• Early treatment of any traumatic stress symptoms leads to better outcomes.
• Posttraumatic stress disorder (PTSD) can be screened for using the Primary Care PTSD Screen DSM-5 (PC-PTSD-5), and assessed further using the Clinician Administered PTSD Scale (CAPS-5).
• Trauma-focused cognitive behaviour therapy (TF-CBT) is the recommended treatment for PTSD.
• DVA supports PTSD-recovery programs in several hospitals.

Key characteristics

PTSD is a serious psychological reaction. PTSD may develop in some people following an experience of a traumatic event, such as:

• combat
• assault
• sexual assault
• natural disaster
• an accident
• torture

PTSD is a complex disorder that can present quite differently in different people. In all cases there are symptoms from each of the following clusters:

Intrusions or re-experiencing symptoms

• distressing memories or dreams related to the traumatic event
• distress and/or physiological reactions to reminders of the trauma
• flashbacks and other dissociative reactions (more rarely)

Persistent avoidance

• internal reminders of trauma such as thoughts, feelings and physical sensations and/or 
• external reminders such as" people, places and activities associated with the trauma

Negative alterations in cognitions and moods

• unrealistic expectations about one’s self, others and the world
• distorted blame of self or others regarding the trauma and its consequences
• diminished interest in activities and inability to experience positive emotions
• detachment from others
• pervasive negative emotional states

Alterations in arousal and reactivity or ‘hyperarousal’

• irritable or self-destructive behaviour
• hypervigilance
• exaggerated startle response
• or problems with sleep or concentration

Some symptoms of PTSD may not be viewed as problematic by veterans. Particularly:

• hypervigilance
• exaggerated startle response
• anger

These responses may have been adaptive in deployment circumstances. They may have even served a critical role in the veteran’s survival and it may be helpful to acknowledge this. It may be helpful to acknowledge this and highlight that they become problematic when they arise in:

1. circumstances when they are no longer needed and
2. when they interfere with day-to-day civilian life

Prevalence

Most people have some kind of psychological reaction to trauma — common feelings are:

• fear
• sadness
• guilt
• anger

Survivors often recover over time. However, a small proportion will develop serious problems, including PTSD.

Prevalence estimates for PTSD vary widely:

• It is likely that 5-20% of veterans will develop PTSD in their lifetime (Ikin et al., 2004; O’Toole et al., 1996).
• In the general population, estimates suggest that 4.4% of Australians will have experienced PTSD in the past year (McEvoy et al., 2011).
• Up to 17% in the veteran population may have experienced PTSD like symptoms in the past year (DVA, 2018).

It is important to note that PTSD is only one of a number of mental health disorders that can result from exposure to a traumatic event. Depression, generalised anxiety and substance use also commonly experienced following trauma.

About acute stress disorder

PTSD is diagnosed if symptoms persist for at least one month after a traumatic experience. Posttraumatic distress between three days and one month after a trauma may be diagnosed as acute stress disorder (ASD).

The key distinguishing feature between the two disorders is the duration of symptoms required for the diagnosis to be made.

Although similar to PTSD, ASD has traditionally placed a greater emphasis on dissociative symptoms such as feeling ‘in a daze’ or having an altered sense of reality. This emphasis on dissociative symptoms is no longer considered critical.

Over half the individuals with ASD may go on to develop PTSD. However, a high proportion of those who develop PTSD did not previously meet the criteria for ASD (Bryant, 2011). There is strong evidence that early treatment of any traumatic stress symptoms leads to better outcomes for veterans (O'Donnell et al., 2008).

Screening and assessment

Untreated PTSD can become a chronic disabling disorder. Screening, early assessment and treatment are critical. Even for veterans who do not meet full criteria for diagnosis.

Use of the Primary Care PTSD Screen DSM-5 (PC-PTSD-5) is recommended. After establishing that a person has experienced a potentially traumatic event, it asks: In the past month:

• have you had nightmares about it or thought about it when you did not want to?
• have you tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
• were you constantly on guard, watchful, or easily startled?
• have you felt numb or detached from others, activities, or your surroundings?
• have you felt guilty or unable to stop blaming yourself or others for the event or any problems the event may have caused?

