Occupational Medicine 2007 57(6):399-403; doi:10.1093/occmed/kqm069
© The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Post-traumatic stress disorder
Jonathan I. Bisson
Department of Psychological Medicine, Cardiff University, Monmouth House, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
Correspondence to: Jonathan I. Bisson, Department of Psychological Medicine, Cardiff University, Monmouth House, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK. Tel: +44 29 2074 4534; fax: +44 29 2074 2284; e-mail: bissonji{at}cardiff.ac.uk
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Abstract
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Post-traumatic stress disorder (PTSD) is an increasingly recognized
and potentially preventable condition. Certain factors, especially
the severity of the trauma, perceived lack of social support
and peri-traumatic dissociation have been associated with its
development. In recent years, a more robust evidence base regarding
the management of individuals involved in traumatic events has
emerged. Immediately after a traumatic event, simple practical,
pragmatic support provided in a sympathetic manner by non-mental
health professionals seems most likely to help. For individuals
who develop persisting PTSD, trauma-focused cognitive behavioural
therapy (TFCBT) may be beneficial within a few months of the
trauma. For those who develop chronic PTSD, TFCBT and eye movement
desensitization and reprocessing are best supported by the current
evidence. Some anti-depressants appear to have a modest beneficial
effect and are recommended as a second-line treatment. The current
evidence base has allowed the development of guidelines that
now require implementation. This has major implications in terms
of planning and developing services that allow appropriately
qualified and trained individuals to be available to cater adequately
for the needs of survivors of traumatic events.
Keywords Cognitive behavioural therapy; eye movement desensitization and reprocessing; medication; post-traumatic stress disorder; PTSD; trauma-focused psychological treatment
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Introduction
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Despite many accounts of apparent post-traumatic stress disorder
(PTSD) over the last few centuries (e.g. [
1,
2]), it was only
formally recognized as a psychiatric disorder in the third edition
of the Diagnostic and Statistical Manual of Mental Disorders
[
3]. The criteria for PTSD have been refined in subsequent editions
and it was first included in the 10th edition of the International
Classification of Diseases [
4]. Its characteristic features
are displayed in
Box 1. In order to satisfy the DSM IV criteria
[
5], an individual has to be exposed to a traumatic event that
involves actual or threatened death or serious injury, or a
threat to the physical integrity of self or others. It is also
essential that the individual experience a response at the time
that involves intense fear, helplessness or horror. The symptoms
must have been present for at least 1 month (the 1 month does
not apply in the ICD10 classification) and cause clinically
significant distress or impairment in social, occupational or
other important areas of functioning. Acute stress disorder
(ASD) occurs within 1 month of a traumatic event and has similar
symptom criteria to PTSD but with more emphasis on dissociation.
Acute PTSD becomes chronic if it continues beyond 3 months.
Symptoms usually begin shortly after the trauma but are said
to have delayed onset if they commence at least 6 months later.
Box 1. Characteristic symptoms of PTSD adapted from DSM IV [5]
Re-experiencing Phenomena (at least one required)- Recurrent and intrusive distressing recollections
- Recurrent distressing dreams
- Acting or feeling as if events recurring
- Intense psychological distress to cues
- Physiological reactivity to cues
Avoidance and numbing (at least three required) - Avoidance of thoughts, feelings and conversations
- Avoidance of reminders
- Psychogenic amnesia
- Markedly diminished interest in significant activities
- Detachment or estrangement feelings
- Restricted range of affect
- Sense of a foreshortened future
Increased arousal (at least two required) - Sleep difficulty
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance
- Exaggerated startle response
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Prevalence and course
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The United States National Co-Morbidity survey [
6] found that
of 5877, 15–54 year olds just >60% of males and just
>50% of females have been exposed to traumatic events with
lifetime prevalence of PTSD of just >10% for females and
5% for males. Over a third of individuals reported having PTSD
6 years after they developed it. There was a 50% chance of remission
at 2 years. In the recently published replication of this work
[
7,
8], the lifetime prevalence was 6.8% and the 12-month prevalence
was 3.5%. PTSD is often co-morbid with other psychiatric disorders.
Over 80% of participants with lifetime PTSD in the United States
National Co-Morbidity survey [
6] had at least one other disorder.
The commonest co-morbid diagnoses are major depressive disorder,
panic disorder, other anxiety disorder and substance abuse or
dependence. In the National Vietnam Veterans readjustment survey
[
9], there was a 99% lifetime co-morbidity.
