Post-traumatic stress disorder (PTSD) describes a range of symptoms people may experience following a traumatic event or situation.

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Post-Traumatic Stress Disorder (PTSD) is a form of anxiety disorder. It happens after an extreme stressful event, e.g. a serious threat to the person’s life or where a loved one is caught up in a catastrophic event e.g. plane crash. The person then re-lives the event over and over again through dreams, feelings and thoughts. PTSD may actually be quite common but often go unnoticed e.g. nearly one in ten people may have some PTSD at some time in their lives. Severe trauma or unpleasant events can actually produce long-lasting changes in brain structure.

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of PTSD. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the symptoms need to be treated anyway, no matter what causes them.

• Acute stress, but not if it has lasted longer than a month

• GAD or Generalised Anxiety Disorder

• Panic disorder

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Depression - usually caused by the PTSD symptoms

• Substance misuse e.g. drug dependence or addiction (usually as a result of the PTSD)

• GAD or Generalised Anxiety Disorder

• Bipolar mood disorder

• ADHD (Attention Deficit Hyperactivity Disorder)

• Social anxiety - which is five times more likely if you have PTSD

^{Updated 5.12}

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Basically, anyone can get PTSD. However, there are some "risk factors" that make it more likely that someone will get the symptoms of PTSD. This is not a complete list but some of the main ones include (roughly in order of importance, most important first):

• A major event - most often rape, plus also combat exposure, childhood abuse, sudden death, physical attack, threatened by weapons. Better known, although less common, are accidents, fire, disaster, torture. It is more likely if the major event is prolonged, repeated, intentional (e.g. torture), abusive or involves children and involves threat to life
• Further life stress
• Childhood adversity e.g. sexual abuse as a child, separation from parents, unstable family
• Having had a trauma before the main event
• Family history of anxiety and substance misuse
• Lower education or being poorer
• Being female - probably about 8% men and 20% women get PTSD. It is also more likely in black or Hispanic people
• Genetics - may be a genetic susceptibility as it is more common in identical twins
• Also having another mental health problem e.g. depression, anxiety

Serotonin is a chemical messenger in the brain that in some parts of the brain seems to control many things, including thoughts, obsessions, mood etc. The only medicines that seem to help PTSD are those that boost serotonin, so it seems low serotonin could be a major cause of the symptoms.

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The following is a list of some of the risks of having PTSD: 

• Symptoms of PTSD can adversely affect quality of life

• Self harming or suicide is a risk with PTSD

• Substance misuse, taking illicit drugs is a risk

• Chronic depression may develop if your PTSD symptoms are not effectively treated early enough

• Risky impulsive behaviour

• Road accidents. Accidents are more likely with PTSD as your concentration may be affected 

• PTSD can be a trigger to an eating disorder, especially anorexia nervosa (Reyes 2011)

• Increased risk of heart disease and high blood pressure (Player 2011)

• Developing dementia (double the risk in men) (Yaffe 2010)

• Suicide - increase the risk by 50% (Nepon 2010)

^{Updated 8.12}

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"Prognosis" is the word used for the likely outcome of any condition. There are several things that will help or not help your prognosis or symptoms and the chances of them improving. You should try to make the most or build on the good prognosis factors, and try to work on or minimise the poor prognosis factors. That will give you the best chance of doing well. You are also likely to do better if you accept the treatment being offered to you.

Factors which may lead to a good outcome (prognosis) (RCPsych).

• Taking whichever medicine you choose exactly as your doctor prescribed it.
• Taking part in any psychological or talking therapy such as family therapy, art therapy or cognitive behavioural therapy (CBT) that may be offered to you.
• If you take your medicines they will help you to get the most out of talking therapies and will help you to sleep
• Learning to trust those trying to help you
• Not stopping taking your medicines without first discussing it with your doctor, nurse or key worker
• Not talking about any medicine side-effects that you cannot cope with. Do not stop taking the medicine. Instead tell your doctor, nurse or key worker as there may be an alternative treatment you can have or an effective way of dealing with the side-effects.
• Trying to keep life as normal as possible and get back to your usual routine as quickly as possible
• Going back to work
• Having good social support and talking about what has happened to you with someone you trust (and not keeping it bottled up)
• Eating and exercise regularly
• Going back to where the traumatic event happened
• Spending time with family and friends
• Expecting to get better
• Keeping the rest of your life as low stress as possible

Factors which can make PTSD worse or which may lead to a poor outcome (prognosis) (RCPsych; Koren 1999; Karamustafalioglu 2006)

