Trauma and stress-related disorders

F43.0/F43.1

DESCRIPTION

Acute stress and post-traumatic stress disorder arise in response to stressful events. The patient should have experienced the event as life threatening or as a physical threat to themselves or others, at which time they felt fear and helplessness.

A range of symptoms are associated with both of these conditions and include:

  • Re-experiencing of the event, e.g. flashbacks, dreams.
  • Avoidance of situations associated with the event.
  • Features of anxiety or increased arousal, e.g. hypervigilance, heightened startle response and insomnia.

The conditions are symptomatically similar but differ with regard to the duration and time of onset of symptoms. The symptoms of acute stress disorder arise within 4 weeks of the event and last up to 4 weeks, whereas the symptoms of post-traumatic stress disorder last longer than 4 weeks, and may arise more than 4 weeks after the traumatic incident.

Child abuse and trauma histories (including traumatic birth experience) and trauma experiences within pregnancy are associated with gestational and postnatal PTSD.

GENERAL MEASURES

Reassurance and support of patient and family.
Psychotherapy, usually of a supportive/cognitive-behavioural nature.
Trauma debriefing is not routinely recommended.

MEDICINE TREATMENT

Acute stress disorder:

Benzodiazepines may be useful in the immediate period following the traumatic event.
Prolonged use > 1 week may be detrimental to adaptation, leading to higher rates of post-traumatic stress disorder.

For acute anxiety or agitation:

  • Clonazepam, oral 0.5–2 mg in divided doses.

LoEIII [35]

For sleep disturbance: See Insomnia .

Post-traumatic stress-disorder:

  • Selective serotonin reuptake inhibitors, e.g.:
  • Citalopram, oral, initial dose 20 mg daily.

LoEIII [36]

OR

  • Fluoxetine, oral, initial dose 20 mg in the morning.
    • A response to SSRI should be expected after 4–6 weeks.
    • If there is no or partial response after 4–8 weeks, increase SSRI dose to 40 mg, if well tolerated.
    • An adequate trail of treatment is 8–12 weeks, before an alternative treatment should be considered.

REFERRAL

  • Persistent symptoms.
  • Inadequate response to treatment.
  • Comorbid conditions.