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A tearful anxious patient - managing PTSD

Consultant psychiatrist Dr Nuri Gené-Cos discusses a patient with generalised anxiety

The case

A 30-year-old woman presents to the GP having been tested at an STD clinic. She does not give details but is tearful throughout the consultation. Although her tests are negative, she begins to obsess about genitourinary symptoms as well as fatigue and muscle pains. In addition, she develops generalised anxiety symptoms, panic attacks and agoraphobia. At times she is unable to leave her home. She has nightmares and severe insomnia. She attends further consultations with her GP in relation to her physical health problems but no organic causes are found.

During a routine gynaecological examination with a male doctor and female nurse present, she begins to scream and refuses the procedure. On questioning she refuses to talk but later mentions to the nurse that she was drug-raped on a blind date eight months earlier. She never reported it to the police as she felt ashamed and blamed herself for what had happened.

Her GP suspects post-traumatic stress disorder and, because of the nature of event, she is seen by a female doctor. On the Impact of Event Scale revised (IES-R)4 (a scale that measures the severity of symptoms), she rated as suffering from severe PTSD.

The problem

PTSD is a condition that arises after a person has been exposed to actual or threatened death, serious injury or sexual violence (DSM-51) in any of the following ways:

  • Directly experiencing the traumatic event or witnessing an event as it occurs to someone else.
  • Learning of a violent or accidental event occurring to a loved one.
  • Experiencing repeatedly or being exposed to aversive details of the traumatic event, for instance for members of the police forces, social services, fire fighters and similar.

Not every person exposed to traumatic events will develop PTSD, and there is always a variety of responses and symptoms in different individuals after the experience of trauma. There are some known risk factors associated with PTSD, such as whether the person has suffered prior traumatic events in their lives and early childhood abuse or severe neglect, as well as poor social support or integration, as in the case of migrants or isolated members of society. PTSD is more common in women than men and there is some evidence of transgenerational trauma as shown in some studies.2

Features and diagnosis

The typical symptoms of PTSD are divided in three sections:

  1. Re-experiencing symptoms: flashbacks, nightmares, intrusive distressing images, thoughts or sensory impressions of the event. Physical symptoms associated with remembering the event are common such as nausea, heart pounding, trembling or irregular breathing.
  2. Avoidant and numbing symptoms: avoiding people, situations or circumstances resembling or associated with the event. The patient may feel detached from other people or numb within herself (inability to feel any emotions or sensing parts of the body). It is common to have amnesia for part of the traumatic event - this is more marked if the person was under the influence of drugs when the traumatic event happened.
  3. Hyperarousal symptoms: the patient often is hyperalert, has an exaggerated startle response and may have sleep problems as well as irritability, paranoia and poor concentration.

Comorbid disorders are common in chronic cases, such as depression, alcohol and drug misuse and unexplained physical symptoms.

Patients with chronic PTSD may exhibit less intrusive symptoms and more general numbing and avoidant behaviours.

The diagnosis of PTSD is often missed3 as patients are unaware that their symptoms are related to the traumatic event. Due to shame or avoidant behaviour, these patients might not volunteer information about the traumatic event and clinicians can forget to ask if any such events have occurred.

Screening is recommended in high risk individuals within one month of a major disaster or traumatic incident or in refugees and asylum seekers.4

In GP surgeries, time is paramount. It is best for the clinician to become familiar with one of the rating scales such as the Impact of Events Scale (IES-R)6, which is a self-rating questionnaire, or others such as the ones listed below. These scales are not diagnostic of the condition but suggestive of PTSD, and the scores can be taken in consideration with a more extensive specialist assessment required to confirm the diagnosis.

Other screening questionnaires include:

  • Post-traumatic stress disorder checklist7
  • The post-traumatic diagnostic scale (PDS)8
  • Trauma screening questionnaire (TSQ)9

Management

NICE guidelines4 recommend trauma-focussed cognitive behavioural therapy (t-CBT) or eye movement desensitisation reprocessing (EMDR) as the main options for treatment. The number of sessions required in acute cases (less than three months after traumatic event) is 12 sessions or less of weekly trauma focus therapy.

It is often found that these patients will require more sessions than the number recommended by NICE and that other trauma focus therapies may be required as some patients do not respond to t-CBT or EMDR.

When there is a comorbid disorder or alcohol or drug misuse, these problems will need to be addressed from the start, otherwise therapy will often fail.