• Being younger you suffered the trauma
• The worse the trauma the harder it is to get over it
• The trauma being caused by a parent or caregiver
• The trauma going on for a long time
• Not seeking or getting effective treatment early
• Not sticking to the chosen treatment, especially if it has worked
• Being male - men often do worse than women
• Being isolated
• Staying in touch with the abuser and/or threats to your safety
• If the symptoms came on very quickly you may not do as well as people who became ill gradually.
• Having worse symptoms may mean you may not do as well as those whose symptoms are less severe li>
• Having another mental health problem e.g. anxiety or depression may make it longer to get better
• Suffering from a mental health problem before the traumatic event happened - you may take longer to get better
• Other people not letting you talk about it, avoiding you, being angry with you, thinking you are weak or blaming you
• Being exposed to continual stress and uncertainty
• Being very stressed e.g. personal problems, financial problems, social issues, any legal actions
• Having "Post-trauma debriefing" - this was thought to be a good idea but can actually make the symptoms worse
• Fear of the trauma occurring again
• Behaviours such as avoidance, not talking about it, safety behaviour, denial, thought depression, rumination, especially early on
• Symptoms getting worse over the first 3 months
• Having bad PTSD symptoms immediately after the event
• Having new traumatic events

^{Updated 6.12}

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Here at C&M we have researched this extensively but don't feel a lot wiser. There are of course many studies to show what works and what doesn't and believe me, we've looked at hundreds.

However, everyone is an individual. Specific symptoms are unique to that person. Your personal circumstances will also be unique. Some books give an idea of what used to happen years ago but of course the world has changed since modern treatments such as medicines and "talking therapies" first became available. It is important to remember that not all books agree with each other about what might happen if you do nothing.

To do nothing is a personal choice unless you are a danger to yourself or others when your symptoms are at their worst. However, you need to know the risks and benefits of having no treatment.

All medicines have side-effects but not everyone will suffer all of the possible side-effects of the medicines they take.

The up-side of no treatment is no side-effects or adverse from medicines or therapy

The down-side of no treatment is;

• Having worse symptoms which last longer and not being able to enjoy your life to the full. (Perkonigg 2005)
• You will be more likely to have new traumatic events. (Perkonigg 2005)
• You will be more likely to have "avoidance symptoms" and need and ask for than people who take medicines or have other forms of help (Perkonigg 2005)
• You may also have more physical symptoms and are more likely to suffer from other anxiety problems. (Perkonigg 2005)
• You may be more likely to take too much alcohol or other drugs to "self medicate" for your symptoms or to control your emotions (RCPsych)
• You may be more likely to feel so bad you want to kill yourself
• You may also be more likely to take risks and act in haste

About one third to a half of people with PTSD seem to get over the trauma without any treatment, usually within the first year. This seems more likely in females than males (Karamustafalioglu 2006). In another study, after eighteen months, about 1 in 5 (20%) had recovered completely, another 1 in 5 (20%) said they were much better, I in 25 (4%) were worse but just over 1 in 2 (56%) were no better. (De Vries 2001).

We've put this into a table, which may (or may not) help:

^{Updated 5.12}

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The list here includes most of the main options but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Self-help

• Watchful waiting – if the symptoms are mild and less than 4 weeks has gone since the trauma
• Taking any medicines regularly and reliably
• Eating healthily and taking exercise  (“exercise to energise”) or being active, regular sleep patterns
• The Royal College of Psychiatrists has a good advice leaflet with some dos and don'ts:
• Do: keep life as normal as possible; get back to your usual routine; talk about it to people you trust; try relaxation exercises; and (if you work) go back to work; drive carefull as your concentration may be worse; and finnalt expect it to improve 
• Do not: beat yourself up about it (this is quite natural, PTSD is not a sign of weakness); don't bottle it up; don't expect memories to go away quickly; don't expect too much of yourself; don't drink more alcohol, smoke more; don't miss meals; don't take holidays on your own; don't go back to the place it happened

