posttraumatic stress disorder (PTSD); includes acute stress disorder
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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
- also see risk factors for posttraumatic stress disorder
Epidemiology
- prevalence
- 4th most-common psychiatric disorder
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)[6]
- persistent re-experiencing 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[6]
- 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[35]
- a set of 28 biomarkers might aid in diagnosing PTSD[28]
Complications
- comorbidities
- depression (37%)
- alcohol & substance abuse (53%)
- domestic abuse
- somatoform disorders
- anxiety disorders (50%)
- complex PTSD/disorder of extreme stress not otherwise specified
- obesity (women)[16]
- hypercoagulabitity, cardiovascular events[6][15]
- stress-related disorders including PTSD are associated with increased risk for life-threatening infections[29]
- 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[12]
- behavioral therapy/psychotherapy
- life-review technique
- debriefing sessions
- cognitive behavioral therapy (CBT)/cognitive processing therapy (CPT)[35]
- very effective for patients who show PTSD symptoms soon after trauma[14]
- effective if therapy is delayed until patients want it[14]
- CBT/EMDR (eye movement desensitization & reprocessing) 6 45 minute sessions useful for children[22]
- durable effects lasting > 12 months[30]
- 2 CBT for PTSD, cognitive processing therapy &/or prolonged exposure are recommended as 1st-line treatments in all PTSD practice guidelines[33]
- 8 sessions of psychotherapy recommended within 14 weeks[18]
- exposure therapy[25]
- mindfulness of benefit[35]
- 3 psychotherapies with equal but low efficacy[24]
- psychotherapy is superior to pharmacotherapy in the long term[27][35]
- group therapy
- individual therapy more effective than group therapy in active-duty military personnel[19]
- not recommended[35]
- smart phone application (PTSD Coach) reduces symptoms of PTSD[20]
- pharmaceutical agents
- analgesics as needed for pain
- antidepressants
- selective-serotonin reuptake inhibitors (SSRIs)[5]
- 1st line therapy for PTSD
- FDA-approved for PTSD
- reduce core symptoms
- may help with depression & anxiety
- ref[17] suggests immediate treatment with an SSRI for bereavement-associated PTSD
- SNRIs alternative 1st line therapy[12]
- atypical antidepressant if SSRI or SNRI ineffective[12]
- tricycic antidepressants may help[5]
- imipramine, amitryptiline
- ketamine may be useful for co-morbid depression[35]
- selective-serotonin reuptake inhibitors (SSRIs)[5]
- prazosin may or may not mitigate nightmares (weak recommendation)[35]
- anxiolytics
- avoid benzodiazepines[12]
- NOT effective when used alone
- adjunctive therapy for anxiety &/or insomnia
- avoid benzodiazepines[12]
- anticonvulsants
- may be useful for flashbacks[5]
- not useful[12]
- atypical antipsychotics
- addition of MDMA to psychtherapy appears promising[32]
- do not prescribe benzodiazepine for PTSD[1]
- acupuncture of benefit for combat veterans[34]
- 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[18]
More general terms
More specific terms
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
References
- ↑ 1.0 1.1 1.2 1.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
Ravindran LN, Stein MB. Pharmacotherapy of PTSD: premises, principles, and priorities. Brain Res. 2009 Oct 13;1293:24-39. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19332035 - ↑ UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ Zeller, Michelle. GRECC West LA, Lecture, 02/10/04
- ↑ Averill PM & Beck JG Posttraumatic stress disorder in older adults: a conceptual review. Anxiety Disorders 14:133, 2000 (review) PMID: https://www.ncbi.nlm.nih.gov/pubmed/10864382
- ↑ 5.0 5.1 5.2 5.3 Prescriber's Letter 12(8): 2005 New Practice Guidelines for the Treatment of Post-traumatic Stress Disorder Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=210812&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 6.0 6.1 6.2 6.3 Edmondson D et al Posttraumatic Stress Disorder Prevalence and Risk of Recurrence in Acute Coronary Syndrome Patients: A Meta-analytic Review PLoS one <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22745687 <Internet> http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0038915
- ↑ Primary Care PTSD Screen (PC-PTSD) Department of Veteran Affairs http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp
- ↑ deprecated reference
- ↑ Depression, PTSD, Substance Abuse Increase in Wake of September 11 Attacks http://www.nida.nih.gov/NIDA_notes/NNVol17N4/Depression.html
- ↑ Anxiety: Management of post-traumatic stress disorder in adults in primary, secondary and community care. http://www.nice.org.uk/page.aspx?o=248114
- ↑ Prescriber's Letter 14(1): 2007 Propranolol for Post-traumatic Stress Disorder Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230111&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Prescriber's Letter 18(8): 2011 CHART: Pharmacotherapy of Post-Traumatic Stress Disorder GUIDELINES: Post-Traumatic Stress Disorder Management (2010) Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=270805&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 13.0 13.1 Krystal JH et al. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: A randomized trial. JAMA 2011 Aug 3; 306:493. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21813427 <Internet> http://jama.ama-assn.org/content/306/5/493.full
Hoge CW. Interventions for war-related posttraumatic stress disorder: Meeting veterans where they are. JAMA 2011 Aug 3; 306:549. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21813436 <Internet> http://jama.ama-assn.org/content/306/5/549.full - ↑ 14.0 14.1 14.2 Shalev AY et al. Prevention of posttraumatic stress disorder by early treatment: Results from the Jerusalem Trauma Outreach and Prevention study. Arch Gen Psychiatry 2011 Oct 3; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21969418 <Internet> http://archpsyc.ama-assn.org/cgi/content/abstract/archgenpsychiatry.2011.127v1
- ↑ 15.0 15.1 von Kanel R et al. Altered blood coagulation in patients with posttraumatic stress disorder. Psychosom Med 2006 Jul/Aug; 68:598-604. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16868270
