Post Traumatic Stress Disorder

PTSD  describes a syndrome where (a) a person witness or was involved in an event involving actual or threatened death or serious injury, and (b) the person reacted initially with intense fear or helplessness.   If these two criteria are not met even if the person has all the other symptoms of PTSD such as nightmares and flashbacks and hypervigilance the diagnosis is Adjustment Disorder.

The one year prevalence of PTSD is 3.5% ;higher for women than men.  Most trauma survivors may present with PTSD initially  but 26% will remit in six months and 40% within a year.  Predictors of  risk for persistence of PTSD symptoms include:

  • history of child abuse
  • past psychiatric history of depression, anxiety disorder or OCD
  • low educational attainment

For military personnel the additional predictors are:

  • lower rank
  • being unmarried
  • being deployed to a forward area close to the enemy
  • perception that work in the theatre was above the individuals training and experience
  • lack of home-coming briefing

In PTSD the salience network of the brain is dysfunctional.  Normally  threatening experiences only stay in working memory whilst they are environmentally relevant. Otherwise they are shifted to long tem memory. This doesn’t happen in PTSD hence the persistent flashbacks, nightmares and hypervigilence.

Management

There are five targets for treatment:

  1. Nightmares & Unrefreshing Sleep
  2. Daytime Anxiety
  3. Irritability
  4. Impaired Concentration and Short Term Memory
  5. Secondary Depression

Generally early progress with Nightmares and Secondary Depression are favourable prognostic signs.

Because persons with PTSD have a lowered stress tolerance they frequently seek to isolate themselves by withdrawing from social contact or even by moving to remote locales. This generally doesn’t help as the stresses from flashbacks and nightmares are not affected by this and often the person ends up in an area with few available treatment services  and they lose valuable friendships.

Management

As a first line its important to treat any comorbid conditions such as depression or alcohol abuse.  Its common for PTSD sufferers to be anti medication as by the nature of their jobs they are trained to be self-reliant ( as soldiers or policemen or fireman).  St Johns Wort  1-2 tabs per day is as effective as commercial antidepressants but being a herb its possible to have an allergic rash to it. It can also disrupt the effectiveness of the OC pill.  An antidepressant Fluvoxamine has the added advantage or potentially reducing nightmares.

There are a number of medications which disrupt nightmares but they are all hit or miss in their effectiveness. The common ones are blood pressure drugs such as Prazocin and Clonidine and  an antihistamine Cyproheptadine.

Daytime anxiety is often improved if nightmares settle and sleep is improved.  Combining Autohypnosis with Exposure therapy is helpful for definitive treatment of anxiety . This is easiest of their is a single traumatic effect – The trauma is recounted and composed as a written document . The trauma is then recounted is subsequent sessions under light trance so that anxiety associated with the event is extinguished. Any faulty beliefs that come up are dealt with as they arise with cognitive behaviour therapy.   An alternate approach is to use a form of CBT called EMDR – but I find a lot of PTSD sufferers are too fragile for this approach. Neurofeedback is also used for PTSD.  Sometimes people with high daytime anxiety need short term medication prior to proceeding with psychotherapy –  usually the best option is to combine to  low dose anti-anxiety agents Clonazepam + Quetiapine in staggered dosing.

There are specific treatment options for irritability,  cognitive problems, and alcohol abuse available.

Generally it takes between 6 months and 2 years depending on severity and treatment response to get on top of PTSD.  People are often left with a lowered stress tolerance for some years afterwards – meaning that things that previously wouldn’t have upset them now cause undue anxiety. This can be countered by building more replenishing activities into the daily routine and learning to defer issues with self-talk and to sleep on them.

The WorkCover process adds to stress no end  because of its lack of a health orientated approach.

I would say about 30% or PTSD sufferers return to their former employment.

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