PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS. Training and Development. Continuing Medical Education Programme

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1 MEDICAL SERVICES PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS Training and Development Continuing Medical Education Programme Update on Post Traumatic Stress Disorder Version Module 2

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3 Foreword This training has been produced as part of a training programme for Health Care Professionals approved by the Department for Work and Pensions Chief Medical Adviser to carry out benefit assessment work. All Health Care Professionals undertaking assessments must be registered practitioners who in addition, have undergone training in disability assessment medicine and specific training in the relevant benefit areas. The training includes theory training in a classroom setting, supervised practical training, and a demonstration of understanding as assessed by quality audit. This training must be read with the understanding that, as experienced practitioners, the Health Care Professionals will have detailed knowledge of the principles and practice of relevant diagnostic techniques, and therefore such information is not contained in this training module. In addition, the training module is not a stand-alone document, and forms only a part of the training and written documentation that the Health Care Professional receives. As disability assessment is a practical occupation, much of the guidance also involves verbal information and coaching. Thus, although the training module may be of interest to non-medical readers, it must be remembered that some of the information may not be readily understood without background medical knowledge and an awareness of the other training given to Health Care Professionals. Office of the Chief Medical Adviser Feb 2014 Page 2

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5 Document Control Superseded documents Version history Version Date Comments 3 rd February 2014 Signed off by HWD and CMMS 6c draft 30 th January 2014 Further external review comments incorporated 6b draft 18 th December 2013 External review comments incorporated 6a draft 11 th November 2013 Schedule 28 review 5 Final 7 th November 2012 Final version signed off by HWWD 5a draft August 2012 Updated for Schedule 28 review 4a draft 21 st July 2011 Schedule 28 review 3 Final 15 th August 2007 Signed of by Contract Management Team 3a draft 11 th July 2007 Updated following schedule 28 review 2 Final 26 th January 2006 Signed Off by Contract Management Team Changes since last version General formatting and amendment of layout Foreword updated Owner and approver of document updated to Clinical Director Reference to Commissioners updated to Upper Tribunal Judges Reference to DSM-IV updated to DSM-5 where relevant Review of document to avoid repetition with certain paragraphs being moved from one section to another for more consistency and removal of any irrelevant information Typos and spelling errors amended Page 7 more information added on severe traumatic events Page 8 - additional information added on people at risk of developing PTSD Page 8 additional information added on symptoms following a severe traumatic event Page 9 wording of last paragraph amended to reflect the process in IIDB reports Page 10 - additional Predisposing factors added Page 3

6 Page 10 - information on DSM-5 added Page 11 information on Complex PTSD included Page 11 - details of incidence in children added Page 12 - prevalence figures updated and more examples given Page 13 - information on screening tests added Page 13 information on symptoms in complex PTSD included Page 14 sequence of bullet points amended Page 16 psychosis added to list of co-morbid conditions Page 18 information on treatment according to NICE guidelines added Page 19 - additional information added on prognosis Page 19 new section of PTSD and disability analysis included Page 24 - additional sources of further reading added Page 25 appendix 1 updated with DSM-5 criteria Page 28 appendix 3 updated with DSM-5 criteria Page 31 - Training and Development Co-ordinator amended to Service Delivery Lead Outstanding issues and omissions Issue control Author: Owner and approver: Signature: Distribution: Medical Training & Development Clinical Director Date: Page 4

7 Contents Page Section Page Document Control 3 Contents Page 5 1. Introduction 6 2. Post Traumatic Stress Disorder 7 Introduction 7 Aetiology 8 Predisposing factors 10 Diagnostic Criteria 10 Incidence 11 Prevalence 12 Clinical Picture 13 Factors Important in Clinical Assessment 14 Differential diagnosis 15 PTSD and co-morbidity 16 Interventions and Treatment 17 Prognosis 19 PTSD and Disability Analysis Summary and Key Points Training Evaluation Further Reading 24 Appendix 1 - DSM-5 Criteria for PTSD 25 Appendix 2 - ICD-10 Criteria for PTSD 27 Appendix 3 - DSM-5 Criteria for Acute Stress Disorder 28 Appendix 4 - ICD-10 Criteria for Acute Stress Reaction 30 Observation form 31 Page 5

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9 1. Introduction This review of Post Traumatic Stress Disorder (PTSD) is part of the Atos Healthcare programme of Continuing Medical Education (CME) aimed at updating disability analysts on key clinical topics. Although this review of PTSD was initially aimed at Health Care Professionals involved in the assessment of claimants for Industrial Injuries Disablement Benefit (IIDB), it presents a clear and comprehensive account which will be of interest and relevance to all Health Care Professionals (HCPs). There will be differences in the advice required for the different benefit types, however all HCPs will benefit from a common framework of knowledge for assessing claimants with this condition. Health Care Professionals will need to remain aware of the extreme sensitivities surrounding the questioning techniques used. This is dealt with in the module Improving the Claimant s Experience and Avoiding Complaints (MED CMEP CEAC ~ 0063(a)), available on SharePoint. We hope that you find this update relevant and helpful in your work in this field. Page 6

