Post-traumatic stress disorder

Last updated: November 2021

An event is “traumatic” when someone has been directly confronted with death, either by seeing another person being killed or seriously injured as the result of violence, or by experiencing serious harm, such as a threat to his/her life or physical integrity (e.g. rape, torture). Exposure to one or several of these events causes feelings of helplessness and horror.

Immediate, transitory symptoms (disorientation, anxiety, sadness, fleeing, etc.) are to be distinguished from secondary, long-lasting problems that appear and/or last several weeks or months after the event: post-traumatic stress, often associated with depression (Depression), or sometimes acute psychosis (Psychotic disorders), even in people with no history of psychotic symptoms.

Post-traumatic stress disorder is characterized by three types of psychological response, generally seen in combination [1] Citation 1. World Health Organization. Post traumatic stress disorder. International Classification of Diseases for Mortality and Morbidity Statistics, Eleventh Revision (ICD-11).
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/2070699808 [Accessed 26 January 2021] .

• Persistent re-experiencing
  The patient describes:
  • images, thoughts or perceptions related to the traumatic experience, which intrude despite efforts to block them out, including at night in the form of distressing dreams;
  • flashbacks during which the patient “relives” parts of the traumatic scene.
• Avoidance 
  The patient tries to avoid: 
  • places, situations and people that might be associated with the trauma;
  • having thoughts or feelings related to the trauma; patients may use alcohol, drugs or any psychotropic agents for this purpose.
• Persistent perceptions of heightened current threat 

Hypervigilance (constant state of alert), exaggerated startle reaction, anxiety, insomnia, poor concentration; sometimes somatic symptoms (sweating, shaking, tachycardia, headache, etc.).

Re-experiencing is highly distressing and causes disorders that may worsen over time; people isolate themselves, behave differently, stop fulfilling their family/social obligations, and experience diffuse pain and mental exhaustion.

Management

Psychological intervention is essential to reduce the suffering, disabling symptoms and social handicaps resulting from PTSD.

It is important to reassure the patient that their symptoms are a normal response to an abnormal event. Sessions should be conducted with tact. The patient should be listened to. Avoid intensely questioning the patient about their emotions: leave it to the patient to decide how far they want to go.

Associated symptoms (anxiety or insomnia), if persistent, can be relieved by symptomatic treatment (see Anxiety and Insomnia) for no more than two weeks.

If the patient has severe symptoms (obsessive thoughts, pronounced hypervigilance, comorbid despression etc.), the pharmacological treatment is fluoxetine PO (20 mg once daily) or paroxetine PO (10 to 20 mg once daily) or sertraline PO (50 mg once daily), to be continued for 2 to 3 months after symptoms resolve then, stop gradually.