Management of Trauma and PTSD up to 50% of the Population Will Experience a Significant Traumatic Event in Their Lifetime

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Management of trauma and PTSD Up to 50% of the population will experience a significant traumatic event in their lifetime.

J J Benson-Martin, MB ChB, Dr Med (Zurich), CML (Unisa), FCPsych (SA) Lecturer, Department of Psychiatry and Mental Health, University of Cape Town and Consultant Psychiatrist, Valkenberg Hospital, Cape Town Janine Benson-Martin did both her undergraduate and postgraduate training at the University of Cape Town. Her interests are women’s mental health and trauma, as well as electroconvulsive therapy.

Correspondence to: J Benson-Martin ([email protected])

Whereas the majority of trauma survivors horror and helplessness. The individual With time this response should disappear recover without clinical sequelae, 10 - 20% perceives the event as a potential threat and the vast majority of individuals of these individuals develop the syndrome to their or others’ well-being or life and experience spontaneous recovery from of post-traumatic stress disorder (PTSD). [1] experiences clinically significant distress these feelings. The problem arises when this In the USA, the National Comorbidity or impairment in functioning as a result of spontaneous recovery fails to occur. PTSD Survey estimated that between 5% and this distress.[6] and related pathology could therefore be 9% of the general population suffer from conceptualised as a disorder where there is PTSD.[2,3] In the primary healthcare setting Diagnosis failure to recover:[7] the prevalence of PTSD is estimated to Mental pathology as a result of a traumatic • ASD is limited to the first 4 weeks after be two to three times higher.[4] The South event was first entered in the Diagnostic the traumatic event, with the distur- African Stress and Health Study (SASH) and Statistical Manual III (DSM-III), but bance lasting at least 2 days.[6] It is char- – the first large population-based study of was formerly known in soldiers as ‘war acterised by the presence of four sets of mental disorders in South Africa – found neurosis’. The nosology has been refined symptoms: dissociative features (numb- anxiety disorders, as a class, to be the most over time, and is in the process of further ing, derealisation, depersonalisation); prevalent 12-month and lifetime disorder, change in the proposed DSM-V. Acute persistent re-experiencing of the event; while the 12-month prevalence of PTSD stress disorder (ASD) and PTSD are marked avoidance of stimuli associated was 2.3%.[5] manifestations of mental illness in relation with the trauma; and symptoms of anxi- to exposure to a severe traumatic event. ety and hyperarousal. • Acute PTSD is diagnosed after 4 weeks Acute stress disorder The expected response to a severe trauma is with the presence of the triad of re- (ASD) and PTSD are one of shock, fear, horror and helplessness. experiencing, avoidance and signs and manifestations of mental illness in relation to • Intrusive recollections/dreams exposure to a severe Re-experience traumatic event. • Distress on cues

Anxiety and trauma Normal anxiety is universally experienced in response to a threat. It is associated with a range of cognitions and physiological responses from apprehension, intense feelings of dread, as well as hyperactive autonomic Traumatic event phenomena (e.g. abdominal discomfort, restlessness, perspiration, palpitations). It is a normal reaction to an abnormal or unpre- dictable event. Avoidance Arousal Trauma is described in the Diagnostic and Statistical Manual IV – Text Revised (DSM- • Avoid feelings, people & • Poor sleep IV-TR) as the experience or the witnessing places linked to event • Irritability of ‘an event or events that involved actual • Emotional numbing • Hypervigilance or threatened death or serious injury, or a threat to the physical integrity of self or others’. It evokes feelings of intense fear, Fig.1. PTSD symptoms.

