event with symptoms that date back to it.

There would appear to be some cultural expectation and predisposition in terms of response to trauma. A review of servicemen from 1872 until the Gulf War showed a changing pattern of presentation with time. All modern wars have been associated with a syndrome characterised by unexplained medical 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.⁴ There is still considerable controversy as to the aetiology of Gulf War Syndrome and whether it represents PTSD or neurotoxicity.

• Many people are denied treatment for PTSD because the condition is unrecognised.
• After a major disaster there may be a screening process to recognise those at risk but for most people recognition comes as part of care for assault, trauma, rape or after identification of child sexual abuse.
• Children often need to be asked directly about their experiences.
• There may be other issues including depression or substance abuse that complicate the picture.
• 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.

Screening for PTSD is of value. There are many different tests but results are generally good with an overall diagnostic efficiency of 86.5%.⁵ Only those at high risk should be screened.

If a patient presents with avoidance, hyperarousal, depression, emotional numbing, drug or alcohol misuse or anger, make sensitive enquiry about traumatic experiences in the past, giving examples such as assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth.
Make similar enquiries of frequent attenders with unexplained physical symptoms or those with problems of alcohol abuse. Diagnosis of alcohol abuse may be elusive.

• Ask adults about re-experiencing including flashbacks and nightmares or hyperarousal including an exaggerated startle response or sleep disturbance.
• For children, especially younger children, ask about sleep disturbance or significant changes in sleeping patterns.
• 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 but single-session debriefing is not recommended.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.
• Children, especially under 8, may simply present with sleep disturbance. The child needs to be questioned directly rather than relying on reports from adults. Diagnostic criteria for those under 8, and especially those under 5, may need reappraisal. 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.⁶

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.⁷

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.⁸
• If symptoms are mild and the event was less than a month ago, watch and wait with a view to interventions if it does not resolve.
• For those with severe symptoms in the first month, cognitive behavioural therapy should be offered.
• Treatment can be trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR).
• Psychological treatments have been assessed by a Cochrane review.⁹

Eye Movement Desensitisation and Reprocessing

CBT has been discussed in its own article but EMDR needs more explanation.

EMDR (Eye Movement Desensitisation and Reprocessing) is a technique which uses eye movements to help the brain to process flashbacks and to make sense of the traumatic experience. NICE recommends that it is as effective as cognitive and behavioural therapy.¹ It is a simple procedure suitable 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 outpouring of emotion when confronted by a cue associated with the original event. They often describe themselves being aware of the flashback but that it is to one side and although they can look at it they are no longer inconvenienced or paralysed by it.

This is quite a simple technique that is not time consuming and it can be employed within the 10 minute consultation. The sustained efficacy of brief intervention with EMDR has been demonstrated¹⁰ and it is a technique that can be used in children and adolescents.¹¹ This is a group for whom drug use is usually best avoided.

Children

• Older children with severe PTSD should be offered trauma-focused 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 trauma-focused CBT adjusted to suit their age and maturity.

Drug Treatment

• Drug treatment should not be used in preference to psychological therapy.
• If patients refuse psychological therapy but want drugs then paroxetine or mirtazapine can be used in primary care but amitriptyline or phenelzine should be initiated only by a psychiatrist. Of these drugs, only paroxetine has a product licence for treating PTSD although its evidence base is the worst of the four. Sertraline is licensed for use but only in women. NICE reiterated 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.
• 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 including depression, general anxiety or alcohol or substance misuse may be present. They are usually 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 so severe as to interfere with treatment of the PTSD, it should be treated first.

The work of the Truth and Reconciliation Committee in post-apartheid South Africa has shown the importance of forgiveness.¹² All too often we live in a world lacking all forgiveness and demanding retribution instead. The charisma of its leader, Archbishop Desmond Tutu and his personal commitment to the Christian values of forgiveness were probably indispensable.

Sufferers from PTSD are more likely to abuse drugs or alcohol² 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.¹³
• At least a third will remain symptomatic after 3 years and have increased risk of substance abuse.²
• This raises the question of when to initiate treatment. 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.¹⁴
• The severity of symptoms in the initial days or the first week after trauma is not a good predictor of persistent PTSD.^15,16
• Evidence suggests that benefit from treatment does not decline with the elapse of time since the traumatic event and so bearing in mind the natural rate of remission the question arises of when to offer intervention.

This is a difficult question that NICE addresses but the evidence is limited. 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.¹⁷ In other words, in the absence of effective therapy, the long-term effects of life-threatening, traumatic events in childhood can be severe.

There are considerable implications in terms of planning for coping with disasters or helping refugees who have suffered severe trauma.

During the First World War many servicemen on both sides who had suffered intolerable stress were executed for cowardice or desertion. During the Second World War, there was a refusal to medicalise those who suffered psychological distress but after the Vietnam War there was extensive medicalisation of the response to trauma, with the pendulum arguably swinging too far. Some felt that it encouraged compensation neurosis and delayed recovery.¹⁸ After exposure to major accidents or act of terrorism we may be too eager to thrust counselling upon those exposed, perhaps from excessive altruism, perhaps for fear of subsequent litigation or perhaps through failure to understand that life is a rich tapestry of pleasant and unpleasant events and the concept that we should never be sad or scared is misplaced.

The idea that risk is to be abhorred is opposed by the popularity of "extreme sports" and even fairground rides. Horror, terror and carnage appear on cinema and television screens in the form of entertainment. There is no shortage of potential recruits for elite military units and they tend to have a low incidence of PTSD. Traditional approaches to risk management by reducing exposure have not been successful, and may 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. Some thrive on it.²⁰

As the health of the nation improves, the ability to cope with untreatable problems, many of which are social rather than medical, decreases.²¹ Claims for compensation delay recovery.²² The doctor may be faced with a dilemma as to whether to support the patient's claim for financial compensation for what was not a financial loss or whether to tell him to forget about his claim and get himself a life again.

We should commend and reward bravery and resilience, whilst caring for victims. We need to respect courage, but not to stigmatize breakdown. There is value in focusing on resilience during and after traumas.

Society needs to find a balance between the stiff upper lip culture that prevents people from admitting to problems and seeking help when they are truly having difficulties and the whimp culture that expects everyone to need counselling and rewards alleged failure to cope with financial compensation. There are even occasions when passers-by at an accident have sought financial recompense for having been upset. This is not just a medical but a social and political issue too.²³