10 2. Post Traumatic Stress Disorder Introduction Post Traumatic Stress Disorder (PTSD) is a response to a stressful event of exceptionally threatening or catastrophic nature outside the range of everyday experience, which would be likely to cause distress in almost everyone. It may develop in an individual who either experiences or witnesses a severe traumatic event, which usually involves a perceived or actual threat to the life or physical integrity of a person. It usually results within six months of such an experience, however it may also develop after a delay of several months or even years following the traumatic event. The condition may be persistent, but usually resolves within three to five years and is of variable severity. A severe traumatic event is described as: A stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive disease in almost anyone (ICD-10) Exposure to actual or threatened death, serious injury, or sexual violence (DSM-5) Examples of severe traumatic events include: Serious accidents such as serious road traffic accidents, airplane crashes, house/factory explosions, fires, shipwrecks Military combat Violent personal assault sexual assault, physical attack, abuse, robbery, mugging, riots, bombing, torture, hostage situations Terrorist attack Natural or man-made disasters floods, earthquakes, hurricanes, tsunamis, volcano eruptions Being diagnosed with a life-threatening illness Hearing about unexpected injury or violent death of a family member or close friend Although certain situations such as relationship breakdown, loss of a job, failing an examination, financial problems, etc may be considered to be traumatic by an individual, they would not normally be considered to be serious traumatic events. This module attempts to summarise those key points which are essential to a greater understanding of the nature, diagnosis and assessment of PTSD. It formulates recommendations which should ensure that Health Care Professionals have clear guidance to assist them in properly recognising the essential features of Page 7

11 the illness, differentiating between other likely diagnoses and exercising evidencebased clinical judgements in determining questions of aetiology and causation where relevant, and offering appropriate advice to Decision Makers on likely effect on function where appropriate. Aetiology PTSD is not a new phenomenon, though the current nomenclature was adopted in the early 1980s. Prior to that, the disorder had been long recognised under a variety of different names, for example, shell shock in the First World War, and combat neurosis in the 1960s. PTSD is a response to a severe traumatic event. It can affect individuals who are directly involved in the event but also witnesses and people who help individuals suffering from PTSD. Members of the armed forces, police, journalists, prison services, rescue services, fire services, ambulance and emergency personnel, nursing and medical professionals, together with communities or families affected by a serious event, can be at risk of developing PTSD. However it may be difficult to determine the level or nature of precipitating trauma that is likely to result in PTSD in individuals, who by the very nature of their occupation, are regularly exposed to experiences and events which would distress almost anyone unaccustomed to such situations. What is out with normal experience and control for the majority of the population may not be applicable in those involved in the emergency services due to the nature of their work. The exposure to traumatic events as part of one s occupation or the news that a family member or close friend has been the subject of a severe trauma, may be considered traumatic, however exposure to traumatic events through electronic media, such as television and internet, is not usually considered as traumatic. There are no convincing experimental models of PTSD. The organic basis for the presumed functional disturbances in the central nervous system remains obscure; however, abnormalities of the anterior cingulate, amygdala and hippocampus have been demonstrated on MRI scanning. The existence of specific objective markers for PTSD remains non-proven. Endocrine disturbances have been reported, but these are variable; the studies carried out sometimes lack adequate controls and are compromised by the co-existence of other psychiatric disorders such as depressive illness. Most people who experience a severe traumatic event may experience physical and emotional symptoms such as: Sleep disturbance and nightmares Eating disturbance loss of appetite or comfort eating Sexual dysfunction Page 8

12 Fatigue, loss of energy Aches and pains, muscle tension Palpitations Depression, tearfulness, sadness, hopelessness, grief Anxiety, panic attacks, fear Irritability, agitation, anger Obsessive and/or compulsive behaviour Shock, denial, disbelief Emotional numbness Withdrawal from others or from usual routines Poor concentration, confusion, memory loss Guilt, shame, self blame Flashbacks Hypervigilance These may persist for a few weeks until eventually the individual accepts what has happened and the stress symptoms gradually improve and resolve. Studies show that about 25-30% of individuals continue to experience symptoms and may eventually be diagnosed with PTSD. It remains unclear why some people develop PTSD, whereas others subjected to the same stressor have a much more transient condition, and the great majority are apparently unaffected by such overwhelming traumatic events. However, there are recognised predisposing factors. The ease of recall of the terrifying event, the overwhelming psychological and physical responses to the evoked memory and the pervasive psychiatric disability are evidently those features which characterise PTSD as an illness. Unfortunately, despite attempts by the American Psychiatric Association (APA) to define the diagnostic criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013), and the World Health Organisation (WHO) in the International Classification of Diseases (ICD-10, 1992), there has been a tendency over recent years for the condition to be diagnosed in persons who have by no means been exposed to an event that involved actual or threatened death or serious injury to self or others. There may be some cases where a claimant presents with a diagnosis of PTSD without evidence of a severe traumatic event. In Industrial Injuries Disablement Benefit assessments, HCPs need to identify the relevant loss of faculty and disability, and advise on the disablement assessment as Page 9

