Assessment
These are the approved guidelines published by the South African Society of Psychiatrists to provide an overview on treatment and management of commonly diagnosed psychiatric illnesses. The guidelines include consensus recommendations, based on peer contribution and using the international evidence based guidelines that are suitable for the local South African health service.
Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
As a general rule, a comprehensive review of the differential diagnosis of the anxiety symptoms should be done, ruling out or treating other psychiatric diagnoses and medical causes. Thus, as part of the initial diagnostic assessment, and after each subsequent treatment trial, should response to treatment be unsatisfactory, it is important to evaluate symptoms associated with PTSD (e.g. insomnia, aggression, nightmares, suicidality, psychotic symptoms).
Other considerations include comorbid diagnoses (including depression, other anxiety disorders, substance abuse, bipolar disorder), other issues such as concurrent medical illness especially that which may be undiagnosed (e.g. thyroid disease), ongoing trauma, and legal/compensation issues, ongoing use of anxiety-producing substances (e.g. caffeine, other stimulants), pregnancy, and poor adherence to treatment.[7] Those with PTSD, with and without depression, are at increased risk for suicidality, and it is important to assess suicide risk both at the initial evaluation and subsequent follow-up visits.[7]
Longitudinal studies indicate that PTSD is a disorder of chronicity in that symptoms appear shortly after the traumatic event, subside in many individuals, but can persist in as many as 40% in the form of chronic PTSD.[5] Given that a significant number of cases of PTSD are undiagnosed and under treated, it is important to inquire about exposure to trauma, and to maintain a high index of suspicion and a high level of awareness of the disorder.
Patients with PTSD are frequent users of general medical and psychiatric services, have high rates of coexisting psychiatric (e.g. major depressive disorder, alcohol and drug use disorders, other anxiety disorders) and medical conditions (e.g. asthma, gastrointestinal disorders), and, as already mentioned, are at a high risk for suicide attempts.[8,9] These comorbid diagnoses may complicate proper diagnosis and alter the course of treatment.
The disorder is also highly reactive to environmental reminders of the traumatic event and to subsequent stressful life events and can therefore have a fluctuating course.