Post-Traumatic Stress Disorder

Aka: Post-Traumatic Stress Disorder, Posttraumatic Stress Disorder, PTSD

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II. Pathophysiology

  1. See Spectrum of Trauma Response

III. Causes: Trauma triggers for PTSD

  1. See Posttraumatic Stress Disorder Triggers

IV. Risk Factors

  1. See Posttraumatic Stress Disorder Risk Factors

V. Symptoms

  1. Intrusive re-experiencing the Trauma
    1. Recurrent intrusive thoughts, images, dreams
    2. Intense distress when remembering Trauma
    3. Avoidance of reminders of Trauma
  2. Increased autonomic arousal
    1. Insomnia
    2. Angry outbursts or other anti-social behaviors
    3. Hyper-vigilance and suspiciousness
    4. Exaggerated startle response
    5. Change in activity, appetite, sleep, sex and social functioning
    6. Unable to rest (pacing)
  3. Cognitive symptoms
    1. Poor concentration, memory decision making, problem solving or attention
    2. Intrusive images or Nightmares
  4. Emotional symptoms
    1. Agitation or irritability
    2. Anxiety, apprehension or fear
    3. Depressed mood or guilt
    4. Denial or blaming
    5. Emotional numbing or dissociation
  5. Physical symptoms
    1. Chills or sweats
    2. Dizziness, Faintness or weakness
    3. Muscle Tremors or twitching
    4. Dyspnea
    5. Bruxism
    6. Increased Blood Pressure
    7. Tachycardia (or Palpitations)

VI. History

  1. Reexperiencing
    1. Times that you relive event when it is not happening?
    2. Think about event when you do not want to (e.g. Nightmares)?
    3. Fear and anxiousness when reminded of event?
  2. Avoidance
    1. Avoid specific places, people, conversation topics or situations since the event?
    2. Avoid previously pleasurable activities?
    3. Less connected with family and friends?
    4. Others notice you are unhappy or detached?
    5. Change in life goals?
  3. Increased Arousal
    1. Insomnia since the event?
    2. Prone to anger, arguments or Violence since the event?
    3. Difficulty maintaining attention or completing tasks?
    4. Are there places you feel safe or are you always on guard?
    5. Are you startled by certain triggers, new since the event?

VII. Associated Conditions

  1. Major Depression
  2. Substance Abuse
  3. Aggressive outbursts
  4. Panic Attacks or Panic Disorder
  5. Profound demoralization and low self esteem
  6. Pervasive guilt, grief or suspiciousness
  7. Suicidal Ideation
  8. Somatic complaints
  9. Interpersonal and work related Impairment
  10. Sexual Dysfunction

VIII. Diagnosis: Screening

  1. Primary Care PTSD Screen (PC-PTSD)
  2. DREAMS Mnemonic
  3. SPAN Questionnaire

IX. Diagnosis: DSM-V Criteria

  1. See Spectrum of Trauma Response
  2. More than 1 MONTH of the following criteria
    1. Results in significantly impaired function
    2. Not due to other conditions
  3. Actual or threatened EXPOSURE to risk of death, serious injury or Sexual Violence (1 or more required)
    1. Includes witnessing events where other people were at risk
    2. Includes hearing of a serious event affecting close friends or family
    3. Exposure to extreme Trauma-related details or after-effects (only includes media if related to work)
  4. RE-EXPERIENCING the Trauma (1 or more required)
    1. Distressing, intrusive, recurrent event memories (or play themes in children over age 6 years)
    2. Recurrent related Nightmares
    3. Flashbacks in which the event is re-lived
    4. Intense emotional distress or physiologic reaction in response to associated triggers
  5. AVOIDANCE (1 or more required)
    1. Avoid related distressing memories, thoughts or feelings
    2. Avoid external reminders of event (e.g. people, places, situations or activities)
  6. NEGATIVE MOOD or Thought Process since the event (2 or more of the following)
    1. Key details of the event are not remembered
    2. Persistent negativity about self and others since the event
    3. Distorted thoughts about causes and consequences of the Traumatic event
    4. Persistent negative emotions (e.g. fear, guilt or anger)
    5. Avoidance of previously pleasurable activities
    6. Detachment from others (family, friends)
    7. Inability to experience happiness, satisfaction or other positive emotions
  7. Increased AROUSAL or reactivity since event (2 or more)?
    1. Outbursts of anger or irritability with minimal provocation
    2. Reckless behavior
    3. Hypervigilance
    4. Increased startle reaction
    5. Difficult concentration
    6. Insomnia
  8. Variations
    1. Delayed expression (manifests >6 months after event)
    2. Dissociation
      1. Depersonalization
        1. Sense of detachment from self (feelings, body)
        2. As if observing self from another person's perspective
      2. Derealization
        1. Sense that surrounding world is unreal
  9. References
    1. (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA, Washington, DC, p. 271-2