49 CME February 2013 Vol. 31 No. 2 Trauma and PTSD

symptoms of heightened arousal (Fig. 1). like responses, dissociative responses, and Appropriate care for injuries, including pain Th ere is a large overlap between ASD and pronounced distress, were associated with control, is essential. Convey compassion PTSD, the diff erence being the duration a higher frequency of developing PTSD, and enlist basic listening skills. However, and dissociative symptoms of ASD. as well as trauma severity, additional life it is important not to force emotional • Chronic PTSD refers to the presence of stressors and lack of support.[11] reactions from the individual. Provide symptoms for 3 months or longer. It is of- adequate information and assist in re- ten co-morbid with depression, substance Assessment and treatment orientating the individual. Facilitate with use disorders, and other anxiety disor- Acute aftermath: Secondary prevention mobilising support, which could involve ders. Th e individual remains reactive to in PTSD – ‘the golden hour/s’ practical processes such as contacting environmental triggers or reminders and Previously, the concept of debriefi ng, which relatives. Lastly, aﬃ rm the expectation of therefore symptoms oft en fl uctuate.[8] involved the recall and rehearsing of the returning to normality.[11] Zohar suggests • Delayed PTSD is the emergence of traumatic event, was recommended as using the mnemonic ERASE (Table 1). symptoms for the fi rst time more than 6 the treatment of choice. Th e impetus for months aft er the trauma. this was the understanding that this type • A subtype of PTSD has been described of intervention could reduce continuing Normal anxiety is and is called ‘disorders of extreme stress psychological diﬃ culties and prevent the not otherwise specifi ed’ (DESNOS). It onset of PTSD. Th ere is now strong evidence universally experienced highlights a more chronic and disabling to suggest that psychological debriefi ng or in response to a threat. path and is associated with early age of critical incident stress management is no onset of trauma, chronic interpersonal longer benefi cial and in fact could delay violence and sexual abuse.[9] recovery.[12] Th e early administration of benzodiazepines to ameliorate distress or as a stress- Th e timelines described are important as Recent work suggests that an alternative busting prophylactic measure is no longer they determine the appropriate action to be approach could potentially prevent the recommended. Studies suggest that it taken. Th e rest of this article focuses on the emergence of PTSD. Just as re-perfusion actually worsens outcome by interfering with identifi cation and management of ASD and of an infarct-related artery in the fi rst hour the potent natural recovery process.[13] Other PTSD. could reduce mortality, trauma researchers novel interventions such as risperidone (an are suggesting that appropriate intervention atypical antipsychotic),[14] propanonol, and Risk factors for the immediately aft er trauma could prevent gabapentin,[15] administered aft er traumatic development of PTSD potential stress-related pathology such events, all demonstrated no benefi t in the A meta-analysis conducted by Brewin et as PTSD. A distinction has been made al.[10] found that factors such as gender, in the literature between acute distress age at trauma and race predicted PTSD management and acute stress treatment, in some populations but not in others. where treatment would traditionally Other pre-trauma predictive factors refer to psychological debriefi ng and such as previous trauma, education, administration of medication. Th e aim of general childhood adversity and family intervention at this stage is to assist with psychiatric history were more uniform maintaining emotional control, restoring in their predictive eff ects. It was noted, interpersonal communication, and helping however, that factors operating during the the person to return to full functional trauma and immediately aft erwards had capacity. Th is can be accomplished by the strongest eff ects. Th erefore emotional ensuring that safety and basic needs such reactions during the event, such as panic- as shelter and nutrition are provided for.

Table 1. Goals of acute stress management – ERASE

E Reduce Exposure to stress (e.g. secure place) R Restore physiological needs (nutrition, pain control) A Provide Access to information/orientation S Locate source of Support (relatives, religion) E Emphasise Expectation of returning to normal

Adapted with permission from Zohar et al.[11]

50 CME February 2013 Vol. 31 No. 2 Trauma and PTSD

prevention of PTSD. Preliminary results acting hypnotic may be used. The patient symptoms and when to seek help, from a study by Shelling et al. where the must be followed up within 4 weeks to as well as of treatments available to administration of prophylactic doses of check if the symptoms have resolved, treat symptoms if they should emerge. cortisol to injured trauma survivors showed preferably by the doctor who initially saw The ultimate aim is to normalise the reduction in PTSD symptoms emergence is the patient. experience, provide reassurance that promising but needs to be replicated.[16] only a minority of people will develop PTSD, but also to ensure help-seeking However, there are certain procedures that There is now strong behaviour if symptoms should develop. should not be done. These are summarised evidence to suggest that If symptoms are distressing or continue, as the 3 Ps: do not pathologise; do not it is highly likely that the patient has psychologise; and do not pharmacologise psychological debriefing developed acute PTSD. (Table 2). or critical incident stress management is no PTSD Acute stress disorder As a healthcare provider it would be ASD develops in the first 4 weeks after a longer beneficial and pertinent to screen for symptoms of PTSD. traumatic event. Zohar et al. recommend could delay recovery. Breslau and colleagues devised a 7-item ‘watchful waiting’ and reassurance during short screening scale for PTSD,[17] which has this period.[7] There is no evidence for been shown to have validity and reliability the routine use of medication, but if the The clinician should provide information in both primary care settings[18] and general patient suffers from insomnia a short- to the victim and the carers about population samples[19] (Table 3). A score

