Throwing some light on post-traumatic stress disorder.

STRESS is part and parcel of life. The situations that lead to stress are varied, eg sitting for or failing examinations, separation or divorce, etc. Most people develop mechanisms to cope with such upsetting situations. With the passage of time, the stressful situation fades away.

Post-traumatic stress disorder (PTSD) is different. It is a psychological and physical condition that occurs after a person experiences traumatic events, which include road traffic accidents, violent personal assaults like robbery, mugging and sexual assault, natural or man-made disasters, terrorist attacks, sudden deaths, violent deaths, etc.

PTSD was initially described in soldiers in the First World War. They suffered tormenting experiences even after they ceased fighting. The terminology used then was “shell shock” or “battle fatigue” syndrome.

The term PTSD was first used after the Vietnam War and is now recognised as a mental health condition. It was only recently accepted that events other than war situations could cause PTSD.

PTSD occurs in about 30% of people who experience a traumatic event. It can affect a person at any age, including childhood, and is more common in females. About 40% of PTSD patients develop the condition after the sudden death of someone close to them.

Traumatic stress

The causal mechanisms of PTSD are not well understood. Some people who experience a traumatic event develop PTSD whilst others do not. However, there are risk factors that increase the likelihood of developing PTSD. They include a past history of anxiety or depression, and lack of support from family and/or friend(s).

The likelihood of PTSD is increased if one’s parent has a mental health problem, indicating that there is a genetic factor.

There is evidence that PTSD patients have abnormally high levels of hormones that are usually produced by the body when exposed to danger. These hormones, which lead to numbed emotions and feelings of detachment, are produced even when there is no danger to the PTSD patients.

The hippocampus, which is the part of the brain that deals with memory and emotion, has been found to be different in magnetic resonance imaging (MRI) of PTSD patients. The abnormal amounts of hormones produced in PTSD leads to malfunction of the hippocampus, resulting in repeated flashbacks and nightmares.

When the hormones return to normal levels, the brain undergoes self-repair and the flashbacks and nightmares slowly cease.

Clinical features

PTSD usually occurs immediately after the traumatic event. However, there may be a delay of weeks, months and even years in its onset in some patients.

Some patients experience a reduction of their symptoms for periods of time followed by periods where there is an increased intensity. Other patients have severe and constant symptoms.

The majority of people who experience or witness a traumatic event have some of the symptoms of PTSD, the nature and severity of which varies considerably.

The Royal College of Psychiatrists of the United Kingdom have several criteria to determine if someone who has experienced or witnessed a traumatic event has PTSD. They are:

·Having vivid memories, flashbacks or nightmares

·Attempting to avoid reminders of the event

·Having no feelings at all (emotionally numb)

·Feeling irritable and anxious for no apparent reason

·Eating more than usual

·Drugs or alcohol misuse or abuse

·Inability to control mood

·Finding it increasingly difficult to get on with others

·Feelings of depression or exhaustion

If the symptoms occur less than six weeks after the traumatic event and are improving, it may be part of the normal coping process.

If the symptoms persist or do not improve more than six weeks after the traumatic event, one is advised to seek medical attention.

Other symptoms include poor concentration, sleep problems, guilt feelings, irritability and angry outbursts.

There may be unexplained physical symptoms like sweating, shaking, dizziness and chest pains.

PTSD sometimes leads to breakdown in relationships and work problems.

Children who have PTSD may act out the traumatic event through play and/or have unpleasant dreams. They may also have no interest in activities that they used to enjoy previously.

The diagnosis of PTSD is challenging because some sufferers do not want to express their feelings and/or there is delay in seeking medical attention.

Managing PTSD

When a traumatic event occurs, PTSD can occur days, months or even years after the event. Coming to terms with the event with the assistance of healthcare professionals is frequently the only effective treatment for PTSD. It is never too late to seek treatment.

The management of PTSD starts with a detailed evaluation which will form the basis of a treatment plan that is individualised. An initial consultation with the doctor will be most helpful. Depending on the patient’s circumstances, a referral may be made to a psychiatrist, psychologist or a counsellor for specialised care. The consent and co-operation of the patient is vital for the success of the treatment plan.

If the symptoms are mild and have been present for less than four weeks after the traumatic event, the doctor may recommend doing nothing but observing to see if they improve or worsen. In such cases, it is usual to have a follow-up appointment within a month.

Psychotherapy is an effective treatment modality. It is also used for other mental health conditions like anxiety and depression. This involves the doctor or a psychotherapist listening to the patient’s problems and then suggesting ways of resolving them. If the PTSD is severe or persistent, medications may be prescribed in addition to the psychotherapy.

Cognitive behavioural therapy (CBT) is a type of psychotherapy in which the patient is taught how to alter any negative thought processes. This involves using mental imagery of the traumatic event to enable the patient to overcome the fear and distress. CBT may be offered for severe and/or persistent symptoms of PTSD.

The treatment sessions may take one to two months.

Eye movement desensitisation and reprocessing (EMDR) reduces the distress of many PTSD patients. It involves making sets of side-to side eye movements when recalling the traumatic event. The objective of EMDR is to assist the brain in processing the flashbacks to enable the patient to develop more positive thinking.

The above treatment modalities are usually prescribed first before medications are considered. The indications for medications include:

·The patient decides not to have CBT

·The patient is unable to commence psychotherapy because of an increased risk of additional trauma

·The patient has limited or no response to CBT

·The patient has severe depression which affects the ability to respond to psychotherapy

The medicine, paroxetine, which is a selective serotonin reuptake inhibitor (SSRI), or the antidepressants, mirtazapine or amitriptyline, are prescribed for the treatment of PTSD.

The side effects of paroxetine include nerve problems leading to muscle spasms of the face and mouth, yawning, raised cholesterol, irregular heartbeats, temporary blood pressure changes, incontinence of urine, and confusion.

The side effects of mirtazapine include increased appetite and weight, drowsiness, dizziness, headache, increased liver enzyme levels, jaundice, and rash.

The side effects of amitriptyline include postural hypotension, rapid heartbeats, dry mouth, weight gain, sour or metallic taste in the mouth, and constipation.

If the medications prescribed are effective, they have to be taken for at least one year before they are gradually withdrawn over a period of at least a month. There may be some side effects when the medications are withdrawn. The dosages of the medications may have to be increased if their effectiveness is limited.

PTSD in children is usually treated with CBT, preferably with the involvement of their family. Play, art or family therapies are effective treatment modalities.

> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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