X. Management: General Approach

  1. Evaluate for Suicidality
    1. Requires immediate management
  2. Assess for associated conditions
    1. Chemical Dependency
    2. Mood Disorder (e.g. Major Depression)
    3. Traumatic Brain Injury
  3. Reassurance
    1. PTSD is a reaction to the stress of Trauma
    2. Predictable course and often resolves with treatment
  4. Anticipatory guidance
    1. Prepare patient for possible symptoms in future
    2. Be careful in somatizing or suggestible patients
  5. Cognitive behavioral approaches (individual or group therapy)
    1. Psychotherapy is a preferred first-line therapy with long lasting effects
      1. Medications, if needed, should only be adjunctive
    2. Cognitive processing therapy
      1. Challenge maladaptive beliefs about safety, trust, esteem
    3. Prolonged exposure therapy
      1. Breathing retraining to decrease arousal
      2. Repeated remembering of Trauma to teach memories are not dangerous
      3. Re-exposure to real world, feared situations
    4. References
      1. Coffey (2015) Am Fam Physician 92(9):807-12 [PubMed]

XI. Management: Medications - General Approach

  1. Efficacy
    1. SSRI and SNRI agents are effective, first-line therapies with the best evidence
      1. Reduce intrusive thoughts and flashbacks
      2. Decrease irritability, anger and hyperarousal
      3. Improve anxiety and depressed mood
    2. Other psychoactive agents have been used for more specific indications
  2. Precautions
    1. When SSRI and SNRI medications are stopped, relapse is common (taper off)
    2. Titrating to maximal doses is typically required
    3. Trial a medication for at least 2 months at maximal dose before excluding as ineffective
    4. Treat for at least 6-12 months before discontinuation
  3. Selective Serotonin Reuptake Inhibitor (SSRI)
    1. Sertraline (Zoloft) - FDA approved for PTSD
    2. Paroxetine (Paxil) - FDA approved for PTSD
    3. Citalopram (Celexa)
    4. Escitalopram (Lexapro)
    5. Fluoxetine (Prozac)
  4. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
    1. Venlafaxine (Effexor)
      1. Davidson (2006) Arch Gen Psychiatry 63:1158-65 [PubMed]
    2. Desvenlafaxine (Pristiq)
    3. Duloxetine (Cymbalta)

XII. Management: Medications - Specific Indications

  1. Dissociative flashbacks or intrusive memories
    1. Propranolol (Inderal) 10-20 mg PO qid prn
  2. Nightmares of Trauma
    1. Prazosin (Minipress)
    2. Cyproheptadine (Periactin) 4 mg PO qhs
    3. Trazodone
    4. Sedative-Hypnotics (short-term)
      1. Zolpidem (Ambien)
      2. Zaleplon (Sonata)
  3. Hallucinations of the Trauma
    1. Olanzapine (Zyprexa) 2.5 to 5 mg PO qd
  4. Avoidance, numbing sensation or diminished interests
    1. Selective Serotonin Reuptake Inhibitor (SSRI)
    2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
  5. Hyperarousal or Irritability
    1. Propranolol (Inderal) 10-20 mg PO qid prn
    2. Buspirone (Buspar)
    3. Benzodiazepines are not recommended
      1. Risk of paraxodical worsening of PTSD symptoms
      2. No evidence of benefit and risk of dependence
    4. Marijuana is not recommended
      1. No evidence of benefit and may worsen symptoms
  6. Mixed PTSD Symptoms - Mood stabilizers (based on weak evidence)
    1. Divalproex (Depakote) 250-500 mg tid (or 750 mg qhs)
    2. Carbamazepine (Tegretol) 400-800 mg PO qd
    3. Lamotrigine (Lamictal)
    4. Topiramate (Topamax)
    5. Gabapentin (Neurontin)
    6. Lithium