13 a result of the industrial accident. This differs from our usual role as disability analysts assessing the functional restrictions as a result of the condition and not querying whether the diagnosis provided is correct or not. What may be considered traumatic to one individual may not be considered to be so by another and it is the way the particular individual responds to, and is affected by, an event which is important in our role. Predisposing factors Several predisposing factors have been identified which may account for the fact that only a small proportion of people exposed to a major untoward event develop the disorder: Gender - the disorder is more common in women Prolonged childhood separation from parents or adverse childhood experiences Family history of mental health problems Pre-existing mental health problems Age - PTSD is more common in children and in the elderly Ethnic minority groups Refugees and asylum seekers Lower socioeconomic status Living in traumatised communities, war zones, areas of famine, repeated natural disaster areas Diagnostic Criteria The diagnostic criteria commonly used are those described in the DSM-5 and the ICD-10 (See Appendices 1 and 2). DSM-III had specified that the stressor experienced should be one that was outside the range of usual human experience which would distress almost anyone. In DSM- IV the wording was modified, but retained the principle of a single, overwhelmingly traumatic event. In DSM-5, PTSD is no longer categorised as an Anxiety Disorder and a new category Trauma - and Stressor - Related Disorders has been developed. The diagnostic criteria have been revised and 2 new subtypes added. (See Appendix 1) ICD-10 introduced the category Reaction to severe stress and adjustment disorders. Within this category ICD-10 considers three main diagnoses: Acute stress reaction Post-traumatic stress disorder Page 10

14 Adjustment disorder Two other diagnoses include: Other reactions to severe stress Reaction to severe stress, unspecified The diagnostic criteria for PTSD outlined in ICD-10 are similar to those of DSM-5, and involve the identification of a threatening event of exceptional severity, which is thought to be necessary in the onset of the disorder. This precipitant (or stressor) is quite specific in that the person must have been exposed to a serious or catastrophic event that involved actual or threatened death or real or major injury to self or others. In PTSD, the person has to meet a minimal number of symptoms from each list for at least one month and to suffer demonstrable impairment of occupational, social or other important areas of functioning. The definition reinforces the fundamental concept that psychiatric illnesses can, and must be, defined on the basis of antecedent events and history, symptoms, nature, evolution and course of the illness. Problems are frequently met when PTSD is apparently diagnosed in persons where the precipitating event has not directly threatened them and they have, in fact, been displaced both in space and time from the actual event. Although not formally recognised as a separate diagnosis within DSM-5 and ICD-10, the term Complex PTSD is often used to explain symptoms which arise in people who sustain chronic, repeated or long-lasting traumatic events. It is also known as Disorders of Extreme Stress Not Otherwise Specified. These traumatic events usually involve physical or emotional captivity, such as long term childhood abuse (sexual, physical or emotional), long term domestic abuse, prisoners of war or prolonged hostage situations. Many of these individuals may also fulfil the criteria for PTSD. When dealing with such a case in IIDB you will need to consider whether the condition has arisen by accident or by process and advise accordingly. Incidence Overall approximately 25-30% of people exposed to a traumatic event will develop the disorder. For Children, The British National Survey of Mental Health gave an incidence of 0.2% for children aged 5-15 years (Meltzer et al, 2000), however in children who attended the emergency departments following a traumatic injury, the incidence rose to up to 30% (National Collaborating Centre for Mental Health, 2005). Page 11

