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About posttraumatic stress disorder
Posttraumatic stress disorder (PTSD) is a serious psychological reaction that develops in some people following an experience of a traumatic event, such as combat, assault, sexual assault, natural disaster, an accident or torture. Most people have some kind of psychological reaction to trauma — feelings of fear, sadness, guilt and anger are common. However, most survivors recover over time, with only a small proportion developing serious problems including PTSD. Prevalence estimates vary widely, however it is likely that between 5 and 20 per cent of veterans will develop PTSD in their lifetime (Ikin et al., 2004; O’Toole et al., 1996). 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, with depression, generalised anxiety and substance use also commonly experienced following trauma. PTSD is a complex disorder that can present quite differently in different people. In all cases, however, there are symptoms present from each of the groups or clusters outlined below:
- Intrusions or re-experiencing symptoms, e.g., distressing memories or dreams related to the traumatic event; distress and/or physiological reactions to reminders of the trauma; and more rarely, flashbacks and other dissociative reactions.
- Persistent avoidance of 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, e.g., 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’, e.g., irritable or self-destructive behaviour, hypervigilance, exaggerated startle response, or problems with sleep or concentration.
Some symptoms of PTSD, particularly arousal symptoms such as hypervigilance, exaggerated startle response and anger, might not be recognised by veterans as problematic. These responses may have been adaptive in deployment circumstances and may have even served a critical role in the veteran’s survival. It may be helpful to acknowledge this and emphasise that these responses can become problematic when they arise in circumstances when they are no longer needed and when they interfere with day-to-day civilian life.
About acute stress disorder
PTSD is diagnosed if symptoms persist for at least one month after a traumatic experience. For veterans presenting with posttraumatic distress between three days and one month after a trauma, a diagnosis of acute stress disorder (ASD) may be considered. Although similar to PTSD in many ways, ASD has traditionally placed a greater emphasis on dissociative symptoms such as feeling ‘in a daze’ or having an altered sense of reality. It should be noted, however, that the emphasis on dissociative symptoms is no longer considered critical. Thus, the key distinguishing feature between the two disorders is the duration of symptoms required for the diagnosis to be made. There is strong evidence that early treatment of traumatic stress symptoms leads to better outcomes for veterans (O'Donnell, Bryant, Creamer, Carty, 2008).
Screening and assessment
Untreated PTSD can become a chronic disabling disorder, so screening, early assessment and treatment are critical, even for those veterans who do not meet full criteria for diagnosis. Use of the Primary Care PTSD Screen (PC-PTSD; Prins et al., 2003) is recommended. The screen poses the following questions: In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you:
- have had nightmares about it or thought about it when you did not want to?
- tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
- were constantly on guard, watchful, or easily startled?
- felt numb or detached from others, activities, or your surroundings?
Current research suggests that a veteran may have PTSD or trauma-related problems if they answer “yes” to any two items. Further assessment of the veteran’s PTSD symptoms can be conducted using the PTSD Checklist for DSM-5 (Weathers, Litz, Keane, Palmieri, Marx and Schnurr, 2013). See Appendix C or www.at-ease.dva.gov.au for the complete PCL measure, administration and scoring instructions.
Important assessment considerations
As part of a thorough clinical assessment of PTSD particular attention should be paid to the following issues:
- Many veterans have experienced a range of traumatic events including childhood trauma. It is therefore important to conduct a thorough history of traumatic experience/s.
- Because PTSD has a significant impact on functioning and relationships, broader quality of life indicators such as marital and family situation and occupational, legal and financial status should be investigated.
- Physical health is also an important consideration, including issues related to injury and health behaviour change arising from the traumatic incident.
- Because of the sustained nature of some traumatic experiences, people presenting for treatment may still be facing ongoing threat and be at risk of further exposure to trauma. For example, currently serving members about to be re-deployed and people facing ongoing bullying in the workplace may have to return to unsafe environments.
PTSD and comorbidity
Comorbidity is common, with depression, substance misuse and generalised anxiety the most likely disorders to present with PTSD amongst veterans. Thus, 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. Individuals who have experienced prolonged or repeated traumatic events, such as prisoners of war, or survivors of childhood sexual abuse, are more likely to experience a number of problems often associated with PTSD such as substance use or impaired emotional regulation.