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Immediate reactions following trauma
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Exposure to a traumatic event can result in a wide range of
reactions. The focus has often been on pathological reactions
and the development of psychiatric disorders such as PTSD but
more recently resilience has been increasingly recognized as
a common response (e.g. [
10]). The majority of distressing reactions
settle over a matter of weeks or months with a minority developing
into a diagnosable psychiatric disorder, such as PTSD but also
others including depression, anxiety disorders and substance
misuse. Higher impact trauma is more likely to precipitate a
distressing response. Rothbaum and Foa [
11] found that >90%
of female rape victims satisfied the symptom criteria for PTSD
within a week of the event and 40% at 6 months. Following the
September 11th terrorist attacks in New York, Galea
et al. [
12]
found that probable PTSD reduced from 7.5% after 1 month to
0.6% 6 months afterwards among over a 1000 residents of New
York. The rates were highest among those who lived closest to
the site of the attacks. This recovery trajectory is all important
in considering how best to provide for individuals following
traumatic events.
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Predicting the development of PTSD
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It is difficult to predict exactly who will go on to develop
PTSD after a traumatic event. Two large systematic reviews [
13,
14]
have found relatively weak but positive associations of PTSD
with the factors shown in
Box 2. Those most associated with
PTSD were perceived lack of social support and peri-traumatic
dissociation, although even these had an effect size of <0.5.
Other possible predictors such as increased heart rate after
trauma have been shown to be associated with the development
of PTSD but are not very discriminating (e.g. [
15]). The possibility
of detecting individuals who will go on to develop PTSD has
led to attempts to predictively screen shortly after a traumatic
event. Several screening instruments for chronic PTSD have been
developed (see [
16] for review). The 10-item Trauma Screening
Questionnaire (TSQ) [
17] is one of the best validated. Walters
et al. [
18] considered the TSQ as a predictive screening instrument
with victims of violent crime 1–3 weeks after the assault.
Very high rates of sensitivity (0.85) and specificity (0.89)
were found but a much lower positive predictive value (0.48)
meaning that although it detected the vast majority of PTSD
sufferers at 1 month, 50% of those who screened positive did
not develop PTSD. It remains to be seen whether a predictive
screening instrument can be developed that will be practical
and acceptable in the future.
Box 2. Predictive factors
Pre-traumatic risk factors- Previous psychiatric disorder
- Gender (female greater than male)
- Personality (external locus of control greater than internal locus of control)
- Lower socioeconomic status
- Lack of education
- Race (minority status)
- Previous trauma
- Family psychiatric history
Peri-traumatic risk factors - Trauma severity
- Perceived life threat
- Peri-traumatic emotions
- Peri-traumatic dissociation
Post-traumatic risk factors - Perceived lack of social support
- Subsequent life stress
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Prevention of PTSD
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Several systematic reviews of early interventions following
traumatic events have been published in the last few years (e.g.
[
19,
20]). Two main approaches have been considered—interventions
for everyone involved and interventions targeted at individuals
who remain symptomatic after a certain amount of time.
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Interventions for everyone
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Single session psychological interventions
Twelve randomized controlled trials of single session psychological
interventions have been published, most commonly variants of
critical incident stress debriefing [
21]. Meta-analysis provides
no evidence of a positive overall effect. Some studies have
raised the possibility that single session individual debriefing
may cause harm to some individuals [
22,
23]. The only study of
group debriefing [
24] gave neutral results. A recently published
dismantling study showed that individuals who received an ‘emotional
debriefing’ fared worse than those who received a debriefing
that did not contain the emotional components but focused on
education, particularly in individuals who were more markedly
hyper aroused [
25]. A trend for individuals who were more traumatized
to do worse with debriefing has been found in other studies
and two of the debriefing studies that produced positive outcomes
excluded more traumatized individuals [
26,
27].
Early pharmacological interventions
There have been three randomized controlled trials of early pharmacological interventions following traumatic events. Schelling et al. [28] found that early administration of intravenous hydrocortisone in 20 septic shock victims on an intensive care unit in Switzerland resulted in lower rates of PTSD at 31-month follow-up compared to placebo. These results are particularly interesting given the suggestion that low cortisol levels may mediate the development of PTSD. Propranolol [29] and temazepam [30] did not reduce PTSD development.
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Targeted interventions
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Psychological
Given the disappointing results of one-off interventions, several
researchers have advocated using more complex interventions
for individuals who develop more symptoms. The most researched
interventions have been trauma-focused cognitive behavioural
therapy (TFCBT) occurring >4–12 sessions containing
components such as education, relaxation, imaginal exposure,
in vivo exposure and cognitive restructuring. Overall, the studies
have produced positive results for sufferers of ASD [
31,
32],
acute PTSD [
33] and symptoms of PTSD [
34].
