Provides up-to-date guidance for general practitioners (GPs) in the recognition of PTSD and the current best practice recommendations for pharmacological and psychological treatment.

Background
Australians are commonly exposed to traumatic events, which can lead to the development of post-traumatic stress disorder (PTSD). Several recent developments in the trauma field have led to significant changes in how PTSD is diagnosed and treated.

Objective
This article provides up-to-date guidance for general practitioners (GPs) in the recognition of PTSD and the current best practice recommendations for pharmacological and psychological treatment.

Discussion
Often the first port-of-call, GPs are well placed to help patients who have recently experienced a potentially traumatic event and are at risk of developing PTSD. The role of the GP can include initial support, assessment, treatment and, where indicated, appropriate spe-cialist referral. There are recent clinical practice guidelines that GPs can use to assess and determine appropriate treatment for their patients with PTSD.

&nbsp

Andrea Phelps

John Cooper

Olivia Metcalf

English

Analysis and Policy Observatory (APO)

754  REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 11, NOVEMBER 2014
After the event
PTSD – an update for 
general practitioners
Background
Australians are commonly exposed to traumatic events, which 
can lead to the development of post-traumatic stress disorder 
(PTSD). Several recent developments in the trauma field have 
led to significant changes in how PTSD is diagnosed and 
treated.
Objective
This article provides up-to-date guidance for general 
practitioners (GPs) in the recognition of PTSD and the current 
best practice recommendations for pharmacological and 
psychological treatment.
Discussion
Often the first port-of-call, GPs are well placed to help patients 
who have recently experienced a potentially traumatic event 
and are at risk of developing PTSD. The role of the GP can 
include initial support, assessment, treatment and, where 
indicated, appropriate specialist referral. There are recent 
clinical practice guidelines that GPs can use to assess and 
determine appropriate treatment for their patients with PTSD.
Keywords
stress disorders, post-traumatic; diagnosis; general practice
Post-traumatic stress disorder (PTSD) is one of the more 
common mental health problems that can arise following 
exposure to psychological trauma. Approximately two-
thirds of the Australian population will experience events 
that are potentially traumatic,1 so called to reflect the 
subjective element in what is perceived as traumatic. The 
Australian prevalence rates for PTSD are 4.4% (12 month) 
and 7.2% (lifetime).2 Rates are higher after specific traumas; 
interpersonal trauma such as rape and torture leading 
to lifetime prevalence rates as high as 50%.3 The impact 
of these traumatic experiences has been recently well 
publicised in the context of The Royal Commission into 
Institutional Responses to Child Sexual Abuse. There are 
also increasing numbers of contemporary veterans leaving 
the Australian Defence Force, including those who have 
been deployed to Afghanistan and Iraq, where high rates 
of traumatic exposure have occurred. These are examples 
of the backgrounds of many patients who will see general 
practitioners (GPs) and rely on them for timely and accurate 
diagnostic assessment and coordination of necessary 
treatment.
Recent developments in PTSD 
diagnosis 
In the past 18 months there have been two significant developments in 
the domain of post-traumatic mental health that have clinical relevance 
to GPs. The first is the release of the latest edition of the Diagnostic and 
Statistical Manual of Mental Disorders (DSM) published by the American 
Psychiatric Association,4 and the second is the update of the Australian 
Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic 
Stress Disorder (the Guidelines).5 These developments will be outlined, 
and the role of the GP in the management of PTSD considered.
After 19 years of the fourth edition (DSM-IV), the fifth edition 
(DSM-5) was released in May 2013. Significant changes have been 
made to the way PTSD is classified and diagnosed (Table 1). First, 
DSM-5 has separated ‘Trauma- and stressor-related disorders’ from 
the chapter on ‘Anxiety disorders’. The requirements for an event 
to be considered traumatic have been more explicitly defined and 
a subjective response of intense fear, helplessness or horror is no 
John Cooper
Olivia Metcalf
Andrea Phelps
REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 11, NOVEMBER 2014  755
