Treatment of victims of trauma

Not all traumatic events cause post-traumatic stress disorder (PTSD), and people develop PTSD symptoms after events that do not seem to be overwhelmingly traumatic. In order to direct services appropriately, there is a need to distinguish time-limited post-traumatic symptoms and acute stress reactions (that may improve spontaneously without treatment or respond to discrete interventions) from PTSD, with its potentially more chronic pathway and possible long-term effects on the personality. In this article, we describe acute and chronic stress disorders and evidence about the most effective treatments.

This is an update of a paper originally published 7 years ago (Adshead, 2000). Since then there has been increased interest in post-traumatic stress disorder (PTSD). As the world appears to enter a more uncertain period, attention is being paid to the psychological aftermath of terrorism and natural disasters. However, as the language of PTSD has entered the general lexicon, there is a danger of dilution of the meaning of the term and symptoms. Following the terrorist attack in New York on 11 September 2001, probable PTSD was reported in 7.5% of New Yorkers, many of whom had no direct involvement in the attacks (Galea et al, 2003).

Prevalence of PTSD
The prevalence of PTSD within a community will depend to some extent on the prevalence of traumatic events in the life of that community. The National Comorbidity Survey in the USA found the estimated lifetime prevalence of PTSD among adult Americans to be 8%, with women (10%) twice as likely as men (5%) to have PTSD at some point in their lives (Kessler et al, 1995). However, this represents only a small portion of those who have experienced at least one traumatic event: 60% of men and 51% of women reported at least one traumatic event. The most frequently reported traumas were witnessing someone being badly injured or killed, being involved in a natural disaster or life-threatening accident, and combat exposure. In this National Comorbidity Survey (which presents the largest data-set and longest follow-up, albeit with retrospective assessments), the rate of PTSD declined at a relatively constant rate over 12 months, with a more gradual decline over 6 years.

Using DSM–IV criteria in a population from Munich, Perkonigg et al(2000) found a much lower lifetime incidence of traumatic events: 25% in men and 18% in women. The current rate of PTSD was 1% in males and 2% in females. However, in parts of the world where there have been recent conflicts the rates of PTSD can be as high as 38%. These data suggest that it is important to consider context when discussing the prevalence of PTSD in the community, since not all ‘communities’ are the same.

Normal responses to trauma
There is clearly nothing abnormal about feeling bad when bad things happen. It is equally clear that acute psychological stress reactions, however normal, are extremely distressing and uncomfortable. The best analogy is that of the fractured limb: the pain is entirely normal but may be treated none the less. DSM–IV (American Psychiatric Association, 1994) and ICD–10 (World Health Organization, 1992) recognise acute stress reactions as diagnostic entities. The features of normal stress reactions are described in Box 1Go, and DSM–IV criteria for PTSD and acute stress disorder are summarised in Table 1Go. It appears that most people who survive a traumatic event will make a spontaneous, if painful recovery. Only a minority will develop PTSD and related disorders (about 25–40%; Green, 1993). However, the unpleasantness of normal acute stress reactions should not be underestimated, and clinicians might need to remind families of this. Recovery is the norm but may be delayed where there is further stress.

Acute stress disorder is a relatively new diagnosis which involves a shorter timescale and the presence of dissociative symptoms (Table 1Go). Studies of survivors of motor vehicle accidents have found rates of acute stress disorder ranging from about 13% (Harvey & Bryant, 1998) to 21% (Holeva et al, 2001). Higher rates are found for victims of violence (Classen et al, 1998; Elklit, 2002).

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Gwen Adshead and Scott Ferris

Gwen Adshead is Consultant Forensic Psychotherapist at Broadmoor Hospital (Dadd Centre, Crowthorne, Berkshire RG45 7EG, UK. Email: gwen.adshead@wlmht.nhs.uk). Her research interests include psychiatric ethics, moral reasoning in psychiatry and attachment histories in abusive parents. Scott Ferris is Specialist Registrar in Psychotherapy at Forest House, Walthamstow, London and was previously Specialist Registrar in Forensic Psychiatry working in the trauma service at St George’s Hospital, London. His other research interests include attachment and offence representations.