- ↑ 16.0 16.1 Kubzansky LD et al The Weight of Traumatic Stress. A Prospective Study of Posttraumatic Stress Disorder Symptoms and Weight Status in Women. JAMA Psychiatry. Published online November 20, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24258147 <Internet> http://archpsyc.jamanetwork.com/article.aspx?articleid=1780021
- ↑ 17.0 17.1 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
- ↑ 18.0 18.1 18.2 Institute of Medicine Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment 2014 http://www.nap.edu/catalog.php?record_id=18724
- ↑ 19.0 19.1 Resick PA et al. Effect of group vs individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry 2016 Nov 23; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27893032
Hoge CW et al. Refining trauma-focused treatments for servicemembers and veterans with posttraumatic stress disorder: Progress and ongoing challenges. JAMA Psychiatry 2016 Nov 23; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27893037 - ↑ 20.0 20.1 Kuhn E, Kanuri N, Hoffman JE et al. A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. J Consult Clin Psychol 2017 Mar; 85:267 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28221061 <Internet> http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/ccp0000163
- ↑ Shalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. N Engl J Med 2017; 376:2459-2469. June 22, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28636846 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMra1612499
- ↑ 22.0 22.1 de Roos C et al. Comparison of eye movement desensitization and reprocessing therapy, cognitive behavioral writing therapy, and wait-list in pediatric posttraumatic stress disorder following single- incident trauma: A multicenter randomized clinical trial. J Child Psychol Psychiatry 2017 Jun 28; PMID: https://www.ncbi.nlm.nih.gov/pubmed/28660669
- ↑ 23.0 23.1 Raskind MA et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med 2018 Feb 8; 378:507 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29414272 <Internet> http://www.nejm.org/doi/10.1056/NEJMoa1507598
Ressler KJ. Alpha-adrenergic receptors in PTSD - Failure or time for precision medicine? N Engl J Med 2018 Feb 8; 378:575 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29414268 <Internet> http://www.nejm.org/doi/10.1056/NEJMe1716724 - ↑ 24.0 24.1 Foa EB et al. Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. JAMA 2018 Jan 23; 319:354. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29362795 https://jamanetwork.com/journals/jama/article-abstract/2670254
Hoge CW, Chard KM. A window into the evolution of trauma-focused psychotherapies for posttraumatic stress disorder. JAMA 2018 Jan 23; 319:343 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29362777 https://jamanetwork.com/journals/jama/article-abstract/2670236 - ↑ 25.0 25.1 Sloan DM, Marx BP, Lee DJ, Resick PA. A brief exposure-based treatment vs cognitive processing therapy for posttraumatic stress disorder: A randomized noninferiority clinical trial. JAMA Psychiatry 2018 Jan 17 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29344631 https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2669771
- ↑ Ostacher MJ, Cifu AS Management of Posttraumatic Stress Disorder. JAMA. 2019;321(2):200-201 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30556838 https://jamanetwork.com/journals/jama/fullarticle/2719367
- ↑ 27.0 27.1 Merz J, Schwarzer G, Gerger H. Comparative efficacy and acceptability of pharmacological, psychotherapeutic, and combination treatments in adults with posttraumatic stress disorder: A network meta-analysis. JAMA Psychiatry 2019 Jun 12; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31188399
Stein MB, Norman SB. When does meta-analysis of a network not work?: Fishing for answers. JAMA Psychiatry 2019 Jun 12; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31188403 - ↑ 28.0 28.1 Dean KR, Hammamieh R, Mellon SH et al. Multi-omic biomarker identification and validation for diagnosing warzone-related post-traumatic stress disorder. Mol Psychiatry 2019 Sep 10; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31501510 https://www.nature.com/articles/s41380-019-0496-z
- ↑ 29.0 29.1 Song H, Fall K, Fang F et al Stress related disorders and subsequent risk of life threatening infections: population based sibling controlled cohort study. BMJ 2019;367:l5784 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31645334 https://www.bmj.com/content/367/bmj.l5784
- ↑ 30.0 30.1 van Dis EAM, van Veen SC, Hagenaars MA et al Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders. A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online November 23, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31758858 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2756136
- ↑ World Health Organization Assessment and Management of Conditions Specifically Related to Stress. http://apps.who.int/iris/bitstream/10665/85623/1/9789241505932_eng.pdf
- ↑ 32.0 32.1 Monaco K MDMA-Assisted Therapy Offers a Win for PTSD Remission. Trial patients achieved good outcome with addition of psychoactive drug to psychotherapy. MedPage Today May 2, 2021 https://www.medpagetoday.com/meetingcoverage/apa/92379
Mitchell J, et al Efficacy and safety results from the first phase 3 randomized controlled trial of MDMA-assisted psychotherapy for treatment of severe chronic PTSD. American Psychiatric Association (APA) 2021. - ↑ 33.0 33.1 Schnurr PP, Chard KM, Ruzek JI et al Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans. A Randomized Clinical Trial. JAMA Netw Open. 2022;5(1):e2136921. Jan 19. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35044471 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788220
- ↑ 34.0 34.1 Hollifield M, Hsiao AF, Smith T et al Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2024 Feb 21:e235651. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38381417 PMCID: PMC10882512 Free PMC article. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2814938
- ↑ 35.0 35.1 35.2 35.3 35.4 35.5 35.6 35.7 Schnurr PP, Hamblen JL, Wolf J et al. The management of posttraumatic stress disorder and acute stress disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med 2024 Feb 27; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38408360 https://www.acpjournals.org/doi/10.7326/M23-2757