106 Reprinted from Australian Family Physician Vol. 38, No. 3, March 2009
Mark Creamer David Barton
PhD, is Professor, Australian Centre for MBBS, FRANZCP, MRACMA, is Senior Lecturer, Department
Posttraumatic Mental Health, University of of Psychological Medicine, Monash University, and Clinical
Melbourne – Psychiatry, Victoria. Director, Aged Persons Mental Health Program, Victoria.
What is PTSD?
Acute stress disorder and PTSD are disorders characterised by
symptoms that include:
• distressing re-experiencing and active avoidance of the traumatic
memories
• emotional numbing, and
• hyperarousal2 (Table 1).
Acute stress disorder can be diagnosed from 2 days to 4 weeks after
a traumatic event and PTSD can be diagnosed from 4 weeks onward.
What can I expect to see in short term aftermath and what do I do?
While psychological distress in the immediate aftermath of trauma stabilise the patient are required (see What about pharmacotherapy?).
is common, most people will recover using their existing coping It is also important to ensure that the person’s basic needs are met,
strategies and social supports. As such, during the first couple of such as housing and safety.
weeks following trauma it is important for the GP to: It is important to be aware of risk factors that may increase the
• monitor the patient’s mental state likelihood of a patient having a more problematic response. These risk
• encourage the patient to continue to engage in their usual routines factors include:
to the extent that functioning allows, and • the severity of the traumatic exposure
• use existing social supports and coping strategies. • a history of past trauma or previous psychiatric disorder
The aim of this approach, known as 'psychological first aid', is • lack of social supports, or
to maximise the likelihood of natural spontaneous recovery, • experience of further stressful life events.
with intervention only provided as needed (Table 2). Obviously Following the initial session, a review appointment should be
however, if the patient presents with severe distress, usual steps to scheduled in 1–2 weeks to check on the patient’s progress.
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Post-traumatic stress disorder – best practice GP guidelines clinical practice
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clinical practice Post-traumatic stress disorder – best practice GP guidelines
distinguish a preferred SSRI. Other newer antidepressants or Who should I refer to for TFPT?
tricyclic antidepressants would be considered as a second line When referring for psychological therapy, mental health practitioners
pharmacological intervention. Third line treatment may involve the trained in TFPT should be the first choice (see Resources). Most
use of monoamine oxidase inhibitor (MAOI) antidepressants, although commonly mental health practitioners with this type of training are
these should preferably be prescribed by a psychiatrist. Where psychologists, although psychiatrists and clinical social workers
symptoms have not responded to antidepressant treatment, controlled may also have received such training. Referrals to psychology,
studies have demonstrated the potential benefits of adjunctive psychiatry and allied health care can be made under Medicare
atypical antipsychotics. Again, these should preferably be prescribed arrangements. Referrals for mental health care under third party
by a psychiatrist. funding arrangements should be considered where appropriate.
Where pharmacotherapy is required in the acute management
What about less obvious cases – how do I screen?
of a patient with PTSD, sedating, calming or antidepressant
medication may be used. However, benzodiazepines are generally not Many people who develop PTSD do not necessarily present in a
recommended due to risk dependency and the possibility that they straightforward manner. Instead, they may present with problems such
may interfere with natural recovery processes. as depression, anger, relationship problems and poor sleeping habits.
They may present with repeated, nonspecific physical problems
Table 3. Screening for PTSD6 such as headaches, gastrointestinal problems, musculoskeletal pain
syndromes and skin disorders. Patients with trauma histories who
In your life have you ever had any experience that was so present with these problems may not report their exposure to a
frightening, horrible or upsetting that, in the past month, you:
traumatic event. In such cases, GPs should consider asking about
• Have had nightmares about it or thought about it when you
past traumatic events. The event may have taken place in the recent
did not want to?
or distant past (eg. adult survivor of childhood sexual assault). This
YES/NO
can be a difficult area for both GPs and patients to talk about. The
• Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it? guidelines algorithm provides brief screening and advice on how to
YES/NO ask this question (Table 4).
• Were constantly on guard, watchful or easily startled? What are some of the issues in managing more complex
YES/NO presentations?
• Felt numb or detached from others, activities, or your
surroundings? Post-traumatic stress disorder rarely occurs on its own. It is often
YES/NO accompanied by symptoms of depression and/or substance abuse.
If two or more questions are answered with ‘yes’, a diagnosis of In such cases the sequencing of treatment is important. When
PTSD is probable PTSD and depression are both present, PTSD should be treated first
because symptoms of depression often improve as PTSD symptoms
reduce. However, if the depression is severe, it should be treated
Table 4. Screening for past traumatic events first to minimise suicide risk and improve the ability of the person to
tolerate therapy. When PTSD and substance abuse are both present,
Where a person has repeated nonspecific health problems it is
they should be treated simultaneously because the two are likely to
often helpful to ask about specific events that the person may
interact to maintain each other. In such cases, the substance abuse
have experienced, such as:
should be under control before the trauma focused component of
• Serious accident (eg. car accident or industrial accident) therapy begins.
• Natural disaster (eg. fire or flood)
Summary
• Physical attack or assault
• Sexual assault Post-traumatic stress disorder is a common treatable disorder.
In the context of perceived stigma and shame associated with
• Witnessing someone being badly hurt or killed
experiencing some traumatic events, many people may avoid
• Domestic violence or abuse
mentioning them. As a result, traumatic stress reactions are often
• Physical or emotional abuse as a child under diagnosed in routine clinical practice. As primary health
• Being threatened with a weapon or held captive providers, GPs are often the first, and at times the only, health
• War (as a civilian or in the military) practitioners available to people who have experienced a traumatic
• Torture or an act of terrorism event. As such, they play a crucial role in identifying those with
PTSD, managing their care, and referring them for specialised
• Any other extremely stressful or upsetting event
treatment when necessary.
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Post-traumatic stress disorder – best practice GP guidelines clinical practice
Resources
• To order your free copy of the algorithm go to http://tinyurl.com/4286gd
• To download a PDF version of the algorithm go to www.acpmh.unimelb.
edu.au/resources/resources-guidelines.html#1 (brief and full guidelines
are also available at this website)
• The brief screen for PTSD is available at www.acpmh.unimelb.edu.au/
trauma/ptsd.html#screening
• To find practitioners who provide TFPT go to www.psychology.org.au/
findapsychologist or www.racgp.org.au/scriptcontent/ranzcpcomplex.
cfm?section=psychiatrist_referral_directory.
Conflict of interest: none declared.
Disclaimer
It should be noted that irrespective of any funding provided by the Department
of Veterans’ Affairs (DVA), the content of the article is not necessarily the
view of, and is not endorsed by, the Minister for Veterans Affairs or DVA.
References
1. Australian Centre for Posttraumatic Mental Health. Australian guidelines for the
treatment of adults with acute stress disorder and posttraumatic stress disorder:
Melbourne, Victoria: ACPMH, 2007.
2. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th edn. Washington DC: American Psychiatric Association, 1994.
3. Creamer M, Burgess P, McFarlane AC. Post-traumatic stress disorder: findings
from the Australian National Survey of Mental Health and Well-being. Psychol
Med 2001;31:1237–47.
4. Foa EB, Rothbaum BO. Treating the trauma of rape: Cognitive-behavioral therapy
for PTSD. NY: Guilford Press, 1998.
5. American Psychiatric Association. Practice guideline for the treatment of patients
with acute stress disorder and posttraumatic stress disorder. Arlington: VA:
American Psychiatric Association, 2004.
6. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD):
Development and operating characteristics. Primary Care Psychiatry 2004;9–14.
correspondence afp@racgp.org.au
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