Occupational Medicine 2007;57:399403

doi:10.1093/occmed/kqm069

IN-DEPTH REVIEW
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Post-traumatic stress disorder

Jonathan I. Bisson
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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

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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
a sympathetic manner by non-mental health professionals seems most likely to help. For individuals
who develop persisting PTSD, trauma-focused cognitive behavioural therapy (TFCBT) may be
beneficial within a few months of the trauma. For those who develop chronic PTSD, TFCBT and
eye movement desensitization and reprocessing are best supported by the current evidence. Some
anti-depressants appear to have a modest beneficial effect and are recommended as a second-line
treatment. The current evidence base has allowed the development of guidelines that now require
implementation. This has major implications in terms of planning and developing services that allow
appropriately qualified and trained individuals to be available to cater adequately for the needs of
survivors of traumatic events.
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Key words Cognitive behavioural therapy; eye movement desensitization and reprocessing; medication; post-
traumatic stress disorder; PTSD; trauma-focused psychological treatment.
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Introduction Box 1. Characteristic symptoms of PTSD adapted

from DSM IV [5]
Despite many accounts of apparent post-traumatic stress
disorder (PTSD) over the last few centuries (e.g. [1,2]), it Re-experiencing Phenomena (at least one
was only formally recognized as a psychiatric disorder in required)
the third edition of the Diagnostic and Statistical Manual Recurrent and intrusive distressing recollections
of Mental Disorders [3]. The criteria for PTSD have Recurrent distressing dreams
been refined in subsequent editions and it was first in- Acting or feeling as if events recurring
cluded in the 10th edition of the International Classifica- Intense psychological distress to cues
tion of Diseases [4]. Its characteristic features are Physiological reactivity to cues
displayed in Box 1. In order to satisfy the DSM IV criteria
[5], an individual has to be exposed to a traumatic event Avoidance and numbing (at least three
that involves actual or threatened death or serious injury, required)
or a threat to the physical integrity of self or others. It is Avoidance of thoughts, feelings and conversations
also essential that the individual experience a response at Avoidance of reminders
the time that involves intense fear, helplessness or horror. Psychogenic amnesia
The symptoms must have been present for at least Markedly diminished interest in significant
1 month (the 1 month does not apply in the ICD10 classi- activities
fication) and cause clinically significant distress or im- Detachment or estrangement feelings
pairment in social, occupational or other important Restricted range of affect
areas of functioning. Acute stress disorder (ASD) occurs Sense of a foreshortened future
within 1 month of a traumatic event and has similar Increased arousal (at least two required)
Sleep difficulty
Department of Psychological Medicine, Cardiff University, Monmouth House, Irritability or outbursts of anger
University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
Difficulty concentrating
Correspondence to: Jonathan I. Bisson, Department of Psychological Medicine, Hypervigilance
Cardiff University, Monmouth House, University Hospital of Wales, Heath Park,
Cardiff CF14 4XW, UK. Tel: 144 29 2074 4534; fax: 144 29 2074 2284; Exaggerated startle response
e-mail: bissonji@cardiff.ac.uk.

