Case study 1
Betsy is 93 years old and yet she continues to have nightmares about the time she spent in Dachau, decades earlier. The rest of her family all died during the Holocaust and she still feels guilty that she alone survived.

Case study 2
Robert is 70 years old - a retired surgeon who has had several strokes. He moved in with a younger woman several months ago. She has attacked him frequently with kitchen implements and injured him severely on two occasions. Once, when he was unloading the boot of the car, she pushed him into it, locked it, and left him there all night.

PTSD first entered the American Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. In essence, these criteria are threefold and persist for longer than one month following exposure to a traumatic event to which the patient has responded with terror or helplessness:

Although this clinical picture may appear quite clear-cut, in practice there are several difficulties in the diagnosis and management of PTSD.

Some people think that PTSD is basically an illness fabricated by western psychiatrists and lawyers to justify compensation claims or to excuse the poor coping skills of some victims. There are many people who suffer from PTSD, however, who are not involved in any litigation and whose pre-morbid personality showed good coping skills. Moreover, many experts now consider the neurobiology of PTSD to be sufficiently understood and unique for it to be validated as a distinct biological entity. For example, though both depression and PTSD are associated with hyperactivity in the hypothalamic-pituitary-adrenal axis and the catecholamine sympathetic nervous system, PTSD is distinct in being associated with normal or low cortisol levels, despite high levels of corticotrophin-releasing factor³.

Those with a previous history of psychological disorder such as depression or anxiety are more likely to develop PTSD and it is estimated that up to 80 per cent of patients with a diagnosis of PTSD also have at least one other psychiatric condition - approximately 50 per cent have three or more⁴. The commonest comorbid conditions include depression, panic disorder, alcohol and drug misuse, and somatization disorder. These may mask the associated PTSD especially when the history of previous trauma is not revealed because of marked avoidance behaviour. Issues specific to the elderly

A number of issues complicate the diagnosis of PTSD in the elderly. Symptoms such as insomnia and memory impairment are common with ageing and may be unrelated to trauma exposure. Elderly patients with PTSD may fall into one of two different groups: those who were traumatised in later, or much earlier, life.

Those who were traumatised much earlier in life
These patients often have an episodic course. Many world war II veterans say they coped well initially, but then developed symptoms which lasted for up to five years. During middle age, symptoms may have been masked by involvement with jobs and families, often to recur later, up to 45years after the war. The most prominent symptoms were acute distress on exposure to trauma-related events and diminished interest in usual activities⁵.

Delayed onset of PTSD (defined as an onset of symptoms more than 6 months after the trauma) may also occur more commonly in the elderly than in younger adults. This may be due to a reduction in physical and mental resilience with time which reduces their capacity to ward off and cope with trauma-related memories. Additionally, stressors such as bereavement and retirement are increasingly normal as old age advances and they can precept PTSD symptoms as they can symbolically represent war and absence of control.

Symptom patterns in the elderly may show different patterns from younger adults. One study6 of train crash survivors showed that those aged over 65 years had more preoccupation with the accident, avoidance behaviour, sleep disturbance, and intrusive thoughts than those aged between 45-64 years. Older adults affected by the Armenian earthquake, however, showed more hyperarousal symptoms but fewer intrusive thoughts than younger survivors. Older patients with PTSD are also more likely to be diagnosed as having a medical problem because of a tendency to focus on physical symptoms⁷.

A comprehensive assessment of all but the mildest cases of PTSD in the elderly is advisable⁸. This entails a full medical, psychiatric, and social history, a mental state and cognitive assessment, physical examination, and assessment of the patient's support network. Most investigations will also show impairment in activities of daily living (ADL), so ADL needs should also be assessed. This will involve referral, though considerable time may need to be given to explaining the likely benefits to the patient. Avoidance behaviour often means that referral for further help may not be readily accepted, at least at first.

The same types of modalities used on younger patients are usually employed in the treatment of older patients and cognitive-behavioural techniques or psychotherapy, either group or individual, are the most common. In the elderly, however, more time is often needed to work through the traumatic event, and acknowledgement of physical complaints is more significant in therapy than with younger patients.

The mainstays of drug treatment of PTSD in adults are antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) which are effective for several clusters of symptoms, such as avoidance, numbing, and hyperarousal. Paroxetine (Seroxat) is the only SSRI currently licensed specifically for the treatment of PTSD in the UK, though others such as fluoxetine, sertraline, and nefazodone, have been shown to be effective in the USA. It is reasonable to try a dose of 20mg of paroxetine for at least one month to see if there is any improvement particularly if the waiting time for assessment is going to be long.

PTSD is often undetected because of avoidance behaviour preventing the patient from talking easily about the precipitating event. Comorbidity is common and may also make diagnosis more difficult. PTSD is worth detecting in general practice since treatment is effective and the patient can be treated with paroxetine while awaiting specialist assessment.

Dr Trevor Stammers is a GP in South West London, and a Tutor in General Practice, St George's Hospital Medical School, London

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edn. 1994; American Psychiatric Association Press, Washington

2. Ballinger J, Davidson J, Lescrubier Y, et al. Consensus statement on post-traumatic stress disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 2000; 61: 60-66

3. Newport DJ, Nemeroff CB. Neurobiology of post-traumatic stress disorder. Curr Opin Neurobiol 2000; 10: 211-18

4. Brady K. Post-traumatic stress disorder and comorbidity: recognising the many faces of PTSD. J Clin Psychiatry 1997; 58: 12-15

5. Hyer L, Summers B, Braswell L, Boyd S. Post-traumatic stress disorder: silent problem among older combat veterans. Psychotherapy 1994; 32: 348-64

6. Averill P, Beck JG. Post-traumatic stress disorder in older adults: a conceptual view. J Anxiety Disorders 2000; 14: 133-56

7. Weintraub D, Ruskin R. Post-traumatic stress disorder in the elderly: a review. Harvard Rev Psych 1999; 7: 144-52

8. Finnegan AP. Clinical assessment for post-traumatic stress disorder. Br J Nurs 1998; 7: 212-18

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