Treatment of PTSD
Recommended treatments for PTSD focus on confronting the memories and reminders of the traumatic event, as well as addressing associated unhelpful thoughts and beliefs. They include trauma-focussed cognitive behaviour therapy (TF-CBT) and eye movement desensitisation and reprocessing (EMDR). Some PTSD veterans 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 and substance abuse issues. This would normally be followed by psychoeducation and anxiety management prior to attempting to confront the traumatic memories and reminders.
Before starting treatment that focuses on traumatic memories, the practitioner should take care to explain the rationale at the outset and advise the veteran and their family that they may feel worse in the short term, before they begin to feel better as treatment takes effect. Importantly, consistent with general principles of good clinical care, practitioners need to perform ongoing assessments of the client’s functioning and response to treatment, to ensure ongoing client consent and the provision of optimal treatment. Information on self-management strategies to be conveyed to the veteran and his or her family is included in the following text box.
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 and reconnecting with their social supports, e.g., sympathetic family members and friends, and local interpersonal community activities. There is strong evidence that social support is a key factor in preventing deterioration of symptoms and in promoting recovery.
- Reduce substance use. While alcohol and drugs may alleviate distress in the short term, they inhibit recovery and substantially contribute to PTSD becoming chronic. 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, e.g., breathing retraining, problem solving, etc. Veteran handouts are provided in Appendix H and Appendix I, and another useful resource for veterans is the High Res website (www.at-ease.dva.gov.au/highres and app.
- Maintain (or re-establish) daily routines and current roles (e.g., work, family). This is particularly important for veterans who have a lot of unstructured time or have prominent or long-standing avoidance symptoms.
Trauma-focussed cognitive behaviour therapy
TF-CBT is the recommended treatment for PTSD and has been shown to be effective regardless of the time that has elapsed since the trauma. TF-CBT incorporates a range of cognitive behavioural interventions including:
- Imaginal exposure – This teaches veterans to confront traumatic memories in a safe environment, until the memories no longer create high levels of distress.
- 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. Cognitive therapy may be an appropriate first-line treatment for veterans who have significant difficulty tolerating the high levels of arousal that occur during the exposure interventions above, and for those for whom strong feelings of guilt or anger are more prominent than anxiety or fear.
- 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). Arousal management can be used to support other interventions, such as exposure, or as a first-line treatment in itself, where the veteran is unresponsive to, or not yet stable enough for, more intensive treatments.
The practitioner may use the following script as a guide to explain the exposure elements of treatment to the veteran and his or her family:
“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 your mind. Because the memory can cause intense fear, anxiety and distress, people often want to escape or avoid anything associated with the event. Although avoidance provides temporary relief, it is one of the main reasons why people don’t recover. When people start relying on avoidance to cope, they have no opportunity to develop skills that will help them feel safe or comfortable when faced with reminders of the traumatic event. The anxiety then starts to spread to other areas of their lives.
To overcome this, therapy will help you to face the traumatic memories and confront situations, people or places that you have avoided since the event, in a safe way. I will encourage you to gradually recall and think about your traumatic memories until they no longer create high levels of distress. This is called ‘imaginal exposure’. You can do this at your own pace and we will discuss skills to manage any distress. I will also help you to go into situations that you want to avoid, because they remind you of the trauma or trigger anxiety (this is called ‘in vivo exposure’). You will learn skills to help you to achieve important goals, e.g., to start driving a car again after being involved in a car accident, or to go back to work when the trauma occurred in your workplace. We will take things slowly, help you gain control of your fears step by step, and make sure that you never feel overwhelmed by your feelings.”
Eye movement desensitisation and reprocessing
EMDR was originally designed as a form of imaginal exposure that involved the client moving their eyes back and forth across the field of vision while recalling traumatic memories. The technique has evolved over time to incorporate aspects of cognitive therapy, exposure, and imaginal rehearsal of future coping and mastery responses.