Preliminary research suggests that a veteran may have PTSD or trauma-related problems if they answer 'yes' to any three items. If so, further assessment is required.

• The Clinician Administered PTSD Scale (CAPS-5) is the gold-standard assessment tool for PTSD.
• The self-reported PTSD Checklist for DSM-5 (PCL-5) may be used when a clinical assessment is not available. However, this should not be used as a primary diagnostic tool.

Important assessment considerations

A thorough clinical assessment of PTSD should attend to the following issues:

• thorough history of traumatic experience/s. Many veterans may have experienced a range of traumatic events including childhood trauma
• quality of life indicators such as family, marital, occupational, legal and financial status. As PTSD has a significant impact on functioning and relationships
• issues related to injury and health behaviour change arising from the traumatic incident. As Physical health is an important consideration.

Some traumatic experiences can be of a sustained nature. People presenting for treatment may face an ongoing threat and be at risk of further exposure to trauma, such as:

• current serving members about to be re-deployed
• people facing ongoing bullying in the workplace
• return to unsafe environments

PTSD and comorbidity

Comorbidity is common, the most likely disorders to present with PTSD are:

• depression
• substance misuse
• generalised anxiety

Any assessment should go beyond PTSD, covering the broad range of potential mental health problems.

Consideration should also be given to the diagnosis of complicated grief. If the traumatic event involved bereavement and when grief-specific symptoms are reported. In DSM5, the diagnosis 'persistent complex bereavement disorder' is described as a condition for further study.

Exposure to prolonged or repeated traumatic events increase the likelihood of associated problems of substance use or impaired emotional regulation.

Psychological intervention

Interventions include:

Recommended treatments

Treatment for PTSD focus on:

1. confronting the memories and reminders of the traumatic event
2. addressing associated unhelpful thoughts and beliefs

Trauma-focussed cognitive behaviour therapy (TF-CBT) is the recommended treatment, which includes:

• Prolonged Exposure (PE)
• Cognitive Processing Therapy (CPT)
• Eye movement desensitisation and reprocessing (EMDR)

Some veterans with PTSD may initially find confronting traumatic memories overwhelming. Practitioners will need to establish a trusting therapeutic relationship to minimise this, and work on stabilising the veteran’s emotions. Stabilisation should address any:

• current life crises
• suicidal and/or homicidal ideation
• substance abuse issues

This would normally be followed by psychoeducation and anxiety management. Before starting treatment that focuses on traumatic memories the practitioner should:

1. explain to the veteran and their family the rationale for treatment
2. tell the veteran and their family that they may feel worse in the short term, before feeling better as treatment takes effect

Ongoing assessments of the client’s functioning, and response to treatment should be performed. This ensures ongoing client consent and the provision of optimal treatment.

Psychoeducation and self-management strategies

When providing psychoeducation it is important to help the veteran to understand their symptoms, as well as to regain a sense of control and hope. It is also important to encourage the veteran to do the following during the stabilisation phase:

• Prioritise spending time with their social supports. Connect with sympathetic family members and friends, and attend local interpersonal community events. Social support is a key factor in preventing deterioration of symptoms and in promoting recovery.
• Reduce substance use. Alcohol and drugs inhibit recovery and substantially contribute to PTSD becoming chronic. Even though they seem to reduce symptoms in the short term. This is a significant issue amongst veterans, with up to 80 per cent of veterans with PTSD developing substance use issues. Early advice on reducing substance use is effective. If benzodiazepines are used, they should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis.
• Use anxiety management strategies. For example breathing retraining, problem solving etc available through self-help tools and the High Res app.
• Maintain (or re-establish) daily routines and current roles. Work and family routines are important for veterans. Specifically those with unstructured time or prominent or long-standing avoidance symptoms.