15 Prevalence Prevalence is variable and depends on the nature of the traumatic event. The Piper Alpha disaster, where a total of 167 people died, is considered to be the world s worst offshore oil disaster. A study (by Hull, Alexander and Klein) into the long term psychological effects showed that 21% of the survivors (7 out of 33 people interviewed) met the most stringent diagnostic criteria for PTSD over 10 years following the disaster. In the Aberfan disaster, where a colliery spoil tip collapsed onto a village and school killing a total of 144 people, 116 of which were children, a study 33 years after the disaster (by Morgan, Scourfield, Williams, Jasper and Lewis) showed that 46% of the survivors had suffered from PTSD at some point after the event and 29% still met the criteria for ongoing PTSD. In the 2001 World Trade Center disaster, where a total of 2823 people were killed following a terrorist attack on the United States of America, a study (by Perrin, Di Grande, Wheeler, Thorpe, Farfel, Brackbill) of rescue/recovery workers showed that 12.4% of these individuals suffered from PTSD, ranging from 6.2% for police to 21.2% for unaffiliated volunteers. A report (by Stewart) on the effects of the 2005 London Bombings indicated that up to 30% of people involved directly in the events developed PTSD. A Study on the effects of the 2004 Tsunami on people living in the Peraliya area (an area in Sri Lanka where approximately 2,000 people died, 450 families became homeless, and 95% of the village was destroyed) showed that about 21% of individuals had PTSD. The more traumatic the event and the closer to the involvement of the person, the greater the chance of development of PTSD, e.g. rape is associated with greater incidence than other forms of criminal injury. If the person is amongst dead bodies, as opposed to being apart from them, or if the event results in gross deformity, then PTSD is more commonly encountered. Natural disasters usually cause less cases of PTSD than do man-made disasters. A large study on adults in England gave a prevalence of 3% with no significant difference between men (2.6%) and women (3.3%). (McManus et al, 2009) However a US study gave a prevalence of 8%, with 5% for men and 10% for women (Kessler et al, 1995). Studies on Military personnel deployed to Iraq and Afghanistan gave a 4% prevalence rate, although US studies gave figures as high as 30%. Through analysis of various studies it was shown that the prevalence can vary from 1-11%, due to differences in the actual study design and sampling. (Klein and Alexander, 2009) Page 12

16 Clinical Picture The primary symptoms fall into a variable combination of the following three groups, which should have been present for at least a month (not all symptoms are present in every case): Repetitive re-experiencing, in one or more ways, of the traumatic event, e.g. brief intense, intrusive imagery of the incident outside the person's control (flashbacks - see below); recurrent, distressing dreams of the event; psychological distress or anxiety, which often increases when the patient reexperiences or is reminded of the event. Avoidance of stimuli associated with the event, or which arouse recollection of the event; inability or difficulty to recall the incident at will; a feeling of detachment and restricted range of affect; diminished interest in activities. Increased arousal and behavioural abnormalities, e.g. irritability, hypervigilance, insomnia, poor concentration, exaggerated startle reflex. In addition there may be maladaptive coping mechanisms such as aggressive or histrionic behaviour. The term flashbacks is often quoted by claimants in support of their claim that they have PTSD. Flashbacks do not only occur in PTSD, e.g. they can occur in substance abuse notably LSD and it is important to ascertain exactly what they mean by it. In most cases symptoms usually appear within a month of the severe traumatic event however in about 15% of cases symptoms are delayed and may occur months or even years after the event. In most cases however they are usually present by 6 months of the event. Screening questionnaires have been developed to try to identify people with PTSD and are useful tools for Health Care Professionals involved in patient care. The diagnosis should be confirmed by a mental health specialist with expertise in dealing with PTSD, although in adults, the diagnosis may be made by a General Practitioner if they have the appropriate expertise in PTSD. Symptoms in Complex PTSD include: Emotion regulation problems anxiety, anger, sadness, depression, suicidal tendency Changes in consciousness flashbacks, dissociation, forgetting the traumatic events Self Perception helplessness, shame, guilt, stigma, feeling different from others Distorted perceptions of the perpetrator feeling of having no power over the perpetrator, preoccupied with their relationship with perpetrator, preoccupied with revenge Page 13

17 Changes in personal relationships isolation, distrust Changes in the way the person views the world loss of faith, hopelessness about the future People with Complex PTSD may be more at risk of self harm/suicidal tendency and/or substance misuse. Treatment may need to address the specific problems and symptoms which are present. Factors Important in Clinical Assessment In the clinical assessment, a clinician would need to address various issues which may not be fully relevant to a Disability Analyst, although they would still be important for Industrial Injuries Disablement Benefit assessments. These include: Age. PTSD is more common in the elderly and in children. Gender. Women are more often affected than men, and married women are more often affected than unmarried women. Social history. Past occupational history, particularly in those seeking to blame their job for the condition. Full details of the stressor and the individual's role and involvement in the event. The closer the involvement of the person to the stressor, then the greater the chances of developing PTSD. The nature and duration of the symptoms. In order to diagnose PTSD primary symptoms must have been present for at least a month. The previous personality. PTSD has been shown to be more common in individuals with a dependent personality type. The past medical history. A previous history of psychiatric problems, e.g. anxiety or depression, increases the risk of developing PTSD. Physical assessment. If the stressor included a head injury, then a full neurological assessment is required to exclude, for example, a subdural haemorrhage. There are no routine clinical tests other than the history and current symptoms. However, there may be increased autonomic activity. Lowered cortisol levels have been described and some individuals showed enhanced responses to dexamethasone. Careful consideration of the relevance of the condition to the stressor should be given. As with other mental and physical disabilities, the presenting condition may not necessarily be connected to the stressor or may be only partly related to the stressor. Page 14