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
dissociation. Acute PTSD becomes chronic if it contin-
ues beyond 3 months. Symptoms usually begin shortly
after the trauma but are said to have delayed onset if they
commence at least 6 months later.
Prevalence and course
The United States National Co-Morbidity survey [6]
found that of 5877, 1554 year olds just .60% of males
and just .50% of females have been exposed to traumatic
events with lifetime prevalence of PTSD of just .10% for
females and 5% for males. Over a third of individuals
reported having PTSD 6 years after they developed it.
There was a 50% chance of remission at 2 years. In the
recently published replication of this work [7,8], the life-
time prevalence was 6.8% and the 12-month prevalence
was 3.5%. PTSD is often co-morbid with other psychi-
atric disorders. Over 80% of participants with lifetime
PTSD in the United States National Co-Morbidity sur-
vey [6] had at least one other disorder. The commonest
co-morbid diagnoses are major depressive disorder, panic
disorder, other anxiety disorder and substance abuse or
dependence. In the National Vietnam Veterans readjust-
ment survey [9], there was a 99% lifetime co-morbidity.
Immediate reactions following trauma
Exposure to a traumatic event can result in a wide range
of reactions. The focus has often been on pathological
reactions and the development of psychiatric disorders
such as PTSD but more recently resilience has been in-
creasingly recognized as a common response (e.g. [10]).
The majority of distressing reactions settle over a matter
of weeks or months with a minority developing into a di-
agnosable psychiatric disorder, such as PTSD but also
others including depression, anxiety disorders and sub-
stance misuse. Higher impact trauma is more likely to
precipitate a distressing response. Rothbaum and Foa
[11] found that .90% of female rape victims satisfied
the symptom criteria for PTSD within a week of the event
and 40% at 6 months. Following the September 11th
terrorist attacks in New York, Galea et al. [12] found that
probable PTSD reduced from 7.5% after 1 month to
0.6% 6 months afterwards among over a 1000 residents
of New York. The rates were highest among those who
lived closest to the site of the attacks. This recovery tra-
jectory is all important in considering how best to provide
for individuals following traumatic events.
Predicting the development of PTSD
It is difficult to predict exactly who will go on to develop
PTSD after a traumatic event. Two large systematic
reviews [13,14] have found relatively weak but positive
associations of PTSD with the factors shown in Box 2.
Those most associated with PTSD were perceived lack of
social support and peri-traumatic dissociation, although
even these had an effect size of ,0.5. Other possible pre-
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
possibility of detecting individuals who will go on to de-
velop PTSD has led to attempts to predictively screen
shortly after a traumatic event. Several screening instru-
ments for chronic PTSD have been developed (see [16]
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for review). The 10-item Trauma Screening Question-
naire (TSQ) [17] is one of the best validated. Walters
et al. [18] considered the TSQ as a predictive screening
instrument with victims of violent crime 13 weeks after
the assault. Very high rates of sensitivity (0.85) and spec-
ificity (0.89) were found but a much lower positive pre-
dictive value (0.48) meaning that although it detected the
vast majority of PTSD sufferers at 1 month, 50% of those
who screened positive did not develop PTSD. It remains
to be seen whether a predictive screening instrument can
be developed that will be practical and acceptable in the
future.
Box 2. Predictive factors
Pre-traumatic risk factors
Previous psychiatric disorder
Gender (female greater than male)
Personality (external locus of control greater than
internal locus of control)
Lower socioeconomic status
Lack of education
Race (minority status)
Previous trauma
Family psychiatric history
Peri-traumatic risk factors
Trauma severity
Perceived life threat
Peri-traumatic emotions
Peri-traumatic dissociation
Post-traumatic risk factors
Perceived lack of social support
Subsequent life stress
Prevention of PTSD
Several systematic reviews of early interventions follow-
ing traumatic events have been published in the last few
years (e.g. [19,20]). Two main approaches have been
consideredinterventions for everyone involved and
interventions targeted at individuals who remain symp-
tomatic after a certain amount of time.

