Blog entry by Rcgp Learning

anxious personOver the last few months the population of the United Kingdom has witnessed an unusually high number of national tragedies in quick succession: the terror attacks in Manchester, Westminster, London Bridge, Finsbury Park and the devastating fire at Grenfell Tower.

There is clear evidence that traumatic events such as these can lead to the development of a range of psychological and mental health issues, such as adjustment and anxiety disorders, depression, and post-traumatic stress disorder (PTSD). While the spectrum of responses to these traumatic events is broad, they will nevertheless impact on the patient’s ability to function, on their relationships and their ability to work and socialise.

Some of those exposed will experience only a short-term period of distress of up to four weeks, but those who do not recover may develop more serious mental health problems. Even people who are not in close physical proximity to these events may experience heightened anxiety, and there will be some who will be particularly concerned due to real or perceived discrimination because of their religion and/or their ethnicity.

Current PTSD prevalencePrimary care is facing significant and ongoing demands due to these events, as initial treatment is likely to be sought in general practice settings. While the vast majority of GPs will be familiar with the signs and symptoms of the aforementioned mental health problems, the diagnosis of post-traumatic stress disorder may be missed or attributed to depression or anxiety disorders.

To find out what we in general practice could do, I spoke to Dr Jonathan Leach, a GP in Bromsgrove with a special interest in post-traumatic stress disorder and was able to ask him a few questions. Jonathan served 25 years in the military and has personal experience of responding to and supporting colleagues and patients who have been involved in major incidents. I also had a look at the literature on PTSD in primary care and especially the ‘normal response’ to traumatic events and how we can support victims (including ourselves) in general practice.

As expected, the choice of literature is vast, so I started with the 2005 NICE guideline on PTSD (Jonathan Leach is one of the members of the NICE committee working on the update), which as usual was good value. I also liked the Royal College of Psychiatrists guidance on ‘coping after a traumatic event’ which listed the range of emotions and responses to expect after being exposed after a traumatic event. Under the ‘What happens next’ heading, the team of authors listed a range of emotions that victims might be experiencing:

  • Frightened … that the same thing will happen again, or that you might lose control of your feelings and break down
  • Helpless … that something really bad happened and you could do nothing about it. You feel helpless, vulnerable and overwhelmed
  • Angry … about what has happened and with whoever was responsible
  • Guilty … that you have survived when others have suffered or died. You may feel that you could have done something to prevent it
  • Sad … particularly if people were injured or killed, especially someone you knew
  • Ashamed or embarrassed … that you have these strong feelings you can't control, especially if you need others to support you
  • Relieved … that the danger is over and that the danger has gone
  • Hopeful … that your life will return to normal. People can start to feel more positive about things quite soon after a trauma.”

In our conversation Jonathan emphasised that it is important for us to acknowledge to the patient that it’s normal and acceptable to feel like this. He also felt that we should allow our patients to express these feelings and give them time and empathy. Only if the patient does not improve after some time and the feelings and memories are becoming more intrusive, is it time to think about our diagnoses. The so-called ‘normal’ response can vary considerably: some patients will develop a marked reaction that resolves over a few weeks, while others have no or very little symptoms.

PTSD in primary care is common, but underdiagnosed: prevalence of PTSD is around 6-10%Initial treatment sought in GP settings in the civilian population, so we should see a considerable amount of patients with these symptoms, though maybe sometimes without recognising the underlying diagnosis. There seems to be moderate evidence that the primary care PTSD screening test (PC-PTSD) has good accuracy as a screening tool in both military and civilian settings in high risk populations and it is easy to administer in just a minute or two. Jonathan reminded me that those high-risk populations are not only veterans and patients who have suffered a recent mass traumatisation event such as the Grenfell Tower fire, but also women suffering sexual violence. The National Women’s study reported that almost one in three female victims of sexual violence develop PTSD at some stage during their lives. These are often events that can go back a long time, so it is important that the symptoms are recognised and specialised PTSD treatment can be initiated. Brief psychological trauma focused interventions (five sessions) may be effective if treatment starts within the first month after the traumatic event for symptomatic patients, but beyond the first month, treatment should be trauma-focused CBT or EMDR. This of course depends on the availability of PTSD-focussed care on your patch.

For those of us who have been involved in traumatic events at work or outside the workplace, it is important to realise that just because we are doctors we are not immune to developing these symptoms. There are some papers examining the PTSD rates among emergency medicine and other hospital doctors, suggesting the numbers to be around 12-13%, higher than in the general population. I couldn’t find any numbers on PTSD in general practitioners but wouldn’t be surprised if the numbers are similar. Having psychological symptoms resulting from the things we have been exposed to at work is therefore not unusual, and if concerned, seek help from your own GP (or the NHS GP Health Service) and get advice, treatment and if necessary, take some time off.

While not everybody might share my taste in TV-Drama, I always thought the award winning West Wing episode “Noël” dealt with PTSD in a rather mature and touching way, and – while for most health professionals a bit too overdramatised and simplistic – demonstrates the intrusiveness of flashbacks and the emotional changes that victims can go through when exposed to traumatic events. Maybe one to watch on the weekend.

References:

Bisson et al (2007): Early Psychosocial Intervention Following

Traumatic Events. Am J Psychiatry 164:1016 - 1019

Royal College of Psychiatrists (2013): Post-Traumatic Stress Disorder; http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstressdisorder.aspx retrieved 04/08/2017

Royal College of Psychiatrists (2014): Coping after a traumatic event; http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/copingafteratraumaticevent.aspx retrieved 04/08/2017

National Institute for Health and Care Excellence (2005): NG26 Post-traumatic stress disorder;

Bisson JI et al: Early Psychosocial Intervention Following Traumatic Events. Am J Psychiatry July 2007, 164:1016-1019

Sonis, J: PTSD in Primary Care—An Update on Evidence-based Management. Current Psychiatry Reports, Jul 2013, 15:373

Sorkin, A: Noël. The West Wing. Warner Bros; Dec 2000

Spoont et al (2015): Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review. JAMA Aug 04; 314(5), 501-10

Tjaden, P., & Thoennes, N. (1998). Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. National Institute of Justice Research in Brief. Retrieved from https://www.ncjrs.gov/pdffiles/172837.pdf

Wilberforce et al (2010): Post-traumatic stress disorder in physicians from an underserviced area. Family Practice, 27(3), 333-343

[ Modified: Thursday, 14 September 2017, 4:11 PM ]