18 As with all conditions where the diagnosis is made wholly or mainly on the history, the clinician must be careful to establish the veracity of that history, and to be aware of such pitfalls as self-diagnosis, tutoring on the part of pressure groups, etc. Differential diagnosis Other Stress related disorders: Stress is defined as an excess of environmental demands over the individual's capacity to meet them. Stress is a part of normal daily life. Some occupations and lifestyles are more stressful than others, and some individuals are more prone to react to stressors than others. However, stress is a term frequently used by both the physician and the general public to describe both the stressors and the consequences of their action - the strain - on an individual. With increased media interest in PTSD, individuals with stress have increasingly made the self diagnosis of PTSD, possibly believing that the terms are interchangeable; or that PTSD is a more severe manifestation of stress. However, in most cases the diagnosis of PTSD cannot be confirmed due to the absence of a single acute stressor outside normal human experience. Arguments have been put forward that there may be a separate diagnostic category of prolonged duress stress disorder, which has similar features to PTSD but lacks the criterion of an acute stressor out with normal human experience, and therefore cannot be considered to be PTSD. Such a condition, which has not been recognised widely, would be classed as being as a result of process in the context of IIDB. Other Psychiatric conditions: Other anxiety disorders generalised anxiety disorder, panic disorder, phobic disorder Obsessive compulsive neurosis Depressive disorders Schizophrenia and psychosis Personality disorders Alcohol and/or substance abuse Adjustment disorders: Adjustment disorders are responses to stressful events or circumstances, e.g. divorce, major change at work, etc. The symptoms include anxiety, worry, poor concentration, depression, irritability and physical symptoms of autonomic arousal, e.g. palpitations. There can also be maladaptive coping mechanisms of histrionic or aggressive behaviour and self-harm. Thus the symptoms are similar to those of depression and PTSD, but are self-limiting and not of the magnitude or spectrum seen in other disorders. Also the diagnosis is made when the symptoms are not numerous or severe enough to meet the diagnostic criteria of other psychiatric Page 15

19 disorders. Adjustment disorders can arise after a severe stressor, such as is required for the diagnosis of PTSD. PTSD and co-morbidity High rates of co-morbidity have been found with respect to PTSD. The salient conditions being: Alcohol abuse Substance abuse Depressive disorders Other anxiety disorders, e.g. phobias and panic disorders Personality disorders, especially antisocial personality Psychosis PTSD and substance abuse (including alcohol abuse and smoking) often co-exist; and, due to the frequency of these problems, warrants further discussion. The link between PTSD and substance abuse is particularly complex, with the cause and effect difficult to determine. Both PTSD and substance abuse are multifactorial disorders, and understanding their co-morbidity both in an individual and in groups being studied requires detailed investigation of the past medical and social histories. In the context of claims for benefit, care must be taken not to compensate for unrelated conditions and for those which involve personal choice. Different studies have found differing explanations for the co-morbidity of PTSD and substance abuse. It should be pointed out that much of the evidence in the literature is anecdotal. The theories fall into the following broad categories (not listed in any order of preference): Substance abuse pre-dates the onset of PTSD. There is evidence to show that individuals with a history of substance abuse in one form or another have a higher incidence of PTSD than those with no history of such abuse. There are a variety of hypotheses as to why there is this higher incidence, e.g. the individual is more likely to put themselves at risk of a traumatic event, their personality predisposes them to both substance abuse and abnormal reaction to stressors PTSD develops first, and that chemical substances are used as a means of achieving symptom relief (referred to as the self-medication hypothesis in some of the literature) Substance abuse and PTSD co-exist, but are unrelated Page 16

20 Interventions and Treatment Treatment for PTSD is usually effective in resolving or reducing symptoms, even if started several years after the traumatic event, however it can only be offered if the condition is diagnosed. People presenting with symptoms typical of PTSD, especially re-experiencing, avoidance, hypervigilance, emotional numbness, should be asked whether they have experienced a traumatic event. Children should be asked about specific symptoms if they have been involved in a traumatic experience. Following a major disaster, screening tools should be used to identify people at risk of developing PTSD. Refugees and asylum seekers should have a screening test for PTSD as part of their initial healthcare assessment. Family and carers should be offered appropriate support and the individual should have a comprehensive assessment of physical, psychological and social needs, which also includes a risk assessment (for harm to self or others). Treatment plans should be individualised and should take into account the person s age and any cultural/ethnic issues. If symptoms are severe, immediate referral to specialist mental health service with expertise in managing PTSD should be organised. Individuals at risk of harming themselves or others need urgent referral or admission. There is debate regarding the management of PTSD and several proposed strategies have not yet been validated in controlled trials. The following outlines the main intervention and treatment options that have been assessed: Preventive Interventions: Multiple sessions of cognitive behavioural therapy in people with acute stress disorder are likely to be beneficial in reducing the occurrence of PTSD (Clinical Evidence, June 2005) Single session individual debriefing, as a preventive intervention, following exposure to a stressful event does not prevent PTSD and may be harmful (Clinical Evidence, June 2005) Since avoidance is part of the overall picture of PTSD, many severely affected people may not come forward for help, therefore a pro-active policy of seeking out potential sufferers following a stressor should be considered (Clinical Guideline 26, NICE, March 2005) Treatment: Cognitive Behavioural Therapy (CBT) improves PTSD symptoms (Clinical Evidence, June 2005) Page 17