Table 2. What not to do – 3 Ps

Do not pathologise i.e. ‘This is a normal response to an abnormal situation’ Do not psychologise Do not facilitate emotional reactions by e.g. group counselling or debriefing Do not pharmacologise Do not use benzodiazepines etc. in the first few hours

Adapted with permission from Zohar et al.[7]

Table 3. Screening PTSD

DSM- IV items that constitute the 7-item screening scale. In: Breslau N, Peterson EL, Kessler RC. Short screening scale for DSM-IV [17] posttraumatic stress disorder. Am J Psychiatry 1999;156:908-911. C2 Did you avoid being reminded of this experience by staying away from certain places, people or activities? 1.Yes (Remind respondent of life event if necessary) 2. No C4 Did you lose interest in activities that were once important or enjoyable? 1.Yes (Remind respondent of life event if necessary) 2. No C5 Did you begin to feel more isolated or distant from other people? 1.Yes (Remind respondent of life event if necessary) 2. No C6 Did you find it hard to have love or affection for other people? 1.Yes (Remind respondent of life event if necessary) 2. No C7 Did you begin to feel that there was no point in planning for the future? 1.Yes (Remind respondent of life event if necessary) 2. No D1 After this experience were you having more trouble than usual falling asleep or staying asleep? 1.Yes (Remind respondent of life event if necessary) 2. No D5 Did you become jumpy or get easily startled by ordinary noises or movements? 1.Yes (Remind respondent of life event if necessary) 2. No

Based on the Diagnostic Interview Schedule for DSM-IV (DIS-IV), Washington Univ., St Louis, 1995). The 7-item scale screens for DSM-IV PTSD in persons exposed to traumatic events as defined in DSM-IV. It is intended to be used only after establishing that the respondent has experienced a qualifying event. Please read the paper carefully. It contains all the information needed for using the scale. As we emphasise in the paper, the screening scale is not an adequate substitute for a psychiatric diagnosis.

With permission from Breslau et al.[17]

51 CME February 2013 Vol. 31 No. 2 Trauma and PTSD

of 4 or above would identify patients who aspects of the trauma while inducing still remains a paucity of information on would benefi t from further evaluation saccadic eye movements. the long-term treatment of PTSD, symptom and management or referral to a specialty remission, treatment-refractory patients mental health service. Evidence from large randomised controlled and the eff ectiveness of treatments in trials support the use of selective serotonin naturalistic or ‘real-world’ settings. re-uptake inhibitors (SSRIs) and the The expected response serotonin and noradrenaline re-uptake Conclusion inhibitor (SNRI) venlafaxine as fi rst-line Even though major advances have been made to a severe trauma is one treatment in the short- and long-term in PTSD research in the last few years, there of shock, fear, horror and management of PTSD. Sertraline and still remain some pertinent unanswered helplessness. With time paroxetine are FDA-approved for use in this questions. Currently, recommendations disorder.[22] Response can be seen as early as 2 are the ‘watch and wait’ approach in the this response should - 4 weeks aft er starting medication but could early days aft er a traumatic event. CBT disappear and the vast take up to 12 weeks. In the long term, there and EMDR have the best evidence base as majority of individuals is evidence that medication for the treatment psychological interventions for the treatment of chronic PTSD should continue for at least of PTSD. However, the availability and experience spontaneous 12 months to prevent relapse.[23] Despite this, cost-eff ectiveness of such interventions recovery from these a large proportion of patients fail to respond in a developing world setting have to be feelings. to treatment with pharmacotherapy, and taken into consideration as both CBT therefore augmentation is oft en needed. and EMDR are specialised interventions Furthermore, the morbidity of chronic usually performed by trained mental health PTSD is oft en high as a result of co- providers. Furthermore, there is a valid place Meta-analyses by the Cochrane Review[20] morbid conditions such as substance abuse, for pharmacotherapy in the management of and the National Institute of Clinical depression, suicidality and other anxiety PTSD, with the most compelling evidence for Excellence (NICE)[21] found that trauma- disorders that are associated with chronicity the use of SSRIs and venlafaxine. focused cognitive-behaviour therapy of the condition. Findings from a Cochrane (TF-CBT) and eye movement and review on augmentation strategies in anxiety desensitising reprocessing (EMDR) as disorders[24] suggest that adding a course of psychological interventions have the antipsychotics to ongoing treatment of SSRIs References available at www.cmej.org.za strongest evidence for efficacy in PTSD. could be benefi cial. Similarly, prazosin, an Both processes involve forms of exposure alpha-ı antagonist, holds promise. – TF-CBT with a cognitive therapy component, while EMDR involves the Despite a substantive and growing body of therapist asking the patient to visualise evidence on the treatment of PTSD, there

IN A NUTSHELL • According to the SASH study the 12-month prevalence for PTSD is 2.3%. • Immediate intervention aft er a traumatic event involves stress management rather than stress treatment. • Acute stress management aims to assist with maintaining emotional control, restoring communication and helping the individual to return to full functionality. • ASD is characterised by the presence of dissociative features, re-experiencing phenomena, avoidance behaviour, and symptoms of hyperarousal within 4 weeks of a traumatic event. • Th ere is no evidence for the eﬃ cacy of psychological debriefi ng or for the use of benzodiazepines aft er trauma. • Acute PTSD criteria occur when re-experiencing phenomena, avoidance and hyperarousal symptoms are experienced 1 - 3 months aft er a traumatic event. • Chronic PTSD is diagnosed when symptoms persist for more than 3 months. • PTSD is oft en associated with multiple co-morbidities such as depression, other anxiety disorders and substance abuse. • Trauma-focused CBT and EMDR have the most evidence base as psychological treatments. • SSRIs and venlafaxine are used in the pharmacological management of PTSD.

52 CME February 2013 Vol. 31 No. 2 Trauma and PTSD

symptoms of heightened arousal (Fig. 1). like responses, dissociative responses, and Appropriate care for injuries, including pain ere is a large overlap between ASD and pronounced distress, were associated with control, is essential. Convey compassion PTSD, the di erence being the duration a higher frequency of developing PTSD, and enlist basic listening skills. However, and dissociative symptoms of ASD. as well as trauma severity, additional life it is important not to force emotional • Chronic PTSD refers to the presence of stressors and lack of support.[11] reactions from the individual. Provide symptoms for 3 months or longer. It is of- adequate information and assist in re- ten co-morbid with depression, substance Assessment and treatment orientating the individual. Facilitate with use disorders, and other anxiety disor- Acute aftermath: Secondary prevention mobilising support, which could involve ders. e individual remains reactive to in PTSD – ‘the golden hour/s’ practical processes such as contacting environmental triggers or reminders and Previously, the concept of debrie ng, which relatives. Lastly, a rm the expectation of therefore symptoms o en uctuate.[8] involved the recall and rehearsing of the returning to normality.[11] Zohar suggests • Delayed PTSD is the emergence of traumatic event, was recommended as using the mnemonic ERASE (Table 1). symptoms for the rst time more than 6 the treatment of choice. e impetus for months a er the trauma. this was the understanding that this type • A subtype of PTSD has been described of intervention could reduce continuing Normal anxiety is and is called ‘disorders of extreme stress psychological di culties and prevent the not otherwise specifi ed’ (DESNOS). It onset of PTSD. ere is now strong evidence universally experienced highlights a more chronic and disabling to suggest that psychological debrie ng or in response to a threat. path and is associated with early age of critical incident stress management is no onset of trauma, chronic interpersonal longer bene cial and in fact could delay violence and sexual abuse.[9] recovery.[12] e early administration of benzodiazepines to ameliorate distress or as a stress- e timelines described are important as Recent work suggests that an alternative busting prophylactic measure is no longer they determine the appropriate action to be approach could potentially prevent the recommended. Studies suggest that it taken. e rest of this article focuses on the emergence of PTSD. Just as re-perfusion actually worsens outcome by interfering with identi cation and management of ASD and of an infarct-related artery in the rst hour the potent natural recovery process.[13] Other PTSD. could reduce mortality, trauma researchers novel interventions such as risperidone (an are suggesting that appropriate intervention atypical antipsychotic),[14] propanonol, and Risk factors for the immediately a er trauma could prevent gabapentin,[15] administered a er traumatic development of PTSD potential stress-related pathology such events, all demonstrated no bene t in the A meta-analysis conducted by Brewin et as PTSD. A distinction has been made al.[10] found that factors such as gender, in the literature between acute distress age at trauma and race predicted PTSD management and acute stress treatment, in some populations but not in others. where treatment would traditionally Other pre-trauma predictive factors refer to psychological debrie ng and such as previous trauma, education, administration of medication. e aim of general childhood adversity and family intervention at this stage is to assist with psychiatric history were more uniform maintaining emotional control, restoring in their predictive e ects. It was noted, interpersonal communication, and helping however, that factors operating during the the person to return to full functional trauma and immediately a erwards had capacity. is can be accomplished by the strongest e ects. erefore emotional ensuring that safety and basic needs such reactions during the event, such as panic- as shelter and nutrition are provided for.

Table 1. Goals of acute stress management – ERASE

Adapted with permission from Zohar et al.[11]

50 CME February 2013 Vol. 31 No. 2 Trauma and PTSD

prevention of PTSD. Preliminary results acting hypnotic may be used. The patient symptoms and when to seek help, from a study by Shelling et al. where the must be followed up within 4 weeks to as well as of treatments available to administration of prophylactic doses of check if the symptoms have resolved, treat symptoms if they should emerge. cortisol to injured trauma survivors showed preferably by the doctor who initially saw The ultimate aim is to normalise the reduction in PTSD symptoms emergence is the patient. experience, provide reassurance that promising but needs to be replicated.[16] only a minority of people will develop PTSD, but also to ensure help-seeking However, there are certain procedures that There is now strong behaviour if symptoms should develop. should not be done. ese are summarised evidence to suggest that If symptoms are distressing or continue, as the 3 Ps: do not pathologise; do not it is highly likely that the patient has psychologise; and do not pharmacologise psychological debrie ng developed acute PTSD. (Table 2). or critical incident stress management is no PTSD Acute stress disorder As a healthcare provider it would be ASD develops in the first 4 weeks after a longer bene cial and pertinent to screen for symptoms of PTSD. traumatic event. Zohar et al. recommend could delay recovery. Breslau and colleagues devised a 7-item ‘watchful waiting’ and reassurance during short screening scale for PTSD,[17] which has this period.[7] There is no evidence for been shown to have validity and reliability the routine use of medication, but if the The clinician should provide information in both primary care settings[18] and general patient suffers from insomnia a short- to the victim and the carers about population samples[19] (Table 3). A score

Table 2. What not to do – 3 Ps

Do not pathologise i.e. ‘is is a normal response to an abnormal situation’ Do not psychologise Do not facilitate emotional reactions by e.g. group counselling or debrieng Do not pharmacologise Do not use benzodiazepines etc. in the rst few hours

Adapted with permission from Zohar et al.[7]

Table 3. Screening PTSD

DSM- IV items that constitute the 7-item screening scale. In: Breslau N, Peterson EL, Kessler RC. Short screening scale for DSM-IV [17] posttraumatic stress disorder. Am J Psychiatry 1999;156:908-911. C2 Did you avoid being reminded of this experience by staying away from certain places, people or activities? 1.Yes (Remind respondent of life event if necessary) 2. No C4 Did you lose interest in activities that were once important or enjoyable? 1.Yes (Remind respondent of life event if necessary) 2. No C5 Did you begin to feel more isolated or distant from other people? 1.Yes (Remind respondent of life event if necessary) 2. No C6 Did you nd it hard to have love or a ection for other people? 1.Yes (Remind respondent of life event if necessary) 2. No C7 Did you begin to feel that there was no point in planning for the future? 1.Yes (Remind respondent of life event if necessary) 2. No D1 Aer this experience were you having more trouble than usual falling asleep or staying asleep? 1.Yes (Remind respondent of life event if necessary) 2. No D5 Did you become jumpy or get easily startled by ordinary noises or movements? 1.Yes (Remind respondent of life event if necessary) 2. No

Based on the Diagnostic Interview Schedule for DSM-IV (DIS-IV), Washington Univ., St Louis, 1995). e 7-item scale screens for DSM-IV PTSD in persons exposed to traumatic events as dened in DSM-IV. It is intended to be used only aer establishing that the respondent has experienced a qualifying event. Please read the paper carefully. It contains all the information needed for using the scale. As we emphasise in the paper, the screening scale is not an adequate substitute for a psychiatric diagnosis.

With permission from Breslau et al.[17]

51 CME February 2013 Vol. 31 No. 2 Trauma and PTSD

of 4 or above would identify patients who aspects of the trauma while inducing still remains a paucity of information on would bene t from further evaluation saccadic eye movements. the long-term treatment of PTSD, symptom and management or referral to a specialty remission, treatment-refractory patients mental health service. Evidence from large randomised controlled and the e ectiveness of treatments in trials support the use of selective serotonin naturalistic or ‘real-world’ settings. re-uptake inhibitors (SSRIs) and the The expected response serotonin and noradrenaline re-uptake Conclusion inhibitor (SNRI) venlafaxine as rst-line Even though major advances have been made to a severe trauma is one treatment in the short- and long-term in PTSD research in the last few years, there of shock, fear, horror and management of PTSD. Sertraline and still remain some pertinent unanswered helplessness. With time paroxetine are FDA-approved for use in this questions. Currently, recommendations disorder.[22] Response can be seen as early as 2 are the ‘watch and wait’ approach in the this response should - 4 weeks a er starting medication but could early days a er a traumatic event. CBT disappear and the vast take up to 12 weeks. In the long term, there and EMDR have the best evidence base as majority of individuals is evidence that medication for the treatment psychological interventions for the treatment of chronic PTSD should continue for at least of PTSD. However, the availability and experience spontaneous 12 months to prevent relapse.[23] Despite this, cost-e ectiveness of such interventions recovery from these a large proportion of patients fail to respond in a developing world setting have to be feelings. to treatment with pharmacotherapy, and taken into consideration as both CBT therefore augmentation is o en needed. and EMDR are specialised interventions Furthermore, the morbidity of chronic usually performed by trained mental health PTSD is o en high as a result of co- providers. Furthermore, there is a valid place Meta-analyses by the Cochrane Review[20] morbid conditions such as substance abuse, for pharmacotherapy in the management of and the National Institute of Clinical depression, suicidality and other anxiety PTSD, with the most compelling evidence for Excellence (NICE)[21] found that trauma- disorders that are associated with chronicity the use of SSRIs and venlafaxine. focused cognitive-behaviour therapy of the condition. Findings from a Cochrane (TF-CBT) and eye movement and review on augmentation strategies in anxiety desensitising reprocessing (EMDR) as disorders[24] suggest that adding a course of psychological interventions have the antipsychotics to ongoing treatment of SSRIs References available at www.cmej.org.za strongest evidence for efficacy in PTSD. could be bene cial. Similarly, prazosin, an Both processes involve forms of exposure alpha-ı antagonist, holds promise. – TF-CBT with a cognitive therapy component, while EMDR involves the Despite a substantive and growing body of therapist asking the patient to visualise evidence on the treatment of PTSD, there

IN A NUTSHELL • According to the SASH study the 12-month prevalence for PTSD is 2.3%. • Immediate intervention a er a traumatic event involves stress management rather than stress treatment. • Acute stress management aims to assist with maintaining emotional control, restoring communication and helping the individual to return to full functionality. • ASD is characterised by the presence of dissociative features, re-experiencing phenomena, avoidance behaviour, and symptoms of hyperarousal within 4 weeks of a traumatic event. • ere is no evidence for the e cacy of psychological debrie ng or for the use of benzodiazepines a er trauma. • Acute PTSD criteria occur when re-experiencing phenomena, avoidance and hyperarousal symptoms are experienced 1 - 3 months a er a traumatic event. • Chronic PTSD is diagnosed when symptoms persist for more than 3 months. • PTSD is o en associated with multiple co-morbidities such as depression, other anxiety disorders and substance abuse. • Trauma-focused CBT and EMDR have the most evidence base as psychological treatments. • SSRIs and venlafaxine are used in the pharmacological management of PTSD.

52 CME February 2013 Vol. 31 No. 2 References 1. Kessler RC, et al. Posttraumatic stress disorder in the National Comorbidity 14. Stanovic JK, James KA,Vandevere CA. The effectiveness of risperidone on Survey. Arch Gen Psychiatry 1995;52(12):1048-1060. acute stress symptoms in adult burn patients: a preliminary retrospective 2. Frans O, et al. Trauma exposure and post-traumatic stress disorder in the pilot study. J Burn Care Rehabil 2001;22(3):210-213. general population. Acta Psychiatr Scand 2005;111(4):291-299. 15. Pitman RK, et al. Pilot study of secondary prevention of posttraumatic stress 3. Kessler RC, et al. Lifetime prevalence and age-of-onset distributions of disorder with propranolol. Biol Psychiatry 2002;51(2):189-192. DSM-IV disorders in the National Comorbidity Survey Replication. Arch 16. Schelling G, et al. Stress doses of hydrocortisone, traumatic memories, and Gen Psychiatry 2005;62(6):593-602. symptoms of posttraumatic stress disorder in patients after cardiac surgery: 4. Stein MB, et al. Posttraumatic stress disorder in the primary care medical a randomized study. Biol Psychiatry 2004;55(6):627-633. setting. Gen Hosp Psychiatry 2000;22(4):261-269. 17. Breslau N, Peterson EL, Kessler RC. Short screening scale for DSM-IV 5. Stein DJ, et al. Lifetime prevalence of psychiatric disorders in South Africa. posttraumatic stress disorder. Am J Psychiatry 1999;156(6):908-911. Br J Psychiatry 2008;192(2):112-117. 18. Kimerling R, et al. Brief report: Utility of a short screening scale for DSM-IV 6. American Psychiatric Association. Diagnostic and Statistical Manual of PTSD in primary care. J Gen Intern Med 2006;21(1):65-67. Mental Disorders. Washington DC: APA, 1994. 19. Bohnert KM, Breslau N. Assessing the performance of the short screening 7. Zohar J, et al. New insights into secondary prevention in post-traumatic scale for post-traumatic stress disorder in a large nationally-representative stress disorder. Dialogues Clin Neurosci 2011;13(3):301-309. survey. Int J Methods Psychiatr Res 2011;20(1):e1-5. 8. Davidson JR, et al. Posttraumatic stress disorder: acquisition, recognition, 20. Bisson J, Andrew M. Psychological treatment of post-traumatic stress course, and treatment. J Neuropsychiatry Clin Neurosci 2004;6(2):135-147. disorder (PTSD). Cochrane Database Syst Rev 2005;(2):CD003388. 9. Roth S, et al. Complex PTSD in victims exposed to sexual and physical abuse: 21. NICE. Post-Traumatic stress disorder. The management of PTSD in adults results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. J and children in primary and secondary care. CG26. London: National Trauma Stress 1997;10(4):539-555. Institute for Health and Clinical Excellence, 2005. 10. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for 22. Ipser JC, Stein DJ. Evidence-based pharmacotherapy of post-traumatic posttraumatic stress disorder in trauma-exposed adults. J Consult Clin stress disorder (PTSD). Int J Neuropsychopharmacol 2011;Jul:1-16. Psychol 2000;68(5):748-766. 23. Bandelow B, et al. World Federation of Societies of Biological Psychiatry 11. Zohar J, et al. Can posttraumatic stress disorder be prevented? CNS Spectr (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive- 2009;14(1 Suppl 1):44-51. compulsive and post-traumatic stress disorders – first revision. World J Biol 12. Rose S, et al. Psychological debriefing for preventing post traumatic stress Psychiatry 2008;9(4):248-312. disorder (PTSD). Cochrane Database Syst Rev 2002;(2):CD000560. 24. Ipser JC, et al. Pharmacotherapy augmentation strategies in treatment- 13. Gelpin E, et al. Treatment of recent trauma survivors with benzodiazepines: resistant anxiety disorders. Cochrane Database Syst Rev 2006;(4):CD005473. a prospective study. J Clin Psychiatry 1996;57(9):390-394.