Post-traumatic stress disorder (PTSD): an overview

Case scenario

Emma is a 24-year-old paramedic who presents to your pharmacy with a prescription for paroxetine 20 mg daily and lorazepam 1 mg PRN for anxiety. She also requests a Fluvax. While you are giving Emma her flu shot, she mentions recent sudden anger and mood swings. She says she was actually in London last year at the height of the pandemic and witnessed her neighbour and one of her colleagues die. It took her months to get a flight home and she was all alone. Emma starts to cry and apologises. 

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS. 

Introduction

Post-traumatic stress disorder (PTSD) first became a household name when it entered the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. This was as a result of the large number of veterans returning from the Vietnam War who were experiencing what was first termed ‘Post-Vietnam Syndrome’. Earlier conflicts had coined terms such as ‘shell shock’, ‘soldier’s heart’, and ‘war neurosis’. Other non-military terms for trauma such as ‘rape trauma syndrome’ and ‘railway spine’ also emerged in the 19th and 20th centuries.¹

The definition of trauma has been debated for decades by clinicians, and the diagnostic signs and symptoms are constantly under scrutiny. These days, the term ‘PTSD’ is thrown around too often, which can take away from those who are suffering what can be a debilitating illness. 

What is PTSD?

The Australian Psychological Society defines PTSD as a set of symptoms that can emerge following the experience of traumatic exposure to actual or threatened death, serious injury or sexual violence.² 

Patients with PTSD have intense and disturbing thoughts and feelings related to the traumatic experience, persisting long after the event. Flashbacks, nightmares, sadness, anger and interpersonal detachment are common symptoms and may trigger avoidant or maladaptive behaviours that can cause further distress in the patient.³ 

In Australia, with worsening bushfire and natural disaster seasons, and the onset of the COVID-19 pandemic, we expect to see a rise in presentations of PTSD and other mental health disorders, such as depression, anxiety and substance abuse, due to the sudden and challenging nature of these events.⁴

With education, pharmacists can be aware of the signs and symptoms of PTSD and can play an integral role in providing medicines and advice to patients, along with advocating for non-pharmacological options for PTSD.⁵

Epidemiology

Approximately two-thirds of Australians will experience events that are potentially traumatic.⁶ But only a small portion of these will go on to develop PTSD. The prevalence rate for PTSD in Australia is approximately 4.4% and is said to be increasing.⁵ However, the lifetime prevalence of PTSD in Australia is now 12%, with women being almost twice the risk of men.⁷ 

First responders and Australian Defence Force personnel were on the front line of the 2019 bushfire response, which led to an estimated prevalence rate of PTSD of 10% and 8.3% in these cohorts respectively.⁴ Yet, Australian veterans were recently reported to have higher rates of PTSD at 17.7% over the first 4 years following discharge from military services.⁴ 

The impact of rape trauma and child sexual assault has been well publicised in the Royal Commission into Institutional Responses to Child Sexual Abuse. Historical and recent trauma experienced as a result of separation from family, land and cultural identity has also had a serious impact on the social and emotional wellbeing of First Nations people.⁶

Finally, a review of the evidence of the psychological effects of the COVID-19 pandemic reported post-traumatic stress symptoms were higher in those who had been in lockdown, and in healthcare workers, compared to the general public.⁸

Insight into PTSD

‘Imagine you are grocery shopping in a busy supermarket and you start having pervasive thoughts. Horrible images appear. They trickle in, flashbacks of being trapped and frozen. Suddenly, you cannot breathe and your heart is jumping out of your chest. You feel weird and embarrassed, as if everyone can see you struggling, but you are powerless to stop it. Your brain stops working and you cannot remember how to do simple tasks such as reading a shopping list or driving and following your normal route home. You somehow make it home and stare at yourself in the mirror. You feel as though you are not there, a feeling of numbness … of nothing. It is very frightening as it feels like a loss of your sense of self. You frantically grab at your face, trying to feel yourself, to make sure you are really there. Later in your bed, you are woken by the same violent twitching that wakes you every night. You get agitated, angry and resentful that even your serenity in bed has been hijacked.‘

Aetiology

The DSM-V definition of what constitutes a traumatic event is more tightly defined than those in previous editions, and the emotional response of intense fear, helplessness or horror during the traumatic event criterion has been removed. 

The cause(s) of trauma are as follows^9–11: 

Exposure to actual or threatened death, serious injury or sexual violence in one (or more) of the following ways:

1. directly experiencing the traumatic event(s)
2. witnessing in person the event as it occurs to others
3. learning that the traumatic event(s) occurred to a close family member or close friend (in cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental)
4. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion 4 does not apply to exposure through electronic media, television,
movies or pictures, unless this exposure is work-related.^9,11

While much of the pathophysiology of PTSD is still unclear, recent research has revealed that trauma produces physiological and neurological change. Studies using magnetic resonance imaging (MRI) in patients with PTSD have shown that there is a decreased volume of the hippocampus, left amygdala, anterior cingulate and prefrontal cortex. This affects memory, fear, impulse control, emotions and the filtering of relevant information from irrelevant information. 