Interventions for everyone
Single session psychological interventions
Twelve randomized controlled trials of single session
psychological interventions have been published, most
commonly variants of critical incident stress debriefing
[21]. Meta-analysis provides no evidence of a positive
overall effect. Some studies have raised the possibility that
single session individual debriefing may cause harm to
some individuals [22,23]. The only study of group
debriefing [24] gave neutral results. A recently published
dismantling study showed that individuals who received
an emotional debriefing fared worse than those who re-
ceived a debriefing that did not contain the emotional
components but focused on education, particularly in
individuals who were more markedly hyper aroused
[25]. A trend for individuals who were more traumatized
to do worse with debriefing has been found in other studies
and two of the debriefing studies that produced positive
outcomes excluded more traumatized individuals [26,27].
Early pharmacological interventions
There have been three randomized controlled trials of
early pharmacological interventions following traumatic
events. Schelling et al. [28] found that early administra-
tion of intravenous hydrocortisone in 20 septic shock vic-
tims on an intensive care unit in Switzerland resulted in
lower rates of PTSD at 31-month follow-up compared to
placebo. These results are particularly interesting given
the suggestion that low cortisol levels may mediate the
development of PTSD. Propranolol [29] and temazepam
[30] did not reduce PTSD development.
Targeted interventions
Psychological
Given the disappointing results of one-off interventions,
several researchers have advocated using more complex
interventions for individuals who develop more symp-
toms. The most researched interventions have been
trauma-focused cognitive behavioural therapy (TFCBT)
occurring over 412 sessions containing components
such as education, relaxation, imaginal exposure, in vivo
exposure and cognitive restructuring. Overall, the studies
have produced positive results for sufferers of ASD
[31,32], acute PTSD [33] and symptoms of PTSD [34].
Clinical implications for prevention
At present there is no convincing evidence for any inter-
vention for everyone involved in a traumatic event. There
J. I. BISSON: POST-TRAUMATIC STRESS DISORDER 401
is emerging evidence for TFCBT provided 13 months
following the trauma to individuals who are symptomatic.
This evidence resulted in the UKs National Institute for
Health and Clinical Excellences guidelines (NICE) [19]
recommending that immediate practical, social and
emotional support are offered to individuals following
traumatic events but that individuals are not debriefed.
The guidelines state that acute phase symptomatic phar-
macological management could be considered using hyp-
notics or anti-depressants, for example for marked
insomnia. They also recommend that TFCBT be offered
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to individuals within 1 month if they are suffering from
severe symptoms of PTSD or within 3 months if they are
suffering from acute PTSD, and that the sessions should
normally be over 812 sessions, with some sessions of 90
min duration.
Management of chronic PTSD
Most chronic PTSD sufferers presenting for treatment
will receive medication [35]. Many will also receive some
form of psychological treatment, although there are often
long waits for such treatment.
Evidence for psychological treatment
Various psychological treatments have been tested in ran-
domized controlled trials. The NICE guidelines [19] sep-
arated the treatments into individual TFCBT, group
CBT, stress management, eye movement desensitization
and reprocessing (EMDR) and other therapies which in-
cluded supportive therapy, non-directive counselling,
psychodynamic therapies and hypnotherapy. TFCBT
and EMDR fared better than the other therapies. Fewer
individuals were included in the EMDR studies but the
studies that directly compared the two found no evidence
that one of these trauma-focused therapies was better
than the other. Stress management fared slightly worse
than the trauma-focused therapies with the other thera-
pies and group cognitive behavioural therapy faring worse
still. There was a trend for all therapies to perform better
than a waiting list control but only TFCBT and EMDR
reached a pre-determined threshold set by the NICE guide-
line development group as being clinically significant.
Evidence for pharmacological treatment
Various drug treatments have been tested in randomized
controlled trials with more chronic PTSD sufferers en-
tered into randomized controlled drug trials than psycho-
logical ones. Paroxetine, mirtazapine, amitryptyline and
phenelzine all fared statistically significantly better than
placebo, although the last three only included small sam-
ple sizes. No drug reached a pre-determined threshold set
402 OCCUPATIONAL MEDICINE
by the NICE guideline development group as being clin-
ically significant. The other drugs were not statistically
significantly better than placebo (sertraline, fluoxetine,
imipramine, venlafaxine and olanzapine). However, there
was some evidence that olanzapine, if added to an
anti-depressant, was better than adding a placebo to aug-
ment treatment in chronic PTSD sufferers who had not
fully responded to anti-depressant medication alone.
Clinical implications for the
management of chronic PTSD
The NICE guidelines recommended that all chronic
PTSD sufferers should be offered a course of TFCBT
or EMDR, normally on an individual outpatient basis
regardless of time since trauma. Again, they recommen-
ded 812 sessions with some at 90 min if the trauma is
considered during the session. The guidelines also ac-
knowledged that the number of sessions may need to be
increased, particularly following multiple traumatic
events and if there was co-morbidity or traumatic be-
reavement. If individuals did not improve or showed only
little improvement, they were advised to consider an al-
ternative trauma-focused treatment or augmentation
with pharmacological treatment. Drug treatments were
not recommended as routine first-line treatment. A lim-
ited role for paroxetine and mirtazapine was suggested if
prescribed by non-specialists, with amytriptyline and
phenelzine being prescribed by mental health specialists.
Other issues that may precipitate prescription of medica-
tion include patient choice and serious ongoing threat.
In reality, medication is often prescribed as a result of
lack of immediate availability of psychological treatment
but caution is required, not least because of the well-
documented issues with paroxetine in recent years.
Conclusions
It is encouraging that there now exist effective trauma-
focused psychological treatments for chronic PTSD and
promising trauma-focused psychological treatments for
acute PTSD. Unfortunately, no existing treatment is
ideal and there is clearly a great need to develop more
effective and more tolerable treatments for PTSD. The
results of early interventions directed at everybody have
been very disappointing and should encourage anybody
involved in providing a response following a traumatic
event to exercise extreme caution before providing a for-
mal intervention. Simple, practical, pragmatic support
provided in a sympathetic manner by non-mental health
professionals seems most likely to be the best first-line
response but needs better evaluation. Lessons provided
by the existing research should be heeded and inform our
approach in the future. There is emerging evidence that
targeted trauma-focused interventions are effective for
individuals with PTSD symptoms within a few months
of the trauma. This approach should be refined, as should
the detection of symptomatic individuals. Indeed, as
hoped with the trauma risk management model [36],
the optimal way of detecting and treating most people
may be to educate those who are most likely to be in
contact with them about the recognition of problematic
responses such as friends, families, work colleagues,
managers, general practitioners and occupational health
practitioners.
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Conflicts of interest
None declared.
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