Post-traumatic stress disorder

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). These events cause feelings of helplessness and horror.

Immediate, transitory disorders (prostration, disorientation, fleeing, automatic behaviours, etc.) are to be distinguished from secondary, long-lasting problems that appear 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 (PTSD) is characterised by three types of psychological response, generally seen in combination:

– 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.

– Increased arousal
Constant state of alert, exaggerated startle response, anxiety, insomnia, poor concentration. The patient may develop somatic symptoms such as hypertension, 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 his symptoms are a comprehensible response to a very abnormal event. Sessions should be conducted with tact. The patient should be encouraged to talk about his experience. Avoid over active explorations of the patient’s emotions: leave it to the patient to decide how far he wants to go.

Associated symptoms (anxiety or insomnia), if persistent, can be relieved by symptomatic treatment (diazepam) for no more than two weeks1 .

If the patient has severe symptoms (obsessive thoughts, pronounced arousal, etc.), the pharmacological treatment is paroxetine PO (10 to 20 mg once daily at bedtime) or sertraline PO (50 mg once daily with a meal), to be continued for 2 to 3 months after symptoms resolve then, stop gradually.  



Footnotes
Ref Notes
1 Benzodiazepines can lead to dependence and tolerance. They should be used only for severe conditions and for a limited amount of time.