Neurotransmitter activity can be affected where there is an increase in central noradrenaline levels, which can cause down-regulation of central adrenergic receptors. Stress hormones also play a part, with chronically decreased glucocorticoid levels and corresponding up-regulation of their receptors. This may account for the anecdotal observation that higher rates of autoimmune disease occur in patients with PTSD.¹⁰

Table 1 – Risk factors for PTSD

Risk factors 

Risk factors for PTSD are extensive and multifactorial. They can be divided into pre-traumatic, peri-traumatic, and post-traumatic risk factors (see Table 1).¹⁰ 

As primary healthcare providers, pharmacists should be particularly vigilant with persons who work in occupations such as law enforcement, the military, emergency services, communities that have been subject to natural disasters such as floods and bushfires, patients presenting with severe physical injuries or medical emergencies, and patients frequently presenting with non-specific somatic complaints.⁹

Symptoms

The DSM-V lists four symptom clusters of PTSD¹¹:

1. Intrusion symptoms
   • Recurrent, involuntary and intrusive distressing recollections of the event(s)
   • Recurrent distressing nightmares related to the trauma
   • Dissociative reactions (e.g. flashbacks) where the individual feels the traumatic event is recurring; this may occur on a continuum from brief episodes to complete loss of consciousness
   • Intense or prolonged distress or physiological reactivity after exposure to traumatic reminder.
     
2. Avoidance symptoms
   • Effortful avoidance of distressing trauma-related thoughts or feelings
   • Effortful avoidance of trauma-related external reminders (e.g. people, places, conversations, activities, objects or situations).
3. Negative alterations in cognitions and mood
   • Inability to remember an important aspect of the traumatic event(s)
   • Persistent and exaggerated negative beliefs or expectations about oneself, others or the world
   • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
   • Persistent negative emotional state (e.g. fear, horror, anger, guilt or shame)
   • Markedly diminished interest or participation in significant activities
   • Feelings of detachment or estrangement from others
   • Persistent inability to experience positive emotions.
4. Arousal and reactivity symptoms
   • Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
   • Reckless or self-destructive behaviour
   • Hypervigilance
   • Exaggerated startle response
   • Problems with concentration
   • Sleep disturbance.

Diagnosis of PTSD is made by identifying the presence of at least ONE symptom from the intrusion and avoidance clusters, and at least TWO symptoms from each of the remaining clusters. The duration of the symptoms must be more than 1 month, and cause clinically significant distress or impairment to the patient.¹¹

Differential diagnosis

Individuals with PTSD are 80% more likely to have symptoms that meet diagnostic criteria for at least one other mental disorder (e.g. depression, obsessive-compulsive disorder, substance use disorders).¹¹ 

Not all mental disorders that occur in individuals exposed to trauma should necessarily be attributed to PTSD. The diagnosis requires that trauma exposure precedes the onset or exacerbation of pertinent symptoms.¹¹ 

Furthermore, if the symptom pattern to the trauma meets the criteria for another mental disorder, these diagnoses should be given instead of, or in addition to, PTSD – they should not be ignored. If certain symptoms related to trauma are so severe, they may warrant a separate diagnosis and course of treatment (e.g. dissociate amnesia).¹¹ Other common conditions to exclude after a traumatic event are listed in Table 2. 

Table 2 – Other common conditions to exclude after a traumatic event¹¹

Prognosis

PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months following trauma. However, symptoms can be delayed for months or even years, which is referred to as delayed expression.^9,11  

Prognosis for PTSD is variable. Recovery can be heavily influenced by other factors, especially in occupational trauma such as physical disability and loss of employment. Similarly, recovery from PTSD related to receiving financial compensation appears to be less likely, and is more associated with the compensation process itself. Elevated levels of anger may also affect the recovery trajectory. 

Based on several studies, it is reasonable to assume PTSD is less likely to follow a chronic course with evidence-based treatment, and roughly a third of patients will make a good recovery, a third will do moderately well, and a third will be unlikely to improve.¹¹ 

Management

Routine psychological debriefing for those exposed to potentially traumatic events should NOT be offered – there is no evidence that psychological debriefing prevents PTSD, and it may be harmful for some. Instead, guidelines recommend providing information, emotional support and practical assistance in preference to individual or group psychological debriefing.¹¹

The Australian Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder state that individual psychotherapy remains the recommended first-line treatment for PTSD.¹²

First-line recommendations for adults with PTSD¹²:

Trauma-focused cognitive behavioural therapy (TF-CBT) and its variants:

• Cognitive processing therapy (CPT)
• Cognitive therapy (CT)
• Eye movement desensitisation and reprocessing (EMDR)
• Prolonged exposure (PE). 

