PTSD: Post Traumatic Stress Disorder

Definition, complex PTSD (CPTSD), acute stress disorder (ASD), reactions to trauma, specific populations, treatment recommendations, children and adolescents, comorbidity

Three sections follow:

1. Background Material that provides the context for the topic

2. Suggestions for Practice

3. A list of Supporting Material / References

Feedback welcome!

Background Material

What is PTSD

PTSD describes severe and persistent stress reactions after exposure to a traumatic event. A pre-requisite to the symptoms of PTSD is that an individual must be exposed to threatened or actual death or serious injury to self or others, including repeated or extreme exposure to the adverse details of traumatic events, as typically occurs with emergency workers. PTSD comprises four additional major clusters of symptoms:

1. Re-experiencing symptoms, including intrusive memories, flashbacks, nightmares, and distress to reminders of the trauma

2. Avoidance symptoms, including active avoidance of thoughts and situational reminders of the trauma

3. Negative cognitions and mood associated with the traumatic event, such as an inability to remember important details about the event or persistent unusual ideas about the cause of consequence of the traumatic experience

4. Arousal symptoms, including exaggerated startle response, insomnia, irritability, and sleeping and concentration difficulties

The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) requires that for a diagnosis of PTSD, at least one symptom in each of these clusters must be present for more than one month and be associated with significant distress or impairment in social, occupational or other important areas of functioning.  A summary of the DSM-V is available at https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp 

There is strong evidence that many people who are exposed to a traumatic experience commonly report post-traumatic stress reactions in the initial weeks after trauma, but that for most, these symptoms gradually abate.  However mental health symptoms can follow numerous trajectories.  The most notable example of this is delayed-onset PTSD, where the initial symptoms present more than six months after a traumatic incident.

Complex Posttraumatic Stress Disorder (CPTSD)

A subset of individuals with PTSD, more commonly those who have experienced events of an interpersonal, prolonged and repeated nature (e.g., childhood sexual abuse, imprisonment, torture) present with a constellation of characteristic features alongside the core PTSD symptoms (i.e. comorbidity with other disorders). People exhibiting these features are often referred to as having complex PTSD (CPTSD). Australian data suggest that 85% of men and 80% of women with PTSD also meet criteria for another mental health conditions, most commonly depression, generalised anxiety disorder, alcohol abuse or illicit drug use.  CPTSD is characterised by PTSD combined with disorders in self-organisation, including emotion dysregulation, poor self-concept and relational problems. The importance of co-morbidity is threefold: firstly, co-morbid conditions can create diagnostic confusion; secondly, there is a general acceptance that individuals with more than one mental health condition co-occurring have poorer outcomes; and finally, when co-morbidity is present, clinicians need to decide which of the conditions to treat first or whether they can be treated concurrently.

At the level of the individual practitioner, the following principles should guide care:

• promote safety

• promote hope and recovery

• promote calm

• promote connectedness

• promote self-efficacy

• focus on strengths and resources

• focus on your own self-care

Given that CPTSD is a relatively new diagnosis it will take more time before an evidence base emerges about how best to treat it in adults, children and adolescents.  This topic is covered in a separate topic on this site (‘Complex trauma’).  Access via the home/contents tabs.

Trauma and Trauma Reactions

The guidelines focus on acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and complex posttraumatic stress disorder (CPTSD). 

The key distinguishing feature between PTSD and ASD is the duration of symptoms required for the diagnosis to be made.

• ASD is diagnosed between two days and one month following the traumatic event

• PTSD requires that the symptoms be present for at least one month following the traumatic event. In the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), ASD symptoms are not classified within clusters, therefore an individual meets diagnosis based upon expression of symptoms in total.

• PTSD includes non-fear-based symptoms:

  • risky or destructive behaviour,

  • overly negative thoughts and assumptions about oneself or the world,

  • exaggerated blame of self or others for causing the trauma,

  • negative affect,

  • decreased interest in activities,

  • feeling isolated.

• ASD does not include fear-based symptoms.

• PTSD includes a dissociative sub-type, whereas in ASD, depersonalisation and derealisation are included as symptoms under the dissociative heading.

In ICD-11 (International Classification of Disease) In ICD-11, PTSD and CPTSD fall under a general parent category of ‘Disorders Specifically Related to Stress’. PTSD is comprised of three symptom clusters:

1. re-experiencing of the trauma

2. avoidance of traumatic reminders

3. a persistent sense of current threat that is manifested by exaggerated startle and hypervigilance

CPTSD includes the three PTSD clusters and three additional clusters that reflect: ‘disturbances in self-organisation‘ (DSO): problems with self-concept, and disturbances in relationships.

