Recent developments in PTSD diagnosis
In the past 18 months there have been two significant developments in the domain of post-traumatic mental health that have clinical relevance to GPs. The first is the release of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association,4 and the second is the update of the Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder (the Guidelines).5 These developments will be outlined, and the role of the GP in the management of PTSD considered.
After 19 years of the fourth edition (DSM-IV), the fifth edition (DSM-5) was released in May 2013. Significant changes have been made to the way PTSD is classified and diagnosed (Table 1). First, DSM-5 has separated ‘Trauma- and stressor-related disorders’ from the chapter on ‘Anxiety disorders’. The requirements for an event to be considered traumatic have been more explicitly defined and a subjective response of intense fear, helplessness or horror is no longer required to make a diagnosis. Sexual violence has been added as a specific example. There are now four groups of symptoms as the previous grouping ‘avoidance and numbing’ has been separated into two distinct clusters. The avoidance cluster requires one of the two avoidance symptoms (avoidance of memories or thoughts or avoidance of external reminders), whereas the emotional numbing symptoms have been included in a new cluster of negative cognitions and mood, which also includes features typically associated with complex presentations of PTSD, such as persistent negative beliefs about self, others and the world. ‘Recklessness or self-destructive behaviour’ has been added to the arousal cluster of symptoms.
Table 1. Key differences between DSM-IV and DSM-5 PTSD criteria
Broader definition of what constitutes a traumatic event
More tightly defined, with the removal of some stressor events (eg unexpected deaths from natural causes) as well as the exclusion of learning about a traumatic event through electronic media such as television, video games, movies or pictures (unless exposure is work-related)
Stipulates the individual must have experienced an emotional response of intense fear, helplessness or horror during the traumatic event
Emotional response of intense fear, helplessness or horror during the traumatic event criterion has been removed
Three symptom clusters – re-experiencing; avoidance and numbing; increased arousal
Four symptom clusters distinguishing active avoidance from numbing (negative cognitions and emotions) symptoms
Minimum of six symptoms required for diagnosis
Minimum of six symptoms required for diagnosis
Dysphoric mood symptoms added, including persistent distorted blame of self or others and persistent negative emotional state
Despite the substantial changes from DSM-IV to DSM-5, early research suggests that DSM-5 PTSD will be diagnosed at similar or slightly lower prevalence rates than DSM-IV PTSD.6 Although overall rates may not differ, exclusion of those without active avoidance while inclusion of those who did not experience the subjective trauma response at the time of the event may capture a slightly different group.
The revised version of the Guidelines5 was released in 2013 and has been expanded to cover children and adolescents. The Guidelines have been approved by the National Health and Medical Research Council (NHMRC) and endorsed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP), Royal Australian College of General Practitioners (RACGP) and the Australian Psychological Society. The Australian Centre for Post-traumatic Mental Health (ACPMH) developed the Guidelines in collaboration with national experts. The Guidelines also investigate evidence for resilience training and consider the treatment of PTSD in older age groups.
The best available research evidence continues to support the first-line use of trauma-focused psychological treatments for PTSD across all age groups. Other higher-level recommendations include that routine psychological debriefing for those exposed to potentially traumatic events should not be offered. There is no evidence that psychological debriefing prevents PTSD and it may even be harmful for some.
The strongest recommendations around pharmacotherapy are that it should not be offered preferentially over trauma-focused psychological treatment and when pharmacotherapy is considered necessary, selective serotonin reuptake inhibitors (SSRIs) should be considered the first choice. Generally, the evidence base around pharmacotherapy for PTSD is not strong and has not progressed dramatically over the past 7 years, since the previous version of the Guidelines were published. The full Guideline recommendations are available at http://guidelines.acpmh.unimelb.edu.au/.
The role of the GP
The role of GPs in managing PTSD is central and includes:
- provision of initial support and monitoring (eg psychological first aid, PFA)7
- early detection, initial assessment and supportive management
- use of initial pharmacotherapy
- appropriate and timely referral for specialist treatment
- support of family and carers
- crisis assistance
- management of comorbid medical conditions
- maintenance treatment for chronic conditions.