debriefing prevents PTSD and it may even be harmful for some. 
The strongest recommendations around pharmacotherapy are that it 
should not be offered preferentially over trauma-focused psychological 
treatment and when pharmacotherapy is considered necessary, 
selective serotonin reuptake inhibitors (SSRIs) should be considered the 
first choice. Generally, the evidence base around pharmacotherapy for 
PTSD is not strong and has not progressed dramatically over the past 
7 years, since the previous version of the Guidelines were published. 
The full Guideline recommendations are available at http://guidelines.
acpmh.unimelb.edu.au/.
The role of the GP
The role of GPs in managing PTSD is central and includes: 
• provision of initial support and monitoring (eg psychological first aid, 
PFA)7 
• early detection, initial assessment and supportive management
• use of initial pharmacotherapy
• appropriate and timely referral for specialist treatment
• support of family and carers
• crisis assistance
• management of comorbid medical conditions
• maintenance treatment for chronic conditions. 
 GPs with appropriate training and interest may also provide 
evidence-based psychological treatment. 
Recognising PTSD
The consequences of untreated PTSD include poor quality of life, 
chronicity and, at times, mortality.8 GPs can have a substantial role 
in reducing delays in treatment by remaining vigilant. At-risk patients 
may not readily report PTSD symptoms, making it important for GPs 
to ask probing questions, use screening tools and raise the possibility 
of PTSD. GPs should be particularly vigilant with patients who work 
in occupations such as law enforcement, the military and emergency 
services, who are more likely to be exposed to multiple traumatic 
longer required to make a diagnosis. Sexual violence has been added 
as a specific example. There are now four groups of symptoms as the 
previous grouping ‘avoidance and numbing’ has been separated into 
two distinct clusters. The avoidance cluster requires one of the two 
avoidance symptoms (avoidance of memories or thoughts or avoidance 
of external reminders), whereas the emotional numbing symptoms have 
been included in a new cluster of negative cognitions and mood, which 
also includes features typically associated with complex presentations 
of PTSD, such as persistent negative beliefs about self, others and the 
world. ‘Recklessness or self-destructive behaviour’ has been added to 
the arousal cluster of symptoms. 
Despite the substantial changes from DSM-IV to DSM-5, early 
research suggests that DSM-5 PTSD will be diagnosed at similar or 
slightly lower prevalence rates than DSM-IV PTSD.6 Although overall 
rates may not differ, exclusion of those without active avoidance 
while inclusion of those who did not experience the subjective trauma 
response at the time of the event may capture a slightly different group.
The revised version of the Guidelines5 was released in 2013 and has 
been expanded to cover children and adolescents. The Guidelines have 
been approved by the National Health and Medical Research Council 
(NHMRC) and endorsed by the Royal Australian and New Zealand 
College of Psychiatrists (RANZCP), Royal Australian College of General 
Practitioners (RACGP) and the Australian Psychological Society. The 
Australian Centre for Post-traumatic Mental Health (ACPMH) developed 
the Guidelines in collaboration with national experts. The Guidelines 
also investigate evidence for resilience training and consider the 
treatment of PTSD in older age groups. 
Evidence-based management
The best available research evidence continues to support the first-line 
use of trauma-focused psychological treatments for PTSD across all 
age groups. Other higher-level recommendations include that routine 
psychological debriefing for those exposed to potentially traumatic 
events should not be offered. There is no evidence that psychological 
Table 1. Key differences between DSM-IV and DSM-5 PTSD criteria
DSM-IV DSM-5
Broader definition of what constitutes a 
traumatic event
More tightly defined, with the removal of some stressor events (eg 
unexpected deaths from natural causes) as well as the exclusion 
of learning about a traumatic event through electronic media such 
as television, video games, movies or pictures (unless exposure is 
work-related)
Stipulates the individual must have experienced 
an emotional response of intense fear, 
helplessness or horror during the traumatic event
Emotional response of intense fear, helplessness or horror during the 
traumatic event criterion has been removed