Estimates of lifetime prevalence of PTSD range from 5% to 10%. The likelihood of developing PTSD varies according to the nature of the event. In general terms, the highest incidence of PTSD is associated with interpersonal trauma such as rape and other sexual assault; the lowest rate is associated with natural disasters and witnessing harm to others.

Specific populations and trauma types

Detailed information about the following groups is included in chapter 9 of the Australian PTSD Guidelines:

• Aboriginal and Torres Strait Islander Peoples

• Disasters

• Emergency Services Personnel (A 2024 update for this group is available at https://www.blackdoginstitute.org.au/wp-content/uploads/2024/03/BDI_PTSD_Guidelines_A4_DIGITAL.pdf 

• Military and ex-military personnel

• Motor vehicle accident and other traumatic injury survivors

• Older people

• Sexual assault

• Terrorism

• Victims of crime

• Victims of intimate partner violence

• Refugees and asylum seekers

Two Common Psychological treatments for PTSD

Trauma-focused cognitive behavioural therapy (TF-CBY)

Cognitive behavioural therapy (CBT) is based on the underlying rationale that an individual’s affect and behaviour is determined by their cognitions, which are in turn influenced by behaviour. Therapy aims to change an individual’s specific misconceptions and maladaptive assumptions, either directly or via behaviour providing correcting information.  When used in PTSD, CBT should have two main components. The cognitive component of therapy should aim to help individuals identify, challenge and modify distorted thoughts relating to themselves and the world around them that result from their traumatic experience. The behavioural aspect of therapy should utilise prolonged imaginal and in vivo exposure to allow the emergency worker to confront their memory of the traumatic event and trauma-related situations in a gradual and supported manner. Through the process of ‘extinction learning’, these behavioural processes should present corrective information and result in reduced anxiety levels when the client is exposed to their memories of trauma events or situational triggers.

More recently, there has been an increase in research investigating the use of internet- delivered CBT for PTSD, with a number of trials suggesting internet-based CBT can be effective, either by itself or in addition to therapist-based treatment.

CBT treatment is designed to be short term, with most studies of CBT for PTSD using 8 to 12 sessions.

Eye movement desensitisation and reprocessing (EDMR)

EDMR is based on a belief that when PTSD occurs, the emotions and memories of the traumatic event are stored in an unprocessed manner. During EMDR therapy, a patient is asked to repeatedly focus on trauma-related thoughts, experiences and memories while following the movement of a therapist’s finger across their field of vision. It is proposed that this dual attention facilitates the appropriate processing of the traumatic event. EMDR therapy has evolved over time and now usually involves 8 to 12 sessions. It includes many components that are considered core aspects of TF-CBT.  Some have suggested it may be a particularly useful intervention for those who have difficulty verbalising or discussing their traumatic experiences.

Two Pharmacological treatments for PTSD

SSRIs and the SNRI venlafaxine can be recommended as treatment for PTSD, although only in circumstances where evidence-based psychological therapy was not possible or had been ineffective, or where co-morbid conditions such as depression were present.

Suggestions for Practice

Guidance around screening and assessment for clinical practice

For people presenting to primary care services with repeated non-specific physical health problems, it is recommended that the primary care practitioner consider screening for psychological causes, including asking whether the person has experienced a traumatic event and describing some examples of such events.

The importance of a thorough clinical assessment, covering relevant history (including trauma history), PTSD and related diagnoses, general psychiatric status (noting extent of comorbidity), physical health, substance use, marital and family situation, social and occupational functional capacity, and quality of life.

The development of a robust therapeutic alliance should be regarded as the necessary basis for undertaking specific psychological interventions and may require extra time for people who have experienced prolonged and/or repeated traumatic exposure.

Appropriate goals of treatment should be tailored to the unique circumstances and overall mental health care needs of the individual and established in collaboration with the person.

Working with children and adolescents

Key issues for young people include:

• Children and adolescents are typically dependent upon an adult to bring them for treatment, so engagement with the relevant adult is important.

• Children are part of a system (typically a family) so assessment and treatment need to take the whole system into consideration.

• There is a need to be constantly mindful of psychosocial development, and the impact of trauma and appropriateness of treatment in that context

Key guidance points for clinicians:

• Questions about exposure to commonly experienced potentially traumatic events should be included as standard during any psychiatric assessment of children and adolescents. If such exposure is reported, the child should be screened for the presence of PTSD symptoms.

• For children and adolescents, a structured clinical interview is regarded as a better assessment measure when making a diagnosis than a questionnaire.

• Parent/caregiver involvement in assessment and treatment is desirable for children and adolescents with ASD or PTSD.