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Clinical implications for prevention
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At present there is no convincing evidence for any intervention
for everyone involved in a traumatic event. There is emerging
evidence for TFCBT provided 1–3 months following the trauma
to individuals who are symptomatic. This evidence resulted in
the UK's National Institute for Health and Clinical Excellence's
guidelines (NICE) [
19] recommending that immediate practical,
social and emotional support are offered to individuals following
traumatic events but that individuals are not debriefed. The
guidelines state that acute phase symptomatic pharmacological
management could be considered using hypnotics or anti-depressants,
for example for marked insomnia. They also recommend that TFCBT
be offered to individuals within 1 month if they are suffering
from severe symptoms of PTSD or within 3 months if they are
suffering from acute PTSD, and that the sessions should normally
be over 8–12 sessions, with some sessions of 90 min duration.
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Management of chronic PTSD
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Most chronic PTSD sufferers presenting for treatment will receive
medication [
35]. Many will also receive some form of psychological
treatment, although there are often long waits for such treatment.
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Evidence for psychological treatment
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Various psychological treatments have been tested in randomized
controlled trials. The NICE guidelines [
19] separated the treatments
into individual TFCBT, group CBT, stress management, eye movement
desensitization and reprocessing (EMDR) and other therapies
which included supportive therapy, non-directive counselling,
psychodynamic therapies and hypnotherapy. TFCBT and EMDR fared
better than the other therapies. Fewer individuals were included
in the EMDR studies but the studies that directly compared the
two found no evidence that one of these trauma-focused therapies
was better than the other. Stress management fared slightly
worse than the trauma-focused therapies with the other therapies
and group cognitive behavioural therapy faring worse still.
There was a trend for all therapies to perform better than a
waiting list control but only TFCBT and EMDR reached a pre-determined
threshold set by the NICE guideline development group as being
clinically significant.
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Evidence for pharmacological treatment
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Various drug treatments have been tested in randomized controlled
trials with more chronic PTSD sufferers entered into randomized
controlled drug trials than psychological ones. Paroxetine,
mirtazapine, amitryptyline and phenelzine all fared statistically
significantly better than placebo, although the last three only
included small sample sizes. No drug reached a pre-determined
threshold set by the NICE guideline development group as being
clinically significant. The other drugs were not statistically
significantly better than placebo (sertraline, fluoxetine, imipramine,
venlafaxine and olanzapine). However, there was some evidence
that olanzapine, if added to an anti-depressant, was better
than adding a placebo to augment treatment in chronic PTSD sufferers
who had not fully responded to anti-depressant medication alone.
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Clinical implications for the management of chronic PTSD
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The NICE guidelines recommended that all chronic PTSD sufferers
should be offered a course of TFCBT or EMDR, normally on an
individual outpatient basis regardless of time since trauma.
Again, they recommended 8–12 sessions with some at 90
min if the trauma is considered during the session. The guidelines
also acknowledged that the number of sessions may need to be
increased, particularly following multiple traumatic events
and if there was co-morbidity or traumatic bereavement. If individuals
did not improve or showed only little improvement, they were
advised to consider an alternative trauma-focused treatment
or augmentation with pharmacological treatment. Drug treatments
were not recommended as routine first-line treatment. A limited
role for paroxetine and mirtazapine was suggested if prescribed
by non-specialists, with amytriptyline and phenelzine being
prescribed by mental health specialists. Other issues that may
precipitate prescription of medication include patient choice
and serious ongoing threat. In reality, medication is often
prescribed as a result of lack of immediate availability of
psychological treatment but caution is required, not least because
of the well-documented issues with paroxetine in recent years.
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Conclusions
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It is encouraging that there now exist effective trauma-focused
psychological treatments for chronic PTSD and promising trauma-focused
psychological treatments for acute PTSD. Unfortunately, no existing
treatment is ideal and there is clearly a great need to develop
more effective and more tolerable treatments for PTSD. The results
of early interventions directed at everybody have been very
disappointing and should encourage anybody involved in providing
a response following a traumatic event to exercise extreme caution
before providing a formal intervention. Simple practical, pragmatic
support provided in a sympathetic manner by non-mental health
professionals seems most likely to be the best first-line response
but needs better evaluation. Lessons provided by the existing
research should be heeded and inform our approach in the future.
There is emerging evidence that targeted trauma-focused interventions
are effective for individuals with PTSD symptoms within a few
months of the trauma. This approach should be refined, as should
the detection of symptomatic individuals. Indeed, as hoped with
the trauma risk management model [
36], the optimal way of detecting
and treating most people may be to educate those who are most
likely to be in contact with them about the recognition of problematic
responses such as friends, families, work colleagues, managers,
general practitioners and occupational health practitioners.
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Conflicts of interest
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None declared.
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Abstract
Introduction