Help from others

• Trauma-focused psychological treatment may be useful if the symptoms are severe and it is less than 4 weeks since the event
• Trauma-focused cognitive behavioural therapy [TF-CBT], group TFCBT, stress management (SM) or eye movement desensitisation and reprocessing [EMDR] may be helpful for adults who have had PTSD symptoms for several months. There are 15 studies to 2010 that show that brief Trauma Focused-Cognitive Behavioural Therapy (TF-CBT) is better than supportive counseling and better than a waiting list (Roberts 2010)
• Counselling to listen to your concerns  
• Alternative therapies such as  aromatherapy, hypnosis or hypnotherapy, homeopathy (click for a review of the 25 studies in mental health by Davidson 2011) (treating like with like) can be used with (but not instead of) conventional treatments. Acupuncture is used extensively in many countries and may help anxiety, stress and insomnia.The evidence for these treatments is not very good and not tested in PTSD. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Medicines are not usually a first-line treatment but can be very helpful in combination with cognitive behavioural therapy (CBT). Medicines boosting serotonin seem to be the most effective.  The biggest review, of 35 studies, shows that medicines can be effective for reducing the core symptoms and depression and disability (Stein 2006)

A number of other treatments have been tried but not shown to work. Whilst they might help a person, they should only be tried in extreme cases, as they may do more harm than good. "Post-trauma debriefing" has actually been shown to be harmful, probably by reinforcing the memories the brain was trying to forget.

^{Updated 4.13}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines

BNF Listed:

• Serotonin boosters (SSRIs) (such as sertraline up to 200mg a day, and paroxetine up to 50mg a day; although sertraline only appears to work in women, and not that well even then)

Others:

• Other serotonin boosters (SSRIs) may help e.g. fluoxetine, mirtazapine and venlafaxine. Citalopram and escitalopram have been used but there isn't much evidence they work

• Amitriptyline (generally only prescribed by mental health specialists for PTSD)

• Phenelzine (generally only prescribed by mental health specialists for PTSD)

• Antipsychotics (such as olanzapine and risperidone), in addition to other medications in difficult-to-treat symptoms

• Prazosin - especially for nightmares and sleep problems (Byers 2010) although it isn't widely known about in Europe

• Sometimes help with getting to sleep (medicines such as zaleplon, zolpidem, zopiclone or temazepam) have been used but these really must only be for short-term use (up to a couple of weeks), where sleep is a really major problem and where sedative antidepressants such as mirtazapine or trazodone have not worked. The trouble is that once you start relying on sleeping tablets with PTSD it can be very difficult to stop.  

It can be very difficult to decrease the symptoms of PTSD. Doses of SSRIs such as sertraline and paroxetine will generally need to be increased to the top end of the range for 6 to 12 months to get the full effect.

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Download a handy summary chart (PDF format) comparing the main medicines for PTSD e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

^{Updated 5.12}

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

For PTSD, some specific types of CBT (see above) are probably the most effective, but medicines may be useful and helpful. From an analysis of 15 studies, it seems that early and individual TFCBT may be effective but that non-trauma focused treatments probably don't help (CDSR 2010). WHile we know that some medicines and some Talking Therapies both help, we don't yet know if having both is better than either by themselves (CDSR 2010)

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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If you have improved, you should probably go on for at least 12 months before thinking about stopping slowly. If you stop earlier than this there is a high risk of the symptoms returning to their previous level. It seems that about 1 in 4 people relapse or get their symptoms back within 6 months of stopping medicines but only 1 in 20 get them back if staying on a medicine that worked for you. You can go on longer than a year. Whatever you do, stop any medicines slowly.  

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

PTSD (like OCD) can be slow to respond to medicines but medicines can often help (or at least help reduce the symptoms) given enough time. You need to get to the full therapeutic dose (usually much higher than the antidepressant doses) and then stick with it for around 3 months for the effect to build up. If things improve it is almost certainly the medicine working because there is almost no response to the placebo part of medicine trials. If the medicine hasn't worked after three months of the full dose, then it probably won't work so that's the time for a change.

^{Updated 5.12}

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Generally only one antidepressant e.g. an SSRI, but you should make sure you are taking the highest dose you can cope with. Sometimes, antipsychotics and/or sedating antidepressants can help as well.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the PTSD guidelines). There is also a guideline for Common mental health disorders, Identification and pathways to care, and this includes PTSD.

• Scottish Intercollegiate Guidelines Network (SIGN) although they don't have one for PTSD at the moment

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Updated 5.12}

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Use the resources below to find out more information about post traumatic stress disorder. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

The British Association for Psychopharmacology has a BAP public area, which has loads of interesting articles, some mentioning PTSD.

The Big White Wall is a 16+ safe, anonymous web-based service for people experiencing emotional or psychological distress provided entirely online. Professionally staffed 24/7 it offers a wide range of services for improving mental wellbeing including tests, peer support, individual and group therapies, articles, tips and creative self expression. Simply click on the link to learn more, or to join for £2.00 a week.

^{Updated 12.12}

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