Key learning points:
- PTSD can cause significant distress, social impairment and physical health problems
- Evidence-based talking therapies including trauma-focused cognitive behavioural therapy (TF-CBT) are recommended
- Individuals who have been involved in a traumatic incident may benefit if they are given appropriate information about common reactions
- People who have persistent and impairing trauma symptoms should be sensitively encouraged to seek help, as the majority fail to do so and continue to suffer
Exposure to traumatic events, such as road traffic accidents, domestic violence or sexual abuse, is not uncommon.1 Around one in three people in the UK will experience a significant traumatic event during their life, although this figure is significantly higher for those working in trauma-exposed occupations (such as the emergency services or as a war reporter) and in less developed countries.2 Significant numbers of individuals will experience short-term distress post trauma. In the majority of cases, these distress symptoms dissipate over time without the need for formal psychological treatment. However, in a minority of cases, trauma exposure can lead to the development of psychological adjustment problems, including post-traumatic stress disorder (PTSD).
Diagnosing PTSD
Essential for a diagnosis of PTSD is exposure to a traumatic stressor, defined as ‘exposure to actual or threatened death, serious injury or sexual violation’.3 This may occur either through direct witnessing of an event, or by indirectly learning that a close family member or friend has been exposed to a traumatic stressor (the event(s) must have been violent or accidental) or from repeated or extreme indirect exposure to aversive details of traumatic event(s) (for instance, police officers repeatedly exposed to details of child abuse).
It should be noted that the final exposure criterion does not apply to indirect, non-professional exposure to television, movies or pictures.
PTSD consists of four core symptom clusters, each of which must be present to make a diagnosis:
- Intrusive re-experiencing of the event (such as traumatic nightmares, flashbacks or trauma-related play in children).
- Alterations in arousal and reactivity (such as hypervigilance, exaggerated startle response, concentration problems or sleep disturbance).
- Avoidance of reminders of the traumatic event, and negative alterations in mood and cognitions (such as inability to recall key parts of the trauma not caused by alcohol, head injury or drugs, persistent negative emotional state).
These symptoms must have been experienced for more than one month to meet diagnostic criteria.
Life-time prevalence of PTSD in the USA is estimated at 7.8%, with a 5% prevalence rate for males and 10.4% for females.4 Within the UK, the prevalence rate is estimated at 4.4%.2 Rates of PTSD differ considerably between occupational groups, with prevalence rates of up to 20% of ambulance workers, up to 33% of security contractors, up to 20% of war reporters, and between 7-30% of combat troops.5,6
PTSD can be a chronic and debilitating condition associated with:
- Significant social impairment.
- Comorbid mental disorders.
- Physical health problems including cardiovascular and respiratory conditions, major depressive disorder, and substance abuse problems.7-9
Risk factors for PTSD have been found to include female gender, low perceived social support, and previous exposure to traumatic events.10
Studies have also found that high heart rate (>95bpm) during first attendance at an A&E department and acute levels of pain are risk factors for PTSD in individuals with severe physical injury.11,12 However, in cases of physical injury, the relationship between injury severity ratings and PTSD remains unclear.13 This is likely to be because the causes of PTSD are related to cognitive processes rather than objective features.
Theoretical models of PTSD highlight several key factors that are likely to be relevant to the development and maintenance of PTSD, particularly the way in which the traumatic event is encoded in memory and subsequently updated, the propensity for negative appraisals of the traumatic event and its sequelae (for instance, a feeling that ‘the world is dangerous’), and the use of avoidant or other maladaptive coping behaviours.14
Treatment
In the initial four weeks following trauma exposure, formal therapeutic intervention is often unnecessary. Instead, a temporary reduction in exposure to stressors and the provision of social support is thought to facilitate recovery in many cases.15 Individuals who experience more intense and debilitating symptoms within the first month post trauma could meet criteria for ‘acute stress disorder’ and may benefit from formal early intervention from a mental health professional.
However, healthcare workers should be aware that the evidence for the effectiveness of early psychological interventions for children following traumatic events is mixed.16
Trauma-focused cognitive behavioural therapy (TF-CBT) is recommended for individuals who present with PTSD within three months of trauma exposure. TF-CBT is often delivered in eight to 12 weekly sessions, lasting between 60 and 90 minutes. Individuals with PTSD symptoms that persist for longer than three months post trauma should also be offered TF-CBT with additional sessions if needed.17 TF-CBT has been found to be effective for improving both child and adult PTSD symptoms following exposure to a variety of trauma types.18 The other mainstream talking therapy treatment, for which there is good scientifically validated evidence, is eye movement desensitisation and reprocessing (EMDR) which is usually delivered as eight to 12 weekly sessions.18
Role of nurses
Nurses can play a substantial role in the provision of support to individuals with PTSD. They should be knowledgeable about the effects of a traumatic event on an individual and their family, aware of important factors that influence post-trauma adjustment (such as access to appropriate social support), and know about interventions to help them cope following exposure (for instance, protection from further traumatic events while they recover).
One particular role for nurses may be in interacting with family members of those affected by trauma because there is good evidence that a minority of family members of those suffering with PTSD may become vicariously affected themselves.19 It may also be helpful for nurses to readily provide information on common reactions following trauma exposure, symptoms and practical advice about accessing treatment.17
There is a distinct lack of emotional advice routinely offered
to families in emergency departments, especially following child trauma exposure20 and recent research suggests that clinical
care teams should sensitively deliver information regarding children’s psychological recovery on discharge, including psycho-education about common reactions and coping strategies.20
Moreover, while the media often portrays military veterans and emergency service workers as reluctant to seek help for mental health difficulties, a failure to seek help for trauma-related mental health problems is a societal issue rather than the mindset of particular professions.2 Therefore it may be beneficial for healthcare professionals to encourage individuals to access social support or seek formal treatment if they have persistent and impairing trauma symptoms.
Drug treatment for PTSD is not recommended as a routine first-line treatment strategy, although medication may be used to treat comorbid depression or severe hyperarousal.17
Approaching the subject
Community and practice nurses may encounter people who have been affected by trauma in a variety of situations, including providing physical care for those who have been injured in traumatic events. However, such encounters may also include speaking to people who have been the victims of violence or sexual assaults, who have been affected by workplace trauma or indeed have experienced trauma in any area of their lives. Key to proper management of a person’s trauma-related distress is asking, sensitively, about what has happened and the impact it has had on their lives.
Where nurses are concerned about persistence or severity of symptoms, particularly if the traumatic incident happened more than a month before, they should ensure that the individual is referred to an appropriately trained mental health professional who can undertake a full assessment.
Particular attention should be paid to ensuring that people who are referred do actually attend their appointment, as avoidance is a key symptom of PTSD and there can often be a reluctance for trauma-affected individuals to attend healthcare appointments where they know they will be required to talk about the traumatic event.
Encouraging colleagues to seek help
There is good evidence that healthcare workers themselves can be affected by the traumatic nature of the work that they do.21 Nurses can play an important role in encouraging colleagues from all disciplines to seek help if they need to do so. Recent research has found that mental health advice and support from peers can be highly beneficial, both in reducing the impact of traumatic events and in encouraging help-seeking.22
Indeed, many trauma-prone occupations operate an evidence-based peer support programme that nurses are ideally placed to be part of. Within the UK military, there is evidence that investment in improving informal and formal support to trauma-exposed troops is successful, both in protecting service personnel’s mental health and in reducing the stigma around mental health problems within the forces.23
Given the substantial challenges of working in a healthcare role, and the consequential absenteeism and impaired workplace performance (presenteeism), nursing staff who can sensitively talk to trauma-exposed colleagues in order to support their mental health are likely to have a substantial impact on workplace morale and performance.
References
1. Perkonigg A, Kessler RC, Storz S et al. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatr Scand 2000;101:46-59.
2. Fear NT, Bridges S, Hatch S et al. Chapter 4: Posttraumatic stress disorder. In: McManus S, Bebbington P, Jenkins R, Brugha T (eds). Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey. NHS Digital 2016.
3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.) Amercian Psychiatric Association 2013.
4. Kessler RC, Sonnega A, Bromet E et al. Posttraumatic Stress Disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048.
5. Greenberg N, Jones E, Jones N et al. The injured mind in the UK Armed Forces. Philos Trans R Soc B Biol Sci 2010;366.
6. Sterud T, Ekeberg Ø, Hem E et al. Health status in the ambulance services: a systematic review. BMC Health Serv Res 2006;6:82.
7. Chilcoat HD, Breslau N. Investigations of causal pathways between PTSD and drug use disorders. Addict Behav 1998;23:827-40.
8. Sareen J, Cox BJ, Stein MB et al. Physical and mental comorbidity, disability, and suicidal behavior associated with post-traumatic stress disorder in a large community sample. Psychosom Med 2007;69:242-8.
9. Kubzansky LD, Koenen KC. Is post-traumatic stress disorder related to development of heart disease? An update. Cleve Clin J Med 2009; S60.
10. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for post-traumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748-66.
11. Norman SB, Stein MB, Dimsdale JE et al. Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychol Med 2008;38:533-42.
12. Zatzick DF, Rivara FP, Nathens AB et al. A nationwide US study of post-traumatic stress after hospitalisation for physical injury. Psychol Med 2007;37:1469-80.
13. Delahantaya DL, Raimondeb AJ, Spoonsterb E et al. Injury severity, prior trauma history, urinary cortisol levels, and acute PTSD in motor vehicle accident victims. J Anxiety Disord 2003;17:149-64.
14. Ehlers A, Clark D. A cognitive model of post-traumatic stress disorder. Behav Res Ther 2000;38:319-45.
15. Jonas DE, Cusack K, Forneris CA et al. Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD). Agency for Healthcare Research and Quality (US). Report number: 13-EHC011-EF, 2013.
16. Rose S, Bisson J, Wessely S. A systematic review of single-session psychological interventions (’debriefing’) following trauma. Psychother Psychosom 2003;72:176-84.
17. National Institute for Health and Care Excellence (NICE). Post-traumatic stress disorder: management. 2005.
18. Bisson J, Ehlers A, Matthews R et al. Psychological treatments for chronic post-traumatic stress disorder. Br J Psychiatry 2007;198:97-104.
19. Diehle J, Brooks SK, Greenberg N. Veterans are not the only ones suffering from post-traumatic stress symptoms: what do we know about dependents’ secondary traumatic stress? Soc Psychiatry Psychiatr Epidemiol 2016;1-10.
20. Williamson V, Creswell C, Butler I et al. Parental responses to child experiences of trauma following presentation at emergency departments: a qualitative study. BMJ Open 2016;6:e012944.
21. Skogstad M, Skorstad M, Lie A et al. Work-related post-traumatic stress disorder. Occup Med 2013;63:175-82.
22. Whybrow D, Jones N, Greenberg N. Promoting organisational well-being: a comprehensive review of Trauma Risk Management. Occup Med 2015;65:331-6.
23. Osório C, Jones N, Fertout M et al. Changes in stigma and barriers to care over time in UK armed forces deployed to Afghanistan and Iraq between 2008 and 2011. Mil Med 2013;178:846-53.
