posttraumatic stress disorder (PTSD); includes acute stress disorder

Introduction

Aliases: soldier's heart, fright neurosis, combat neurosis, war neurosis, shell shock, survivor syndrome, nuclearism, operational fatigue, compensation neurosis

Etiology

• experiencing or witnessing a traumatic event
  • combat
  • rape, assault, battery
  • trauma, motor vehicle accidents
  • disaster
• also see risk factors for posttraumatic stress disorder

Epidemiology

• prevalence
  • 1-14% in community-based studies (DSM IV)
  • women 10.4%, men 5.0% with 30% of these developing chronic form
  • 25% of US veterans
• 4th most-common psychiatric disorder
• more common in persons with substance use disorder than general population

History

• history of exposure to trauma

Clinical manifestations

• also see DSM IV criteria for posttraumatic stress disorder
• also see Primary Care PTSD Screen (PC-PTSD)
• persistent re-experiencing the traumatic event(s)
  • avoidance of stimuli associated with the traumatic event(s)
• dreams or intrusive thoughts, emotional numbing & autonomic arousal lasting > 3 months
• pelvic or abdominal pain often present
• increased incidence of periodic limb movement disorder
• World War II veterans
  • insomnia (80%)
  • nightmares (75%)
  • irritability (65%)
  • social isolation (50%)
  • flashbacks (45%)
• Pearl Harbor survivors
  • intrusive memories (65%)
  • survivor guilt (42%)
  • avoidance & hyperarousal (33%)
• sleep disturbance & memory impairment more common in elderly
• other common symptoms
  • distrust
  • anger, irritability, rage
  • anxiety
  • chronic depression
  • vigilence, constantly on gaurd, startle reaction, easily startled
  • intrusive throughts
  • sleep disorders & nightmares
  • sexual problems
  • inability to feel emotions
  • alcohol &/or substance abuse
  • suicidal ideation

Diagnostic procedures

• A 5-item tool (the PC-PTSD-5) is recommended for primary care screening
• a set of 28 biomarkers might aid in diagnosing PTSD

Complications

• comorbidities
  • depression (37%)
  • alcohol & substance abuse (53%)
  • domestic abuse
  • somatoform disorders
  • anxiety disorders (50%)
    • panic disorder
    • obsessive-compulsive disorder
    • generalized anxiety disorder
    • agoraphobia
  • complex PTSD/disorder of extreme stress not otherwise specified
  • obesity (women)
• hypercoagulabitity, cardiovascular events
• stress-related disorders including PTSD are associated with increased risk for life-threatening infections

• disease interaction(s) of ADHD with PTSD
• disease interaction(s) of PTSD with acute coronary syndrome

Differential diagnosis

• psychosocial stress (not associated with exposure to trauma)

Management

• treat pain aggressively
• behavioral therapy/psychotherapy
  • life-review technique
  • debriefing sessions
  • cognitive behavioral therapy (CBT)/cognitive processing therapy (CPT)
    • very effective for patients who show PTSD symptoms soon after trauma
    • effective if therapy is delayed until patients want it
    • CBT/EMDR (eye movement desensitization & reprocessing) 6 45 minute sessions useful for children
    • durable effects lasting > 12 months
    • 2 CBT for PTSD, cognitive processing therapy &/or prolonged exposure are recommended as 1st-line treatments in all PTSD practice guidelines
  • 8 sessions of psychotherapy recommended within 14 weeks
  • exposure therapy
  • mindfulness of benefit
  • 3 psychotherapies with equal but low efficacy
  • psychotherapy is superior to pharmacotherapy in the long term
• group therapy
  • individual therapy more effective than group therapy in active-duty military personnel
  • not recommended
• smart phone application (PTSD Coach) reduces symptoms of PTSD
• pharmaceutical agents
  • analgesics as needed for pain
  • antidepressants
    • selective-serotonin reuptake inhibitors (SSRIs)
      • 1st line therapy for PTSD
      • FDA-approved for PTSD
      • reduce core symptoms
      • may help with depression & anxiety
      • ref suggests immediate treatment with an SSRI for bereavement-associated PTSD
    • SNRIs alternative 1st line therapy
    • atypical antidepressant if SSRI or SNRI ineffective
      • nefazodone
    • tricycic antidepressants may help
      • imipramine, amitryptiline
    • ketamine may be useful for co-morbid depression
  • prazosin may or may not mitigate nightmares (weak recommendation)
    • start 1 mg PO QHS; titrate to effect up to 10 mg QHS
    • of no benefit for chronic PTSD in military veterans
  • anxiolytics
    • avoid benzodiazepines
      • NOT effective when used alone
      • adjunctive therapy for anxiety &/or insomnia
  • anticonvulsants
    • may be useful for flashbacks
    • not useful
  • atypical antipsychotics
    • added to an antidepressant to decrease hyperarousal & re-experiencing symptoms
    • not helpful when used alone
    • may be no better than placebo as adjunct to SSRI 4' brexpiprazole plus sertraline more effective than sertraline alone
  • addition of MDMA to psychtherapy appears promising
  • do not prescribe benzodiazepine for PTSD
• acupuncture of benefit for combat veterans
• transcranial magnetic stimulation, direct current stimulation & electroconvulsive therapy not recommended

Notes

• about 50% veterans with PTSD diagnosis receive recommended 8 sessions of psychotherapy within 14 weeks
• outcome data rarely collected

More general terms

• anxiety disorder
• stress disorder

More specific terms

• dyssynergic defecation

Additional terms

• assessment measures for PTSD
• classification of traumatic events for PTSD
• DSM IV criteria for posttraumatic stress disorder
• risk factors for posttraumatic stress disorder

Patient information

posttraumatic stress disorder (PTSD) patient information