• For children and adolescents, treatment needs to be tailored to meet the developmental needs of the individual. Protocols that have been designed specifically for children and adolescents should be used in preference to modifying an adult treatment protocol.

Treatment recommendations

Following a potentially traumatic event, routine psychological debriefing is not recommended. The best approach to helping people following a potentially traumatic experience is to offer information, emotional support and practical assistance, consistent with the set of interventions collectively referred to as ‘psychological first aid’.

For adults with PTSD symptoms within the first three months of a trauma, a stepped or collaborative care model is recommended, i.e. providing information, emotional support, and practical assistance in preference to psychological debriefing. Within this stepped care model, people receive evidence-based treatment tailored to the severity and complexity of their symptoms.

For adults who develop PTSD, the best approach to psychological treatment involves confronting the memory of the traumatic event in order to come to terms with the experience. Recommended treatments include trauma-focussed cognitive behavioural therapy and its variants (TF-CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and prolonged exposure (PE), as well as eye movement desensitisation and reprocessing (EMDR).

For adults, medication should not be used in preference to trauma-focussed therapy but may be considered when the person is not ready or willing to engage in, or has no access to, trauma-focussed therapy, or has additional mental health problems such as depression, or has not benefited from trauma-focussed therapy. When medication is considered, the first choice would be selective serotonin reuptake inhibitors (SSRIs) or venlafaxine, a serotonin noradrenaline reuptake inhibitor (SNRI).

For school age children and adolescents, the best approach to treatment is trauma-focussed cognitive behavioural therapy (TF-CBT). However, this should be appropriately tailored to the developmental stage of the individual child or adolescent.  If TF-CBT is not available, eye movement desensitisation and reprocessing (EMDR) is recommended.

Engaging parents and/or caregivers is very important when working with children and adolescents as they are typically the ones to bring them in for assessment and treatment. Furthermore, children are part of a system (typically a family) and both assessment and treatment must take the whole system into consideration.

Treatment sequencing in the setting of comorbidity

Co-morbid psychiatric diagnoses, particularly depression, problematic anger and substance misuse, are very common amongst those with PTSD.  As a result, treating clinicians need to make decisions about treatment sequencing — specifically, if more than one condition is present, which will be treated first. There is some evidence that effective PTSD treatments can result in some improvements in co-morbid depressive symptoms, with some promising preliminary results suggesting that PTSD and substance misuse can be treated effectively with simultaneous interventions.  However, problematic anger has been shown to influence the development of PTSD, create increased risk of harm to self and others, act as a key factor in PTSD maintenance, and, importantly, negatively influence the outcome of PTSD treatment.  As a result, when anger is present, it must be addressed early in treatment via focused cognitive behavioural interventions such as cognitive remedial work and arousal management training.

Treatment for Complex PTSD

For a more detailed information around treating CPTSD see the ‘Trauma-informed Practice’ topic elsewhere on this site.  Access via the home/contents buttons.

Using the core principles of safety, trustworthiness, choice, collaboration, empowerment and cultural awareness, the social worker should:

• Adopt a genuine, non-judgemental and nonthreatening approach while normalising and validating the person’s feelings and experiences.  Build trust.  Use active listening.

• Combine an exploration of the person’s problems, strengths, and coping strategies with an acknowledgement of the traumatizing events.  Seek only to understand the trauma.  Delving deeply could result in re-traumatisation.

• If the client becomes hyperaroused (visibly agitated) or hypoaroused (dissociated or `spaced out’) cease interaction and assist the person with appropriate, tailored self-regulatory skills.

• Discuss the presenting issues.  Avoid giving advice.  Ask questions to assist clients to define their goals and the means of achieving them. 

• View client problems as coping strategies that may stem from surviving a traumagenic childhood.

• Cognitive behavioural strategies, solution-focused techniques, writing, art, other physical activities are all relevant approaches to use to strengthen self-capacities and manage feelings / experiences. 

• Be aware of the personal impact of trauma counselling.  Utilise supervision, peer support, and ongoing training for support.  Become involved in other professional and recreational activities.

References

(Available on request)

Black Dog Institute.  (2024). Expert guidelines: Diagnosis and treatment of post-traumatic stress disorder in emergency service workers.  https://www.blackdoginstitute.org.au/wp-content/uploads/2024/03/BDI_PTSD_Guidelines_A4_DIGITAL.pdf 

Phoenix Australia.  (2021).  Australian PTSD guidelines.  Australian Government, National Health and Medical Research Council.  https://www.phoenixaustralia.org/australian-guidelines-for-ptsd/

U.S. Department of Veteran Affairs. (2022). PTSD and DDM-5.  https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp