Erica a 23 year old teacher , is accompanied to the psychiatrist by her mother who explains that Erica

has not been the same since she was raped, buggered and left for dead in a track just alongside her
school six months ago.

The mother explained that the family expected some reaction but they were now concerned that
Erica seemed unable to resume her normal activities. Since the attack, Erica continues to be very
fearful, nervous and jumpy. She awakens at night screaming. Even during the day, she would suddenly
get quiet and then become very anxious and tearful and refuses to talk about the attack.

Erica is also refusing to see her boyfriend who was with her on the night of the attack. Mothers main
concern however is that Erica has not returned to her job, because every time she tries to go to the
school, she gets very distressed and refuses to cross the track that leads to the school’s entrance.

PTSD ( post-traumatic stress disorder)

A delayed response to an exceptionally severe traumatic stress associated with particular symptoms
and especially re- experiencing of the trauma in dreams or imagination (intrusive symptoms).
Avoidance, negative alterations in thought and mood, and increased arousal may be others symptoms
experienced.

Examples include : serious road accident, major disaster, severe assault)

The onset may be months or years after the original trauma or may be immediately following the
traumatic event.

A central feature is an involuntary re-experiencing of the traumatic event in nocturnal dreams or as

intrusive ‘flash backs’ often triggered by reminders of the trauma.

Table 10.13 Symptoms of post-traumatic stress disorder (PTSD)

Component Prominent features
Emotion Anxiety and irritability, numbness and
detachment
Cognition Repeated reliving of the event in
images (‘flashbacks’) and nightmares
Behaviour Avoidance of situations associated
with the trauma (triggering stimuli)
somatic symptoms
Exaggerated startle response
Associations Substance misuse, depression,
severe previous stressor

Management –

-Treating any comorbid psychiatric disorder or substance abuse

- first line treatment is antidepressants:

SSRI( FLOUXETINE which forms long acting metabolites, citaprolam, paroxetine)

SNRI(venlafaxine, desvenlafaxineduloxetine)

-prazosin is an alpha 1 addrenergic receptor antagonist which acts centrally and peripherally. It blocks
alpha 1 receptors in the brain relieving PTSD symptoms of nightmares and hyper vigilance. The
increase in CNS adrenergic activity occurs primarily at night, and the hyperresponsiveness of the
postsynaptic alpha1-adrenergic receptors disrupts the sleep cycle and increases feelings of fear.

The alpha- 1 receptors are located in the hippocampus (involved with memory), amygdala (part of the
limbic system that plays a role in emotions, especially fear responses), and other areas of the brain.

-atypical 9 2nd generation ) antipsychotics may be used in severe cases.eg. clozapine , olanzapine,
risperidone, quetiapine, ziprasidone

- encouraging a return to normal activities

- antidepressant drugs are modestly effective

-Trauma focused CBT is also effective

- eye movement desensitization and reprocessing (EMDR) treatment is used but is controversial.

Here the patient is asked to focus on an image from the traumatic event whilst moving their eyes
from side to side.

PTSD has good prognosis, some may become chronic.

More common in women

Risk factor for developing PTSD- exposure to prior trauma , esp during childhood.

Course / prognosis:

-Usually begins within 3 months after trauma

- symptoms may have delayed expression

-50% of patients have complete recovery within 3 months

-Symptoms tend to diminish with old age

-80% of patients with PTSD have another mental disorder eg. MDD( major depressive disorder),
bipolar disorder, anxiety disorder, substance use disorder.
CASE 3

A 24 year old single female school teacher terminated brief psychotherapy after ten sessions.

She had entered treatment 2 weeks after she discovered that the man she had been involved with for
4 months