21 Eye movement desensitisation and reprocessing improves PTSD symptoms (Clinical Evidence, June 2005) There is no convincing evidence that therapies such as supportive therapy, non directive therapy, hypnotherapy or psychodynamic therapy have any beneficial effects in PTSD (Clinical Guideline 26, NICE, March 2005) Fluoxetine and Paroxetine improve symptoms in individuals with PTSD (Clinical Evidence, June 2005) If drug or alcohol dependence co-exist with PTSD, the former should be treated first (Clinical Guideline 26, NICE, March 2005) If PTSD and depression co-exist, treatment of the PTSD should be considered first, as the depression will often improve with successful treatment of the PTSD (Clinical Guideline 26, NICE, March 2005) According to the NICE guidelines: Practical, social and emotional support should be offered to all Non trauma focused interventions should not be offered as part of the routine treatment of PTSD Watchful waiting should be considered for individuals with mild/moderate symptoms which have been present for less than 4 weeks after the trauma. Follow up should be arranged within 1 month If symptoms are present within 3 months of the trauma, the individuals should be offered Trauma-focused CBT (Cognitive Behavioural Therapy). This treatment should be regular and continuous, preferably delivered by the same person, 5-12 sessions should be offered If symptoms are present for more than 3 months after a trauma, 8-12 sessions of Trauma-focussed CBT should be offered. This may be extended beyond 12 sessions if necessary If there is no improvement with a specific trauma focused therapy, then an alternative type of psychological therapy or pharmacological treatment may be offered Pharmacological treatment should not be offered routinely as first line treatment in preference to trauma focused psychological therapy If pharmacological treatment is offered, paroxetine or mirtazapine (for general use) and amitriptyline or phenelzine (for use by specialist mental health services) should be given to adults If sleep disturbance is present, use of a hypnotic (short term use) or suitable antidepressant (longer term use) may be useful Page 18

22 Pharmacological treatment should be continued for 12 months before gradual withdrawal, even if there is response to treatment If there is no response to initial pharmacological treatment, different antidepressants may be offered or olanzapine may be added Regular review of individuals on pharmacological therapy is essential to ensure no potentially serious side effects develop In Children: In children, families and carers may need to be involved in their treatment plan Trauma focused CBT needs to be adapted to the age, circumstance and level of development of the particular child Pharmacological treatment is not usually offered to children Prognosis 60% of cases of PTSD have a slow natural recovery time over a period of about 6 years. Treatment accelerates recovery. Positive factors which improve recovery include good social support, engagement in treatment process, avoidance of retraumatisation and absence of other mental health conditions, including substance misuse. 40% of cases run a chronic course. Cases of PTSD have been reported which have existed in excess of 50 years. Individuals who have prolonged symptoms of PTSD may develop other mental health problems such as substance misuse, anxiety, depression and risk of suicide. Disability assessments performed at intervals of less than 1 year are unlikely to show much change, and after a 6-year interval, those chronically disabled are likely to remain so. PTSD and Disability Analysis Health Care Professionals (HCPs) assessing people with PTSD for the purpose of disability analysis have to focus on the guidance for the particular benefit strand being considered. Different benefits have different regulations, for example the Work Capability Assessment and Disability Living Allowance Assessment focus on overall functional restriction, while Industrial Injuries Disablement Benefit focuses on the actual incident/accident and the functional restriction as a result of the particular Page 19

