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Post-traumatic stress disorder

Introduction

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events.

The type of events that can cause PTSD include:

  • military combat
  • serious road accidents
  • terrorist attacks
  • natural disasters, such as severe floods, earthquakes or tsunamis
  • being held hostage
  • violent deaths
  • violent personal assaults, such as sexual assault, mugging or robbery

PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later.

PTSD can develop in any situation where a person feels extreme fear, horror or helplessness. However, it does not usually develop after situations that are simply upsetting, such as divorce, job loss or failing exams.

Symptoms of PTSD

Someone with PTSD will often relive the traumatic event through nightmares and flashbacks, and they may experience feelings of isolation, irritability and guilt. They may also have problems sleeping, such as insomnia, and find concentrating difficult.

These symptoms are often severe and persistent enough to have a significant impact on the person’s day-to-day life.

Read more about the symptoms of PTSD.

Treating PTSD

PTSD can be successfully treated, even when it develops many years after a traumatic event.

The recommended treatment strategy will depend on the severity of symptoms and how soon they occur after the traumatic event. The following treatment options may be recommended:

  • watchful waiting - waiting to see whether the symptoms improve or get worse without treatment
  • psychological treatment - such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EDMR)
  • medication - such as paroxetine or mirtazapine

Read more about treating PTSD.

How common is PTSD?

PTSD affects up to 30% of people who experience a traumatic event. It affects around 5% of men and 10% of women at some point during their life.

PTSD can occur at any age, including during childhood.

Driving

PTSD it may affect your ability to drive safely, so you should inform the Driver and Vehicle Licensing Agency (DVLA) about your condition.

Find out how to tell the DVLA that you have stopped driving or need to stop.

History of PTSD

Cases of PTSD were first seen during the First World War when soldiers developed shell shock as a result of the harrowing conditions in the trenches.

However, the condition was not officially recognised as a mental health condition until 1980, when it was included in the Diagnostic and Statistical Manual of Mental Disorders, which was developed by the American Psychiatric Association.

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Symptoms

Up to 30% of people who witness a traumatic event experience some of the symptoms of post-traumatic stress disorder (PTSD). These symptoms can vary widely between individuals.

A person with PTSD will often relive the traumatic event through nightmares and flashbacks, and have feelings of isolation, irritability and guilt.

They may also have problems sleeping, such as insomnia, and may find concentrating difficult. The symptoms are often severe and persistent enough to have a significant impact on the person's day-to-day life.

The symptoms of PTSD usually develop during the first month after a person witnesses a traumatic event. However, in a minority of cases (less than 15%), there may be a delay of months or even years before symptoms start to appear.

Some people with PTSD experience long periods when their symptoms are less noticeable. This is known as symptom remission. These periods are often followed by an increase in symptoms. Other people with PTSD have severe symptoms that are constant.

Re-experiencing

Re-experiencing is the most typical symptom of PTSD.

A person will involuntarily and vividly relive the traumatic event in the form of flashbacks, nightmares or repetitive and distressing images or sensations. Being reminded of the traumatic event can evoke distressing memories and cause considerable anguish.

Avoidance

Trying to avoid being reminded of the traumatic event is another key symptom of PTSD.

Reminders can take the form of people, situations or circumstances that resemble or are associated with the event.

Many people with PTSD will try to push memories of the event out of their mind. They do not like thinking or talking about the event in detail.

Some people repeatedly ask themselves questions that prevent them from coming to terms with the event. For example, they may wonder why the event happened to them and whether it could have been prevented.

Hyperarousal (feeling 'on edge')

Someone with PTSD may be very anxious and find it difficult to relax. They may be constantly aware of threats and easily startled. This state of mind is known as hyperarousal.

Irritability, angry outbursts, sleeping problems and difficulty concentrating are also common.

Emotional numbing

Some people with PTSD deal with their feelings by trying not to feel anything at all. This is known as emotional numbing. They may feel detached or isolated from others and have feelings of guilt.

Someone with PTSD can often seem deep in thought and withdrawn. They may also give up activities that they used to enjoy.

Other symptoms

Other possible symptoms of PTSD include:

As with may other mental health conditions, PTSD sometimes leads to the breakdown of relationships and causes work-related problems.