Cognitive processing therapy
Veterans can sometimes become stuck on thoughts about the trauma and its ongoing effect on their life. 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 TF-CBT. Instead, veterans write down their narrative of the traumatic event and its impact, and read the narrative aloud during therapy. CPT has been less thoroughly researched than TF-CBT but evidence to date is promising, particularly in veteran populations. There is some indication that it may be particularly useful for younger veterans and older veterans with relatively mild PTSD, while additional techniques may be required to effectively treat chronic, severe PTSD (Chard, Schumm, Owens, Cottingham, 2010).
Imagery rehearsal therapy
Several studies with promising results have examined imagery rehearsal therapy (IRT) for the treatment of PTSD, in particular for nightmare and sleep disruption symptoms (Long et al., 2011; Nappi, Drummond, & Hall, 2012). This therapy targets posttraumatic nightmares and may be a useful starting point for veterans, who, given the stigma surrounding mental health problems in the military, may be more amenable to receiving treatment for nightmares than for PTSD. In addition to several CBT elements (e.g., psychoeducation, cognitive challenging), IRT involves the veteran constructing an overlapping but alternate and positive script of the nightmare, which promotes a sense of mastery or completion. This alternate script is then rehearsed through reading and imagery.
Although the benefit of group therapy for PTSD has not been established empirically, it may offer an advantage over individual treatment alone in providing the opportunity for veterans to share their experiences and support each other in treatment. It is likely to be most useful for delivering the education and symptom management components of treatment. Group therapy is potentially also useful in addressing trauma-related themes more generally, where veterans are able to share their thoughts about these issues with each other. However, more targeted trauma-focussed interventions, focussing on the more distressing memories, are best done on an individual basis.
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.
Medication is not recommended as a routine first-line treatment for PTSD, however selective serotonin reuptake inhibitor (SSRIs) antidepressants may be considered as the first pharmacological option when the veteran is unwilling or unable to engage in trauma-focussed psychological treatment, when 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
The provision of psychoeducation is an important first step in the treatment of ASD. There is some evidence that brief CBT, including exposure and cognitive challenging, can be useful for veterans with a diagnosis of ASD. Pharmacotherapy is not generally recommended, and there is no evidence to suggest that pharmacotherapy for ASD can prevent the onset of PTSD.
Referral and coordinated care
- VVCS - Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours a day on 1800 011 046. (www.vvcs.gov.au)
- Psychiatrist: for specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at http://www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
- If hospitalisation is required, there are veteran specific mental health wards and treatment programs. To find out their location phone DVA on 133 254 or 1800 555 254.
- A treatment plan should be developed collaboratively with the veteran and his or her family, and coordinated across service providers.
- Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).
- There is also a range of DVA-funded PTSD inpatient and outpatient programs. Phone 133 254 or 1800 555 254.
- Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
- The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.
- Australian Centre for Posttraumatic Mental Health (2013). Recovery after Trauma: A Guide for People with Posttraumatic Stress Disorder. Melbourne: ACPMH. Available to download from www.phoenixaustralia.org.
- Phoenix Australia: Centre for Posttraumatic Mental Health website (www.phoenixaustralia.org) for fact sheets and treatment guidelines.
- DVA has developed an Australian PTSD Coach smartphone app.
- Australian Centre for Posttraumatic Mental Health (2013). Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder: Guidelines Summary. Melbourne: ACPMH. Available for download from www.phoenixaustralia.org.
- Australian Centre for Posttraumatic Mental Health (2007). Treating Traumatic Stress: Conducting Imaginal Exposure in PTSD. Clinician manual and DVD. Melbourne: ACPMH. It is available for purchase from www.phoenixaustralia.org.
This Advice Book has the following resources in the appendices that may be useful for veterans who are experiencing symptoms of PTSD:
- further explanation of CBT elements (Appendix B)
- the PCL-M to assess the veteran’s PTSD symptoms (Appendix C)
- PTSD psychoeducation handout for veteran and general psychoeducation script outline (Appendix D & Appendix L)
- self-monitoring sheets including the distress thermometer (SUDS) and daily activity schedule (Appendix E)
- pleasant events list (Appendix F)
- progressive muscle relaxation (Appendix G)
- breathing retraining instructions (Appendix H)
- information on where veterans can get more help, e.g., Veterans Line, DVA funded psychological and rehabilitation services (Appendix J).
The DVD accompanying this Advice Book includes an example of a practitioner introducing imaginal exposure to their client.