Trauma-focussed cognitive behaviour therapy

TF-CBT incorporates a range of cognitive behavioural interventions including:

• Imaginal exposure – this teaches veterans to confront traumatic memories in a safe environment. Imaginal exposure continues until the memories no longer create high levels of distress. This approach varies between PE and CPT.
• In vivo exposure – this assists veterans to gradually confront the situations, people or places that they have been avoiding due to the associated distress.
• Cognitive therapy – this addresses unhelpful beliefs and assumptions associated with the trauma. 
• Arousal/anxiety management – this teaches the veteran skills in the physical, cognitive and behavioural domains to reduce arousal and manage other unpleasant symptoms. Skills include aerobic exercise, relaxation and breathing retraining (physical), self-instruction and distraction techniques (cognitive), and activity scheduling (behavioural).

Prolonged exposure (PE)

Prolonged exposure (PE) is a manualised treatment which incorporates:

• psychoeducation about common trauma reactions
• breathing retraining
• in vivo and imagery exposure
• processing of thoughts and feelings related to the exposure sessions

PE is founded on the notion that: the most important thing for recovery is to face, and deal with, the memory of the traumatic event. Rather than push it into the back of the mind. PE assists to gradually face the traumatic memories, and confront situations in a safe way.

The practitioner may use this sample script as a guide to explain the exposure elements of treatment to the veteran and his or her family.

Cognitive processing therapy

Cognitive processing therapy (CPT) focuses on making sense of what happened and why the veteran may have found it difficult to recover. It involves less of an imaginal exposure component than PE. Instead, veterans:

1. write down their narrative of the traumatic event 
2. write down the impact of the traumatic event
3. read the narrative aloud during therapy

There is some indication that this may be particularly useful for relatively mild PTSD. Additional techniques may be required to effectively treat chronic, severe PTSD (Chard et al., 2010).

Eye movement desensitisation and reprocessing

Eye movement desensitisation and reprocessing (EMDR) was originally a form of imaginal exposure. This involved the client moving their eyes across their field of vision while recalling traumatic memories. The technique has evolved over time. EMDR now incorporates aspects of cognitive therapy, exposure, and imaginal rehearsal of future coping and mastery responses.

Group therapy

Group therapy provides veterans the opportunity to share experiences and support each other. Group therapy is useful in addressing trauma-related themes more generally. It is likely to be most useful for delivering the education and symptom management components of treatment. The benefit of group therapy for PTSD has not been established empirically.

Interventions that focus on distressing memories are best done on an individual basis.

The Australian Guidelines for the Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD (Phoenix Australia, 2020) suggest that group TF-CBT may be attempted where individual TF-CBT or EMDR is not possible.

Psychological treatment setting and duration

Psychological treatment should be regular and continuous. The trauma-focussed component of treatment is best delivered at least once a week. Eight to twelve weeks of trauma-focussed treatment is usually sufficient when the PTSD results from a single event. Veterans can expect treatment sessions in which the trauma is discussed to last for about 90 minutes. It may be necessary to extend the duration of trauma-focussed treatment beyond 12 sessions for more complex cases, such as veterans with:

• chronic disability resulting from trauma
• significant comorbid disorders
• significant social problems
• a history of multiple traumatic events

Pharmacological interventions

Medication is not recommended as a routine first-line treatment for PTSD. However, selective serotonin reuptake inhibitor (SSRIs) antidepressants (namely sertraline, paroxetine and fluoxetine), or the serotonin-noradrenaline reuptake inhibitor (SNRI) antidepressant venlafaxine, may be considered as the first pharmacological option when the veteran is unwilling or unable to engage in trauma-focussed psychological treatment. If appropriate psychological therapy is not available, or if it fails to produce a sufficient response.

Other newer generation anti-depressants may need to be used as second line options. In situations of complexity or treatment resistance, antidepressant treatment may need to be augmented with additional medication. Atypical antipsychotics have been used in this role but with limited research evidence base. Prazosin, an adrenergic agent, has been shown to assist in the treatment of PTSD nightmares and insomnia (Raskind et al., 2013).

Treatment of ASD

Within the first month of exposure to trauma, before a diagnosis of PTSD can be made, the recommended course of early intervention is a stepped/collaborative care model which ensures individuals receive ongoing monitoring and care commensurate with the severity and complexity of their individual needs, usually using elements derived from CBT and motivational interviewing (Phoenix Australia, 2020). Pharmacotherapy is not generally recommended, and there is no evidence to suggest that pharmacotherapy for ASD can prevent the onset of PTSD.

See also