PTSD

Cognitive Behavioural Treatment

• Cognitive behaviour therapy (CBT) is the preferred treatment for PTSD, encompassing several key components.
• Information is provided on normal stress responses and the necessity of facing traumatic memories or situations.
• Self-monitoring of symptoms is encouraged to track progress.
• Exposure therapy includes imagining feared situations followed by real-life confrontations.
• Patients recall traumatic memories to integrate these into their broader life context.
• Cognitive restructuring involves evaluating and discussing patients’ beliefs and assumptions about their trauma.
• Anger management techniques are employed for those struggling with anger related to their experiences.
• A meta-analysis shows CBT has a therapeutic effect size of around 1.6 compared to waitlist controls, indicating significant effectiveness.
• Roughly 50% of patients cease to meet PTSD criteria following treatment, although some may still experience symptoms.

Eye Movement Desensitization and Reprocessing (EMDR)

• EMDR was developed specifically for PTSD treatment.
• Trials have shown EMDR effects are similar to CBT, yet the supporting evidence is less comprehensive.
• The therapeutic value of eye movements in EMDR is questioned regarding its exposure component.

Narrative Exposure Therapy (NET)

• NET enhances memory processing by framing traumatic experiences within a chronological life narrative.
• Initially developed for victims of multiple traumas, particularly in refugee contexts, NET is delivered successfully by lay therapists and adapted for children.
• The therapy is gaining traction in both low- and middle-income regions, bolstered by an expanding evidence base.

Medication

• Anxiolytics like benzodiazepines should be avoided due to dependency risks in PTSD patients.
• Antidepressants such as SSRIs, SNRIs, tricyclics, and MAO inhibitors have shown effectiveness.
• Mirtazapine and atypical antipsychotics like olanzapine may assist treatment-resistant patients with severe sleep issues.
• The anticonvulsant topiramate shows promise based on limited studies.
• Structured psychotherapies typically yield higher effect sizes than medications and are regarded as the first-line approach for PTSD treatment.

Aetiology

• PTSD necessitates exposure to an exceptionally traumatic event, which need not involve direct harm to the individual.
• Factors such as personal vulnerability, potentially genetic or acquired, influence whether PTSD develops post-trauma.
• Epidemiological studies reveal that while most will encounter a traumatic event, specific types (e.g., interpersonal violence) are more likely to lead to PTSD.
• Women experience PTSD at higher rates than men, even though men encounter more general trauma.

Genetic Factors

• Twin studies indicate a genetic component to susceptibility for PTSD, with genetic variation contributing to approximately one-third of PTSD liability.
• Genetic influences also affect personality traits that might increase risky behaviors, further influencing PTSD risk.

Other Predisposing Factors

• Individual risk factors for PTSD include:
  • Previous trauma.
  • Personal history of mood or anxiety disorders.
  • Female gender.
  • Neuroticism.
  • Lower intelligence.
  • Insufficient social support.

Neurobiological Correlates

• Research highlights the role of monoamine neurotransmitters and HPA axis dysregulation in PTSD.
• Brain imaging reveals:
  • Reduced hippocampal volume, impacting memory processing.
  • Overactive amygdala associated with traumatic stimuli.
  • Decreased activity in the anterior cingulate cortex and prefrontal cortex leading to dysregulated emotional response.

Psychological Factors

• Fear conditioning enhances the symptoms of PTSD through maladaptive responses to trauma.

ICD-10 Criteria for Enduring Personality Changes

• Individuals may exhibit persistent negative attitudes and social withdrawal two years post-trauma, with a distinct change in personality following the event.

Principal Symptoms of PTSD

• Symptoms include:
  • Hyperarousal: Irregular anxiety, irritability, insomnia, poor concentration.
  • Re-experiencing: Flashbacks, recurrent nightmares, intrusive distressing memories.
  • Avoidance: Memory suppression of events, detachment, emotional numbness.

Prevalence of PTSD

• Lifetime prevalence rates in the general population range from 6% to 9%.
• Higher rates may be observed in high-risk groups, such as combat veterans, reaching up to 40%.

Onset and Course

• PTSD symptoms may commence immediately following trauma or up to three months later, with some cases experiencing delayed onset.

Assessment and Treatment

• PTSD assessments encompass a comprehensive review of personal and psychiatric histories and symptom duration.
• Treatment of co-occurring conditions is critical in PTSD management.
• Psychological interventions are preferred, with pharmacological treatments reserved for severe comorbid cases or inadequate psychotherapy responses.

Maintaining Factors

• Negative appraisals of PTSD symptoms and avoidance behaviors can sustain the disorder, complicating recovery and symptom persistence.