(A description of these can be found at www.apa.org/ptsd-guideline/treatments)

Medicines are second-line treatment, with limited evidence producing a short list of recommended antidepressants: sertraline, paroxetine, fluoxetine and venlafaxine. This evidence is not strong and has progressed very little over the years.^4,12 

Treatment with medicines is recommended only if one (or more) of the following circumstances apply¹²:

• the person is unwilling or not in a position to engage in or access recommended psychological therapy
• the person’s circumstances are not sufficiently stable to commence recommended psychological therapy
• the person has a comorbid condition or associated symptoms where SSRIs are indicated
• the person has not gained significant benefit from recommended psychological therapy
• there is a significant wait time before psychological therapy is available.

This short list of recommended antidepressants can be quickly exhausted when prescribers are faced with angry, agitated and highly distressed patients, which can lead to polypharmacy, off-label and idiosyncratic prescribing. Prescribing in such a manner can often result in medicine regimens similar to those seen in treatment-resistant depression.⁴ Using a prescribing algorithm like the one recommended by Phoenix Australia has been shown to result in better clinical outcomes than prescribing based on clinician preference.¹²

Emerging treatments for PTSD include MDMA or psychedelic-assisted psychotherapy, ketamine infusions, meditation, and cannabis and prazosin for minimising nightmares, although the evidence base is not yet robust enough for them to become regular practice.  Veteran affairs organisations in countries such as the US, UK and Australia are at the forefront of investigating these options.^13,14

Knowledge to practice

Pharmacists can play a sentinel role in helping to manage patients with PTSD. Due to the prognosis of PTSD (and despite pharmacotherapy being second-line), patients will commonly present with at least one or more psychotropic medication. Medication adherence may be a problem due to mental state, reduced cognition and substance abuse, which commonly present in PTSD. 

Patients with PTSD will often present with comorbid conditions requiring multiple medicines, ranging from chronic pain medications to medications to help abstain from alcohol. Thus, the need for pharmacist interventions, such as a medication review or referral for further investigation, is greater than ever.⁵

• PTSD is the result of being exposed to actual or threatened death, serious injury or sexual violence. 
• People with PTSD may experience intrusion, avoidance and arousal symptoms, and negative changes in cognition and mood. 
• Psychological therapies remain the forefront of PTSD treatment, which allow reprocessing of the trauma and treatment of any cognitive distortions associated with it.
• Medicines are second-line; however, due to the limited evidence-based options and poor prognosis, PTSD can result in polypharmacy and off-label prescribing. 

Disclaimer

Although children may also be exposed to trauma, they are not included in this article due to space constraints. For more information about PTSD and children, please refer to the DSM-V and the Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD. 

This article is accredited for group 2 CPD credits. Click submit answers to complete the quiz and automatically record CPD against your record.

SUBMIT ANSWERS

If you do get an enrolment error, please click here

References

1. Stein MB, Rothbaum BO. 175 Years of Progress in PTSD Therapeutics. Am J Psych 2018;175:508–16.
2. Australian Pyschological Society. Postraumatic Stress Disorder. 2021. At: www.psychology.org.au/for-the-public/Psychology-topics/Posttraumatic-stress-disorder
3. Torres F. What is Posttraumatic Stress Disorder (PTSD)? 2020. At: www.psychiatry.org/patients-families/ptsd/what-is-ptsd
4. Wallace D. Post-traumatic stress disorder in Australia. Australas Psychiatry 2020;28:251–252.
5. Spaulding AM. A pharmacotherapeutic approach to the management of chronic posttraumatic stress disorder. J Pharmy Pract 2012;25:541–51.
6. McEvoy PM, Grove R, Slade T. Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2011;45:957–67.
7. Australian Government. Australian Institute of Health and Welfare. Stress and Trauma. 2020. At: www.aihw.gov.au/reports/australias-health/stress-and-trauma
8. Brookes SK, Webster, RK, Smith LE, et.al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912–20.
9. Cooper J, Metcalf O, Phelps A. PTSD – an update for general practitioners. Aust Fam Physician 2014;43:754–7.
10. Sareen J. Posttraumatic stress disorder in adults: epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. 2021. At: www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis
11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-V). Washington DC: American Psychiatric Association; 2013.
12. Phoenix Australia. The Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD. 2020. At: www.phoenixaustralia.org/australian-guidelines-for-ptsd/
13. Reisman M, PTSD Treatment for Veterans: what’s working, what’s new, and what’s next. Pharmacy and Therapeutics 2016;41(10):623–7, 632–4.
14. Davis LL. Exciting new developments in pharmacotherapy for PTSD. PTSD Research Quarterly 2021;32(4).

GABRIELLE HANSEN BPharm, Grad Cert Pharmacy Practice is Senior Clinical Pharmacist – Mental Health, Western NSW Health, Bloomfield Hospital, Orange. She has worked for 10 years as a mental health pharmacist and has experience in clinical governance and e-health deployment in one of the largest local health districts in Australia.