Three symptom clusters – re-experiencing; 
avoidance and numbing; increased arousal
Four symptom clusters distinguishing active avoidance from 
numbing (negative cognitions and emotions) symptoms
Minimum of six symptoms required for diagnosis Minimum of six symptoms required for diagnosis
Dysphoric mood symptoms added, including persistent distorted 
blame of self or others and persistent negative emotional state
FOCUS PTSD – an update for general practitioners
756  REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 11, NOVEMBER 2014
but not about, the trauma, but these techniques do not improve core 
symptoms of PTSD. Efficacious trauma-focused interventions include 
therapies such as prolonged exposure, eye movement desensitisation 
and reprocessing (EMDR), and cognitive processing therapy (CPT). 
The common factors in these therapies that are considered to be the 
‘potent’ elements are strategies that:
• enable the patient to confront the distressing traumatic memories
• manage the accompanying avoidance responses
• facilitate reduction and management of the associated arousal. 
These evidence-based psychological treatments are time-limited 
and usually involve 8–12 sessions, although more sessions may be 
required for complex presentations or repeated traumatic experiences. 
Therapies such as prolonged exposure may also require longer 
sessions (ie 90 minutes) to ensure appropriate management of distress. 
In choosing a psychologist to refer patients to, we would recommend 
that the GP enquire about their experience in treating PTSD with 
trauma-focused cognitive behavioural therapy (TF-CBT) or EMDR.
Conclusion
PTSD is a common mental health problem. GPs should be aware of 
recent important updates that have been made for the diagnosis and 
treatment of PTSD to assist in their critical role of ensuring evidence-
based care for patients with PTSD. 
Authors
John Cooper MBBS, MPM, FRANZCP, Consultant Psychiatrist, 
Australian Centre for Posttraumatic Mental Health, Department of 
Psychiatry, The University of Melbourne, Parkville, VIC; Heidelberg 
Repatriation Hospital, Heidelberg, VIC. jacooper@netspace.net.au
Olivia Metcalf BA, BSc-Psychology (Hons), PhD, Research Fellow, 
Department of Psychiatry, Australian Centre for Posttraumatic Mental 
Health, Carlton, VIC
Andrea Phelps BA (Hons) MPsych (Clin) PhD, Director Policy and 
Service Development, Australian Centre for Posttraumatic Mental 
Health, Carlton, VIC
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
References
1. Creamer M, Burgess P, McFarlane AC. Posttraumatic stress disorder: find-
ings from the Australian National Survey of Mental Health and Wellbeing. 
Psychol Med 2001;31:1237–47.
2. McEvoy PM, Grove R, Slade T. Epidemiology of anxiety disorders in the 
Australian general population: findings of the 2007 Australian National Survey 
of Mental Health and Wellbeing. Aust N Z J Psychiatry 2011;45:957–67.
3. Breslau N, Peterson E, Poisson L, Schultz L, Lucia V. Estimating posttrau-
matic stress disorder in the community: lifetime perspective and the impact 
of typical traumatic events. Psychol Med 2004;34:889–98.
4. American Psychiatric Association. DSM 5. Arlington VA: American 
Psychiatric Association, 2013.
5. Australian Centre for Posttraumatic Mental Health. Australian Guidelines 
for the Treatment of Acute Stress Disorder and Posttraumatic Stress 
Disorder. Melbourne: ACPMH, 2013. Available at http://guidelines.acpmh.
unimelb.edu.au/ [Accessed 15 September 2014].
6. O’Donnell ML, Alkemade N, Nickerson A, et al. Impact of the diagnostic 
changes to posttraumatic stress disorder for DSM-5 and the proposed 
changes to ICD-11. Br J Psychiatry 2014;205:230–35.
events, communities that are subject to natural disasters such as 
bushfires and floods, and patients presenting with physical injuries, 
for example following motor vehicle accidents. Another group in 
primary care settings with higher rates of PTSD are patients presenting 
repeatedly with non-specific somatic complaints.9–11 
Initiating pharmacotherapy
GPs should consider the use of antidepressant medications such as 
SSRIs for people who:
• are unwilling to seek or do not have access to the preferred first-line 
psychological treatment
• have a comorbid depression or other symptoms that require 
pharmacological treatment
• are in situations that are not sufficiently stable (eg ongoing domestic 
violence) 
• have not benefited from trauma-focused psychological treatment. 
There is evidence that the required doses are higher when treating 
PTSD, compared with uncomplicated depression. When there 
is a good response to an antidepressant, a course of treatment 