PTSD in children

PTSD can affect children who have witnessed a traumatic event, such as a road traffic accident.

They may have problems sleeping and experience frightening and upsetting dreams.

Like adults, children with PTSD may lose interest in activities that they used to enjoy. They may also have physical symptoms such as headaches and stomach aches.

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Causes

Post-traumatic stress disorder (PTSD) can develop after a person witnesses a very stressful, frightening or distressing event.

The type of events that can lead to PTSD include:

  • military combat
  • serious road accidents
  • terrorist attacks
  • natural disasters, such as severe floods, earthquakes or tsunamis
  • being held hostage
  • violent deaths
  • violent personal assaults, such as sexual assault, mugging or robbery

PTSD is not usually related to situations that are simply upsetting, such as divorce, job loss or failing exams.

PTSD develops in about 30% of people who witness a traumatic event. It is not fully understood why some people develop the condition after witnessing a traumatic event while others do not. However, there are a number of risk factors that appear to make certain people more likely to develop PTSD.

Risk factors

If you have had depression or anxiety in the past, or you do not receive much support from family or friends, you are more susceptible to developing PTSD after witnessing a traumatic event.

There may also be a genetic factor involved in PTSD. For example, having a parent with a mental health problem is thought to increase your chances of developing the condition.

Being abused during childhood is also thought to be another risk factor for PTSD.

Abnormal hormone response

Studies have shown that people with PTSD have abnormal levels of stress hormones.

When in danger, the body produces a number of natural chemicals, such as adrenalin. In very stressful situations, adrenalin triggers a reaction in the body, which is often known as the ‘fight or flight’ reaction. Adrenalin helps to deaden the senses and dulls pain.

However, people with PTSD have been found to continue to produce high amounts of fight or flight hormones even when there is no danger. It is thought that this may be responsible for the numbed emotions and feelings of detachment that are experienced by some people with PTSD.

Changes in the brain

The part of the brain responsible for memory and emotions is known as the hippocampus. In people with PTSD, the hippocampus appears different in magnetic resonance imaging (MRI) scans. It is thought that the changes in this part of the brain may be related to memory problems and flashbacks.

If high amounts of stress hormones (such as adrenalin) are produced, the hippocampus can stop working properly, causing repeated flashbacks and nightmares to occur. The malfunctioning hippocampus may prevent flashbacks and nightmares from being properly processed.

If the stress is relieved and the levels of adrenalin return to normal, the brain will begin to repair itself. Over time, the flashbacks and nightmares will gradually disappear.
 

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Diagnosis

Post-traumatic stress disorder (PTSD) can be difficult to diagnose because people who experience traumatic events often do not want to talk about their feelings.

Also, people with PTSD may not seek treatment for many months or years after their symptoms appear.

Signs of PTSD

You may develop PTSD after experiencing a traumatic event, such as a terrorist attack or serious road traffic accident. The typical signs of PTSD are:

  • having vivid memories, flashbacks or nightmares about the event 
  • trying to avoid things that remind you of the event
  • sometimes feeling emotionally numb
  • often feeling irritable and anxious for no apparent reason
  • eating more than usual, or drinking alcohol or using drugs more than usual
  • an inability to control your mood
  • finding it increasingly difficult to get on with others
  • having to keep yourself very busy to cope
  • feeling depressed or exhausted

When to seek medical advice

If it is less than six weeks since you experienced the traumatic event and your symptoms are starting to improve, you may be going through the natural coping process and may not need treatment.

However, you should visit your GP to discuss your feelings if your symptoms have not improved more than six weeks after the traumatic event.

PTSD affects everyone differently, so your GP will want to discuss your symptoms with you in as much detail as possible.

Your GP will ask you whether you have experienced a traumatic event, either in the recent or distant past, and whether you have re-experienced the event through flashbacks or nightmares.

They may also ask you about your overall health and whether you are having any sleeping problems.

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Treatment

The National Institute for Health and Clinical Excellence (NICE) recommends psychotherapy as the first treatment to try for post-traumatic stress disorder (PTSD). In some cases, medication may also be used.

PTSD can develop days, weeks, months or even years after a person experiences a traumatic event.

Such events can be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.

It is possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it is never too late to seek help.