23 incident/accident. The role of the disability analyst is not to make a diagnosis or offer advice on treatment but to see how the condition is affecting the individual s function. However for the purposes of IIDB, the HCP would have to obtain details of the incident/accident and see whether the particular incident/accident has resulted in a loss of faculty and if so, offer advice to the Decision Maker on the disability as a result of this. PTSD may result in development of other mental health conditions such as depression, anxiety, substance misuse. They may have problems with chronic pain, fatigue or other medical conditions such as musculoskeletal and cardiovascular conditions. They may have employment problems due to poor concentration, fatigue, avoidance and/or irritability. PTSD may affect social functioning and relationships. When assessing the functional impairment or disablement arising from PTSD it should be borne in mind that the disabling effects are variable between people and in some the condition may not be significantly disabling. The prognosis is also variable and in some cases symptoms may persist for many years. For IIDB cases, claimed secondary effects, such as an increase in alcohol or substance abuse, are usually within conscious control, and thus should not attract an assessment. In the event of there being physical sequelae of the effects of alcohol and/or substance abuse, particular care should be taken to establish that there is a causal link between this and the stressor and ensure that there has not been a pre-existing alcohol and/or substance abuse problem. Each case should be considered on an individual basis when alcohol and/or substance abuse is alleged to be secondary to PTSD. In such circumstances the severity of the psychiatric morbidity and whether the level of such is likely to affect conscious control of decision making must be evaluated in detail where alcohol and/or substance abuse is found to be present. The HCP will have to provide advice to Decision Makers on the overall level of function, according to the relevant benefit strand. A detailed history is essential to identify whether the claimant is functioning well or whether the effects of PTSD are causing a significant or severe restriction in day to day activities. The HCP will have to consider any associated conditions which are present, these can be physical and/or mental health, and perform relevant physical/mental state examinations. Although this list is not exhaustive and will vary according to the particular individual and specific symptoms which are present, common areas to explore for functional restriction may include: Avoidance symptoms may result in the individual avoiding places, activities or people which remind them of the traumatic event. This may impact on ability to go out, socialising, shopping, undertaking hobbies or various day to day activities Emotional numbness may affect relationships and social interaction, loss of enjoyment in life and hobbies, withdrawal, isolation Page 20

24 Depression/anxiety may vary from mild, moderate to severe Self harm / suicidal tendency increased risk in people with PTSD Aggressive / inappropriate behaviour towards others may result in involvement of authorities, violence towards others, breakdown of families or relationships, problems with social interaction, loss of employment Substance misuse alcohol and/or drugs - increased risk in people with PTSD Physical health problems or physical symptoms Sleep disturbance increased or decreased sleeping patterns may result in further problems such as fatigue, irritability with inability to perform various activities of daily living Cognitive problems poor concentration, memory lapses, confusion, disorientation depending on severity may affect ability to live independently, awareness of hazards, ability to go out, driving, shopping, self care, etc Page 21

25 3. Summary and Key Points PTSD is a condition resulting from an experience that is life-threatening or extremely dangerous to the self or others. It may impair social, occupational and other important areas of functioning The incidence varies, but PTSD occurs in around 25% - 30% of people exposed to a major disaster. It is not clear why some people develop persistent PTSD, others a more transitory condition, while the very great majority of people are apparently unaffected by an overwhelmingly traumatic event. There are pre-disposing factors which may explain why some people develop PTSD whilst the majority do not 60% of cases of PTSD have a slow natural recovery time over a period of about 6 years. Treatment accelerates recovery. 40% of cases run a chronic course The characteristics of PTSD include re-experiencing the traumatic event in some way, avoidance of stimuli which may cause recollection of the event and increased arousal. The majority of the features overlap with other specific psychiatric illnesses PTSD must not be confused with other specific psychiatric illnesses or with milder forms of reaction to stress, including acute stress reaction, adjustment disorders or prolonged duress stress disorder The more traumatic the event, and the closer the involvement of the person concerned, the greater the likelihood of subsequent PTSD Premorbid characteristics, including psychological, biological and social factors, may contribute, although they remain ill-defined There are no routine objective tests for PTSD. Clinical appraisal rests on the history and largely subjective symptoms. Changes on MRI, increased autonomic activity and lowered cortisol levels have been described though the significance of these findings is unclear Accuracy in the diagnosis of PTSD can only be achieved by close attention to eliciting a thorough description of the putative extremely threatening event, the pattern of evolution of presenting symptoms and examination of the person's mental state, supplemented by a series of simple questions. Interview technique, with the use of open-questions, is of pivotal importance Page 22

26 4. Training Evaluation Title of Training Module Name: UPDATE ON POST TRAUMATIC STRESS DISORDER GMC/NMC/HCPC Number: Please return this form to the Clinical Manager at your local MSC 1. It is rare for other psychiatric disorders to coexist with PTSD 2. There is a clear correlation between endocrine disturbance and the occurrence of PTSD 3. Adverse childhood experiences are a pre-disposing factor in the development of PTSD 4. On average, 25% of people exposed to a major disaster will develop the disorder 5. PTSD is an all-embracing term, which encompasses many types of abnormal reaction to stress 6. Individuals with a history of alcohol abuse have a greater incidence of PTSD 7. High rates of co-morbidity have been found with PTSD 8. PTSD can be regarded as one of the adjustment disorders True True True True True True True True False False False False False False False False 9. Histrionic and aggressive behaviour are diagnostic of PTSD True False 10. PTSD is commoner at the extremes of life True False Page 23