In chronic cases (more than three months), in cases where there are personality difficulties, or marked avoidant behaviour as well as dissociative symptoms, the length of therapy is a minimum of 24 sessions.

Social factors such as homelessness, ongoing domestic violence or threats of repatriation need to be dealt with prior to trauma therapy. In these cases, medication may be required as patients may not feel safe enough to embark in a therapy where traumatic events need to be revisited in order to integrate the memories of these events.

The choice of treatment will be dictated by availability but more importantly by the type of trauma and clinical presentation. For instance, in cases where the memory is patchy, as in cases when the patient was not fully conscious, when shame is a prominent feature (e.g. in rape) and when intrusive symptoms are marked, then EMDR may be the treatment of choice as language is not so relevant to the treatment. In patients where there are fewer intrusions and in patients who are not able to tolerate the eye movements or feel overwhelmed by emotions when try to do EMDR, t-CBT may be more suitable.

Other treatments that may benefit when these patients are not responding to NICE-recommended treatment are sensorimotor psychotherapy, narrative exposure therapy and lifespan integration therapy among others. The evidence for some of these treatments is beginning to emerge.5

Although medication is not recommended in most cases of PTSD, it may be relevant when there is a depressive illness, when anxiety symptoms and insomnia are marked and as an adjunct when there is no response to psychotherapy. Mirtazepine is often used as an antidepressant at a dose of 30mg at night or at a lower dose (7.5-15mg at night) as a sleeping tablet. Other antidepressants, such as SSRIs and duloxetine, may also be used when depression is the reason for using medication and sedation not required.

Dr Nuri Gené-Cos is a consultant psychiatrist and the traumatic stress service lead at the South London and Maudsley NHS Foundation Trust.

References

  1. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) - 5th ed. American Psychiatric Publishing, Washington, DC.
  2. Rachel Yehuda, Linda M Bierer (2009) The relevance of epigenetics to PTSD: Implications for the DSM-V, Journal of Trauma Stress, October: 427-434.
  3. Anke Ehlers, Nuri Gene-Cos & Sean Perrin (2009) Low recognition of posttraumatic stress disorder in primary care, London Journal of Primary Care, 2:1, 36-42.
  4. National Institute for Clinical Excellence (NICE) 2005. Post - traumatic stress disorder. The management of PTSD in adults and in children in primary and secondary care.
  5. Gene-Cos N, Fisher J, Ogden P, Cantrell A (2016) Sensorimotor Psychotherapy Group Therapy in the Treatment of Complex PTSD. Ann Psychiatry Ment Health 4(6): 1080.
  6. Weiss DS, Marmar CR (1997) The impact of event scale – revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD. New York: Guilford Press; pp. 399–411.
  7. Edward B Blanchard, Jacqueline Jones-Alexander, Todd C. Buckley and Catherine A Fornesis (1996)Psyhometric Properties of the PTSD checklist (PCL) Behav. Res. Ther. Vol. 34, No. 8, pp. 6694i73.
  8. Foa EB (1995) Posttraumatic Stress Diagnostic Scale Manual. National Computer Systems Inc.
  9. The NHS Information Centre for health and social care. Adult psychiatric morbidity in England, 2007. Results of a household survey.

 

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Readers' comments (2)

  • The Body Keeps The Score by Bessel van der Kolk is the best exploration of PTSD I've read and shows how the USA are leaps and bounds ahead of us in terms of trauma management (mainly because of the Vietnam war, 9/11 etc). I've struggled to manage PTSD well because EMDR and t-CBT simply aren't available locally, despite their proven benefits. I'm sure a lot of our demographic have issues w. complex trauma and would benefit more from the above recommendations that the ineffective depression/anxiety pathways they get filtered into. Trauma centres as per USA practice would be a fantastic development.

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  • E-mdr? 2 year wait.

    T-cbt? Whazzat? You might get to see a psychologist or someone with general training who might be able to focus more... but only after you have failed with standard cbt delivered diy with phone support from a “generic mental health worker,”

    The system defends itself from needing to provide these things by saying they havent got ptsd, they have personality disorders or drug and alcohol issues.... and says they have to be 3 months living in hell without their only drug (alcohol) before they will even asses them.

    Pts and doctors all just give up.the result is family break up if you are lucky. Suicide and homelessness if not.

    And btw, docs and paramedics get it just from working and getting the inevitable complaints and abuse.

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