Treatment plan

Treatment for PTSD usually begins with a detailed assessment of your symptoms before drawing up a treatment plan that is tailored to your individual needs.

Your GP should discuss your treatment plan with you, and any decisions regarding your treatment should be clearly explained to you.

Your GP may feel that you would benefit from seeing a mental health specialist such as a:

  • psychologist - an expert in how the mind works
  • community psychiatric nurse - a nurse who specialises in mental healthcare
  • psychiatrist - a mental health specialist who diagnoses and treats mental health conditions

If you are referred to a mental health specialist, they should always treat you with sensitivity and understanding.

Watchful waiting

Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse.

It may be recommended in cases of PTSD where the symptoms are mild or have been present for less than four weeks after the traumatic event.

If watchful waiting is recommended, you should have a follow-up appointment within one month.

Psychotherapy

Psychotherapy is a type of therapy that is often used to treat emotional problems and mental health conditions, such as PTSD, depression, anxiety and obsessive compulsive disorder.

A psychotherapist is a trained mental health professional. They will listen to your problems and suggest strategies to help you resolve them.

If you have severe or persistent PTSD, a combination of psychotherapy and medication may be recommended.

Read more about psychotherapy.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act.

Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event.

For example, replacing negative thoughts associated with the traumatic event with positive ones. The aim is to help you work through the trauma and gain control of your fear and distress. You may be offered trauma-focused CBT if:

  • your symptoms of PTSD are severe and develop within one month of a traumatic event
  • you still have PTSD symptoms within three months of a traumatic event

You will have 8 to 12 weekly sessions of trauma-focused CBT, although less (about five) may be needed if the treatment starts within one month of the traumatic event. Sessions where the trauma is discussed will last for around 90 minutes.

Read more about CBT.

Eye movement desensitisation and reprocessing (EMDR)

Eye movement desensitisation and reprocessing (EMDR) is a relatively new treatment that has been found to reduce the symptoms of PTSD.

EMDR involves making side-to-side eye movements while recalling the traumatic incident. It works by helping the malfunctioning part of the brain (the hippocampus) to process distressing memories and flashbacks so that their influence over your mind is reduced.

Read more about EMDR.

Medication

NICE recommends that the antidepressants paroxetine or mirtazapine should be considered for treating PTSD in adults.

However, these medications will only be used if you:

  • choose not to have trauma-focused psychological treatment
  • cannot start psychological treatment due to a high risk of further trauma
  • have gained little or no benefit from a course of trauma-focused psychological treatment
  • have severe depression or hypersensitivity that significantly affects your ability to benefit from psychological treatment

Amitriptyline or phenelzine may also be used under the supervision of a mental health specialist. The same criteria as above apply.

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety and to help with sleeping problems. However, they are not usually prescribed for people younger than 18 unless recommended by a specialist.

If medication for PTSD is effective, it will usually be continued for a minimum of 12 months before being gradually withdrawn over the course of four weeks or longer. If a medication is ineffective at reducing your symptoms, your dosage may be increased.

Before prescribing a medication to treat PTSD, you doctor should inform you about possible side effects that you may experience while taking it, along with any withdrawal symptoms that you may have when the medication is withdrawn.

For example, common side effects of paroxetine include:

Possible withdrawal symptoms associated with paroxetine include sleep disturbances, intense dreams, anxiety and irritability.

Children and young people

NICE recommends that trauma-focused CBT should be used to treat older children with severe symptoms of PTSD in the first month after a traumatic event.

Three months after the trauma, the following treatment is recommended:

  • A course of trauma-focused CBT that is adapted to suit the child’s age, circumstances and level of development.
  • A course of 8 to 12 trauma-focused sessions for children and young people who have chronic (long-term) PTSD following a traumatic event.
  • The psychological treatment should be regular and continuous (at least one session a week) and should be delivered by the same person.
  • Where appropriate, the child and their family should be involved in the treatment plan.
  • Where appropriate, the child’s parents or guardians should be informed that trauma-focused psychological treatment has proved to be an effective method of treating PTSD. They should also be made aware that there is no evidence to show that other forms of therapy, such as play therapy, art therapy or family therapy are effective.

The NICE guidelines contain more detailed information about how post-traumatic stress disorder is treated.

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