Trauma and Stress-Related Disorders

Description

General measures

Medicine treatment

Referral

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ICD-10 code: F43.0/F43.1/F43.2/F43.8-9 + (Z55-Z65) 

Description

Acute stress and post-traumatic stress disorder arise in response to stressful events. The patient should have experienced the event as life threatening or as a physical threat to themselves or others, at which time they felt fear and helplessness.

A range of symptoms are associated with both of these conditions and include:

• Re-experiencing of the event, e.g. flashbacks, dreams.
• Avoidance of situations associated with the event.
• Features of anxiety or increased arousal, e.g. hypervigilance, heightened startle response and insomnia.

The conditions are symptomatically similar but differ with regard to the duration and time of onset of symptoms. The symptoms of acute stress disorder arise within 4 weeks of the event and last up to 4 weeks, whereas the symptoms of posttraumatic stress disorder last longer than 4 weeks and may arise more than 4 weeks after the traumatic incident.

General Measures

• Provide reassurance and support of patient and family.
• Assess risk to patient’s safety: refer to police, social welfare and/or legal services as needed to ensure immediate safety.
• If patient has an ongoing/recent crisis: refer to social worker or registered counsellor for emotional containment and stress management.
• Psychotherapy, usually of a supportive / cognitive-behavioural nature.
• Trauma debriefing is not routinely recommended.

Medicine Treatment

Acute stress disorder:

• Benzodiazepines may be useful in the immediate period following the traumatic event.
• Prolonged use > 1 week may be detrimental to adaptation, leading to higher rates of post-traumatic stress disorder.

For acute anxiety or agitation:

• Clonazepam, oral, 0.5–2 mg per day in 3 divided doses.

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For sleep disturbance: See Insomnia.

Post-traumatic stress-disorder:

• Selective serotonin reuptake inhibitors, e.g.:
• Citalopram, oral, initial dose 20 mg daily.

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OR

• Fluoxetine, oral, initial dose 20 mg in the morning.

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Note:
- A response to SSRI should be expected after 4–6 weeks.
- If there is no/partial response after 4–8 weeks, increase SSRI dose to 40 mg, if well tolerated.
- An adequate trial of treatment is 8–12 weeks, before an alternative treatment should be considered.
- Suicidal ideation may increase in the first few weeks of SSRI therapy. See PHC STGs and EML, 2023: Suicide risk assessment.

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PREGNANCY AND BREASTFEEDING

- Perinatal PTSD is associated with low birth weight babies and poor mother baby interactions.
- Experiences in pregnancy and childbirth may be traumatic and exacerbate existing PTSD or trigger new onset PTSD.
- Women with a history of childhood adversity, sexual abuse, or other previous trauma are at risk of perinatal PTSD.
- Treatment of PTSD in pregnancy is the same as for non-pregnant women.
- Avoid fluoxetine due to long half-life and relatively high concentration in breastmilk. Consider citalopram as alternative.
- All antidepressants: possible increased risk of miscarriage, transient neonatal symptoms (jitteriness, irritability), and persistent pulmonary hypertension of the newborn. Assess and discuss risk/benefit profile with patient.
- Avoid benzodiazepines – some association with neurodevelopmental delay in the child; neonatal sedation if used late in pregnancy.

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Referral

• Persistent symptoms.
• Inadequate response to treatment.
• Comorbid conditions.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults_Chapter 15: Mental Health Conditions and Substance Misuse_NEMLC Recommendations for Medicine Amendments 2020-2023