GPs with appropriate training and interest may also provide evidence-based psychological treatment.
The consequences of untreated PTSD include poor quality of life, chronicity and, at times, mortality.8 GPs can have a substantial role in reducing delays in treatment by remaining vigilant. At-risk patients may not readily report PTSD symptoms, making it important for GPs to ask probing questions, use screening tools and raise the possibility of PTSD. GPs should be particularly vigilant with patients who work in occupations such as law enforcement, the military and emergency services, who are more likely to be exposed to multiple traumatic events, communities that are subject to natural disasters such as bushfires and floods, and patients presenting with physical injuries, for example following motor vehicle accidents. Another group in primary care settings with higher rates of PTSD are patients presenting repeatedly with non-specific somatic complaints.9–11
GPs should consider the use of antidepressant medications such as SSRIs for people who:
- are unwilling to seek or do not have access to the preferred first-line psychological treatment
- have a comorbid depression or other symptoms that require pharmacological treatment
- are in situations that are not sufficiently stable (eg ongoing domestic violence)
- have not benefited from trauma-focused psychological treatment. There is evidence that the required doses are higher when treating PTSD, compared with uncomplicated depression. When there is a good response to an antidepressant, a course of treatment lasting at least 12 months reduces rates of relapse. When second- and third-line pharmacotherapy options need to be considered because of non-response or side effects, other newer-generation antidepressants such as selective serotonin and noradrenaline reuptake inhibitors (SNRIs), mirtazepine or moclobemide are recommended.12
Poor response to initial treatments, complex comorbidities, safety concerns and patient request should lead to referral for psychiatric assessment. Additional treatments such as tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), atypical antipsychotics (APs), mood stabilisers and benzodiazepines may need to be considered, but clinicians need to be aware of the limited evidence base supporting the efficacy of these treatments, inform patients accordingly and carefully manage associated risks (eg metabolic syndrome with APs, abuse and dependency with benzodiazepines, risk of overdose with TCAs).
Augmentation strategies used to treat more severe and complex PTSD come in and out of favour. The evidence base supporting the use of APs is weak and, if they are to be used, the well-established and significant side effect profile must be assessed for acceptability and be outweighed by the expected and actual benefits.13 In comparison, prazosin, an alpha-1 adrenoreceptor antagonist, has been proven to have a more favourable risk–benefit profile. While this profile has been established specifically in the treatment of PTSD insomnia and nightmares, a recent well-designed study also showed benefit for overall PTSD symptoms.14
It is important for GPs to have a good working knowledge of what treatment entails when referring patients for evidence-based psychological treatment of PTSD. Often, patients appreciate general counselling, dealing with daily issues and stresses, and talking around, but not about, the trauma, but these techniques do not improve core symptoms of PTSD. Efficacious trauma-focused interventions include therapies such as prolonged exposure, eye movement desensitisation and reprocessing (EMDR), and cognitive processing therapy (CPT). The common factors in these therapies that are considered to be the ‘potent’ elements are strategies that:
- enable the patient to confront the distressing traumatic memories
- manage the accompanying avoidance responses
- facilitate reduction and management of the associated arousal.
These evidence-based psychological treatments are time-limited and usually involve 8–12 sessions, although more sessions may be required for complex presentations or repeated traumatic experiences. Therapies such as prolonged exposure may also require longer sessions (ie 90 minutes) to ensure appropriate management of distress. In choosing a psychologist to refer patients to, we would recommend that the GP enquire about their experience in treating PTSD with trauma-focused cognitive behavioural therapy (TF-CBT) or EMDR.
PTSD is a common mental health problem. GPs should be aware of recent important updates that have been made for the diagnosis and treatment of PTSD to assist in their critical role of ensuring evidence-based care for patients with PTSD.
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.