27 5. Further Reading The interested reader is referred for further reading to the following literature: Bisson J I (2007) Post-traumatic stress disorder. BMJ: 334: McDonald G (2007) Mental health consequences of long term conflict. BMJ: 334: National Institute for Clinical Excellence (NICE) - Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. (CG 26). Department for Work and Pensions Information on Post Traumatic Stress Disorder - NHS Choices Post-Traumatic Stress Disorder - Royal college of Psychiatrists: - Post Traumatic Stress Disorder - sdisorder.aspx United States Department of Veterans Affairs National Center for PTSD - T A Gore (2013) Posttraumatic Stress Disorder Medscape article - Page 24

28 Appendix 1 - DSM-5 Criteria for PTSD Criterion A: Stressor (one required) The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: 1. Direct exposure 2. Witnessing, in person 3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. (This excludes unexpected death due to natural causes) 4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures Criterion B: Intrusion symptoms (one required) The traumatic event is persistently re-experienced in the following way(s): 1. Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play 2. Traumatic nightmares Note: Children may have frightening dreams without content related to the trauma(s) 3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness Note: Children may re-enact the event in play 4. Intense or prolonged distress after exposure to traumatic reminders 5. Marked physiologic reactivity after exposure to trauma-related stimuli Criterion C: Avoidance (one required) Persistent effortful avoidance of distressing trauma-related stimuli after the event: 1. Trauma-related thoughts or feelings 2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations) Criterion D: Negative alterations in cognitions and mood (Two required) Negative alterations in cognitions and mood that began or worsened after the traumatic event: 1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs) 2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous.") Page 25

29 3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences 4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame) 5. Markedly diminished interest in (pre-traumatic) significant activities 6. Feeling alienated from others (e.g., detachment or estrangement) 7. Constricted affect: persistent inability to experience positive emotions Criterion E: Alterations in arousal and reactivity (Two required) Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: 1. Irritable or aggressive behaviour 2. Self-destructive or reckless behaviour 3. Hypervigilance 4. Exaggerated startle response 5. Problems in concentration 6. Sleep disturbance Criterion F: Duration Persistence of symptoms (in Criteria B, C, D and E) for more than one month Criterion G: Functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational) Criterion H: Exclusion Disturbance is not due to medication, substance use, or other illness Dissociative Subtype of PTSD: In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: 1. Depersonalisation: experience of being an outside observer of or detached from oneself 2. Derealisation: experience of unreality, distance, or distortion Delayed expression subtype of PTSD: Full diagnosis is not met until at least 6 months after the trauma(s), although onset of symptoms may occur immediately. NOTE: DSM-5 has also introduced a Preschool subtype of PTSD for children aged 6 years or younger. The above criteria refer to adults, adolescents and children older than 6 years. Page 26

30 Appendix 2 - ICD-10 Criteria for PTSD A. The individual must have been exposed to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature which would likely cause pervasive distress in almost anyone B. There must be persistent remembering or reliving of the stressor in intrusive flashbacks, vivid memories or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor C. The individual must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor D. Either of the following must be present: 1. Inability to recall either partially or completely some important aspect of the period of exposure to the stressor, OR 2. Persistent symptoms of increased psychological sensitivity and arousal shown by any two of the following: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response E. Criteria B, C and D must all arise within 6 months of the period of stress. The diagnostic guidelines show that the disorder should only be diagnosed after six months if the symptoms are typical and do not constitute one of the other psychiatric diagnoses such as phobic conditions, other anxiety disorders, depression etc. REACTION TO EXTREME STRESS UNSPECIFIED If not all of the criteria are met the diagnosis of "Reaction to extreme stress, unspecified" may be a more appropriate label. However the criterion of the presence of the extreme stressor must be fulfilled. Page 27

31 Appendix 3 - Disorder DSM-5 Criteria for Acute Stress The diagnosis of Acute Stress Disorder may be made if symptoms last from 3 days to 1 month following the traumatic event. Symptoms persisting for longer would need to be reassessed for the possibility of PTSD. A. PTSD - A Criterion The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: Direct exposure Witnessing, in person Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect nonprofessional exposure through electronic media, television, movies, or pictures B. No mandatory (e.g. dissociative, etc.) symptoms from any cluster C. Nine (or more) of the following (with onset or exacerbation after the traumatic event): Intrusion 1. Recurrent, involuntary, and intrusive memories Note: Children older than 6 may express this symptom in repetitive play 2. Traumatic nightmares Note: Children may have frightening dreams without content related to the trauma(s) 3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness Note: Children may re-enact the event in play 4. Intense or prolonged distress or marked physiologic reactivity after exposure to trauma-related stimuli Negative Mood 1. Persistent inability to experience positive emotions such as happiness, love, satisfaction Page 28