lasting at least 12 months reduces rates of relapse. When second- 
and third-line pharmacotherapy options need to be considered 
because of non-response or side effects, other newer-generation 
antidepressants such as selective serotonin and noradrenaline 
reuptake inhibitors (SNRIs), mirtazepine or moclobemide are 
recommended.12 
Poor response to initial treatments, complex comorbidities, safety 
concerns and patient request should lead to referral for psychiatric 
assessment. Additional treatments such as tricyclic antidepressants 
(TCAs), monoamine oxidase inhibitors (MAOIs), atypical antipsychotics 
(APs), mood stabilisers and benzodiazepines may need to be 
considered, but clinicians need to be aware of the limited evidence 
base supporting the efficacy of these treatments, inform patients 
accordingly and carefully manage associated risks (eg metabolic 
syndrome with APs, abuse and dependency with benzodiazepines, risk 
of overdose with TCAs).
Augmentation strategies used to treat more severe and complex 
PTSD come in and out of favour. The evidence base supporting the use 
of APs is weak and, if they are to be used, the well-established and 
significant side effect profile must be assessed for acceptability and 
be outweighed by the expected and actual benefits.13 In comparison, 
prazosin, an alpha-1 adrenoreceptor antagonist, has been proven to 
have a more favourable risk–benefit profile. While this profile has 
been established specifically in the treatment of PTSD insomnia and 
nightmares, a recent well-designed study also showed benefit for 
overall PTSD symptoms.14 
Psychological therapy
It is important for GPs to have a good working knowledge of what 
treatment entails when referring patients for evidence-based 
psychological treatment of PTSD. Often, patients appreciate general 
counselling, dealing with daily issues and stresses, and talking around, 
FOCUSPTSD – an update for general practitioners
REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 11, NOVEMBER 2014  757
7. Wade D, Howard A, Fletcher S, Cooper J, Forbes D. Early response to psy-
chological trauma: What GPs can do. Aust Fam Physician 2013;42:610.
8. Priebe S, Matanov A, Jankovi Gavrilovi J, et al. Consequences of untreated 
posttraumatic stress disorder following war in former Yugoslavia: morbid-
ity, subjective quality of life, and care costs. Croat Med J 2009;50:465–75.
9. Hoge C, Terhakopian A, Castro C, Messer S, Engel C. Association of post-
traumatic stress disorder with somatic symptoms, health care visits, and 
absenteeism among Iraq war veterans. Am J Psychiatry 2007;164:150–53.
10. Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic 
stress disorder in the primary care medical setting. Gen Hosp Psychiatry 
2000;22:261–69.
11. Gillock KL, Zayfert C, Hegel MT, Ferguson RJ. Posttraumatic stress disorder 
in primary care: prevalence and relationships with physical symptoms and 
medical utilization. Gen Hosp Psychiatry 2005;27:392–99.
12. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based guidelines for 
the pharmacological treatment of anxiety disorders: recommendations 
from the British Association for Psychopharmacology. J Psychopharmacol 
2005;19:567–96.
13. Krystal JH, Rosenheck RA, Cramer JA, et al. Adjunctive risperidone 
treatment for antidepressant-resistant symptoms of chronic military 
service–related ptsd: A randomized trial. JAMA 2011;306:493–502. 
14. Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat 
trauma PTSD with nightmares in active-duty soldiers returned from Iraq 
and Afghanistan. Am J Psychiatry 2013;170:1003–10.


A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan.

Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service–related ptsd: A randomized trial.

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Consequences of untreated posttraumatic stress disorder following war in former Yugoslavia: morbidity, subjective quality of life, and care costs.

Early response to psychological trauma: What GPs can do. Aust Fam Physician 2013;42:610.

Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology.

Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization. Gen Hosp Psychiatry 2005;27:392–99.

Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry

PTSD – an update for general practitioners

http://apo.org.au/sites/all/modules/pubdlcnt/pubdlcnt.php?nid=42314&file=http://www.racgp.org.au/download/Documents/AFP/2014/November/201411Focus-Cooper.pdf

PTSD – an update for general practitioners

Abstract

Similar works

Full text

Available Versions

Analysis and Policy Observatory (APO)