Professional Documents
Culture Documents
doi:10.1093/occmed/kqm069
IN-DEPTH REVIEW
...............................................................................................................................................................................................
Abstract Post-traumatic stress disorder (PTSD) is an increasingly recognized and potentially preventable
condition. Certain factors, especially the severity of the trauma, perceived lack of social support
and peri-traumatic dissociation have been associated with its development. In recent years, a more
robust evidence base regarding the management of individuals involved in traumatic events has
emerged. Immediately after a traumatic event, simple practical, pragmatic support provided in
Key words Cognitive behavioural therapy; eye movement desensitization and reprocessing; medication; post-
traumatic stress disorder; PTSD; trauma-focused psychological treatment.
...................................................................................................................................................................................
The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
400 OCCUPATIONAL MEDICINE
symptom criteria to PTSD but with more emphasis on associations of PTSD with the factors shown in Box 2.
dissociation. Acute PTSD becomes chronic if it contin- Those most associated with PTSD were perceived lack of
ues beyond 3 months. Symptoms usually begin shortly social support and peri-traumatic dissociation, although
after the trauma but are said to have delayed onset if they even these had an effect size of ,0.5. Other possible pre-
commence at least 6 months later. dictors such as increased heart rate after trauma have
been shown to be associated with the development of
PTSD but are not very discriminating (e.g. [15]). The
Prevalence and course possibility of detecting individuals who will go on to de-
velop PTSD has led to attempts to predictively screen
The United States National Co-Morbidity survey [6] shortly after a traumatic event. Several screening instru-
found that of 5877, 15–54 year olds just .60% of males ments for chronic PTSD have been developed (see [16]
and just .50% of females have been exposed to traumatic for review). The 10-item Trauma Screening Question-
events with lifetime prevalence of PTSD of just .10% for naire (TSQ) [17] is one of the best validated. Walters
females and 5% for males. Over a third of individuals
Interventions for everyone is emerging evidence for TFCBT provided 1–3 months
following the trauma to individuals who are symptomatic.
This evidence resulted in the UK’s National Institute for
Single session psychological interventions
Health and Clinical Excellence’s guidelines (NICE) [19]
Twelve randomized controlled trials of single session recommending that immediate practical, social and
psychological interventions have been published, most emotional support are offered to individuals following
commonly variants of critical incident stress debriefing traumatic events but that individuals are not debriefed.
[21]. Meta-analysis provides no evidence of a positive The guidelines state that acute phase symptomatic phar-
overall effect. Some studies have raised the possibility that macological management could be considered using hyp-
single session individual debriefing may cause harm to notics or anti-depressants, for example for marked
some individuals [22,23]. The only study of group insomnia. They also recommend that TFCBT be offered
debriefing [24] gave neutral results. A recently published to individuals within 1 month if they are suffering from
dismantling study showed that individuals who received severe symptoms of PTSD or within 3 months if they are
by the NICE guideline development group as being clin- individuals with PTSD symptoms within a few months
ically significant. The other drugs were not statistically of the trauma. This approach should be refined, as should
significantly better than placebo (sertraline, fluoxetine, the detection of symptomatic individuals. Indeed, as
imipramine, venlafaxine and olanzapine). However, there hoped with the trauma risk management model [36],
was some evidence that olanzapine, if added to an the optimal way of detecting and treating most people
anti-depressant, was better than adding a placebo to aug- may be to educate those who are most likely to be in
ment treatment in chronic PTSD sufferers who had not contact with them about the recognition of problematic
fully responded to anti-depressant medication alone. responses such as friends, families, work colleagues,
managers, general practitioners and occupational health
practitioners.
Clinical implications for the
management of chronic PTSD
The NICE guidelines recommended that all chronic Conflicts of interest
13. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk trauma, a randomised controlled trial. Br J Psychiatry
factors for posttraumatic stress disorder in trauma-exposed 2006;189:150–155.
adults. J Consult Clin Psychol 2000;68:748ÿ766. 26. Campfield K, Hills A. Effect of timing of critical incident
14. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of post- stress debriefing (CISD) on posttraumatic symptoms.
traumatic stress disorder and symptoms in adults: a meta- J Trauma Stress 2001;14:327–340.
analysis. Psychol Bull 2003;129:52–73. 27. Small R, Lumley J, Donohue L, Potter A, Walderstrom U.
15. Shalev A, Sahar T, Freedman S et al. A prospective study of Mid-wife-led debriefing to reduce maternal depression fol-
heart rate response following trauma and the subsequent lowing operative birth: a randomised controlled trial. Br
development of posttraumatic stress disorder. Arch Gen Med J 2000;321:1043–1047.
Psychiatry 1998;55:553–559. 28. Schelling G, Briegal J, Roozendaal B, Stoll C, Rothenhaus-
16. Brewin CR. Systematic review of screening instruments for ler H, Kapfhammer H. The effect of stress doses of hydro-
adults at risk of PTSD. J Trauma Stress 2005;18:53–62. cortisone during septic shock on posttraumatic stress
17. Brewin CR, Rose S, Andrews B et al. Brief screening in- disorder in survivors. Biol Psychiatry 2001;50:978–985.
strument for post-traumatic stress disorder. Br J Psychiatry 29. Pitman RK, Sanders KM, Zusman RM et al. Pilot study of