XIII. Resources

  1. National Center for PTSD
    1. http://www.ptsd.va.gov/public
  2. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
    1. http://www.dcoe.mil/psychologicalhealth.aspx
  3. National Child Traumatic Stress Network
    1. http://www.nctsnet.org
  4. SAMHSA National Help Line (for patients, staffed 24/7)
    1. https://www.samhsa.gov/find-help/national-helpline

XIV. References

  1. (2017) Presc Lett 24(10): 58
  2. Butler (1999) Am Fam Physician 60(2):524-30 [PubMed]
  3. Bowles (2000) Am Fam Physician 61(6):1689-96 [PubMed]
  4. Ursano (2004) Am J Psychiatry 161(11 suppl): 3-31 [PubMed]
  5. Warner (2013) Am Fam Physician 88(12): 827-34 [PubMed]

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Related Studies

Ontology: Post-Traumatic Stress Disorder (C0038436)

Definition (MEDLINEPLUS)

Post-traumatic stress disorder (PTSD) is a real illness. You can get PTSD after living through or seeing a traumatic event, such as war, a hurricane, sexual assault, physical abuse, or a bad accident. PTSD makes you feel stressed and afraid after the danger is over. It affects your life and the people around you.

PTSD can cause problems like

  • Flashbacks, or feeling like the event is happening again
  • Trouble sleeping or nightmares
  • Feeling alone
  • Angry outbursts
  • Feeling worried, guilty, or sad

PTSD starts at different times for different people. Signs of PTSD may start soon after a frightening event and then continue. Other people develop new or more severe signs months or even years later. PTSD can happen to anyone, even children.

Treatment may include talk therapy, medicines, or both. Treatment might take 6 to 12 weeks. For some people, it takes longer.

NIH: National Institute of Mental Health
Definition (NCI) An anxiety disorder precipitated by an experience of intense fear or horror while exposed to a traumatic (especially life-threatening) event. The disorder is characterized by intrusive recurring thoughts or images of the traumatic event; avoidance of anything associated with the event; a state of hyperarousal and diminished emotional responsiveness. These symptoms are present for at least one month and the disorder is usually long-term.
Definition (NCI_NCI-GLOSS) An anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress, such as military combat, violent assault, natural disaster, or other life-threatening events. Having cancer may also lead to post-traumatic stress disorder. Symptoms interfere with day-to-day living and include reliving the event in nightmares or flashbacks; avoiding people, places, and things connected to the event; feeling alone and losing interest in daily activities; and having trouble concentrating and sleeping.
Definition (MSH) A class of traumatic stress disorders with symptoms that last more than one month. There are various forms of post-traumatic stress disorder, depending on the time of onset and the duration of these stress symptoms. In the acute form, the duration of the symptoms is between 1 to 3 months. In the chronic form, symptoms last more than 3 months. With delayed onset, symptoms develop more than 6 months after the traumatic event.
Definition (PSY) Acute, chronic, or delayed reactions to traumatic events such as military combat, assault, or natural disaster.
Definition (CSP) acute, chronic, or delayed reactions to traumatic events such as military combat, assault, or natural disaster.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D013313
ICD9 309.81
ICD10 F43.1 , F43.10
SnomedCT 192415000, 47505003
DSM4 309.81
LNC LP94805-6, LA10583-5
English Neuroses, Post Traumatic, Neuroses, Post-Traumatic, Neuroses, Posttraumatic, Post Traumatic Stress Disorders, Post-Traumatic Neuroses, Post-Traumatic Stress Disorders, Posttraumatic Neuroses, Posttraumatic Stress Disorders, PTSD, Stress Disorder, Post Traumatic, Stress Disorder, Post-Traumatic, Stress Disorder, Posttraumatic, Stress Disorders, Post Traumatic, Stress Disorders, Post-Traumatic, Stress Disorders, Posttraumatic, posttraumatic stress disorder, Post-Traumatic Stress Disorder (PTSD), POSTTRAUMATIC STRESS DISORDERS, POST TRAUMATIC STRESS DIS, POSTTRAUMATIC STRESS DIS, STRESS DIS POSTTRAUMATIC, STRESS DIS POST TRAUMATIC, PTSD - Post-traum stress disor, combat fatigue, traumatic neurosis, post-traumatic stress disorder (diagnosis), post-traumatic stress disorder, Posttraumatic stress dis, Post-traumatic stress disorder (PTSD), Post-traumatic stress disorder, unspecified, Stress Disorders, Post-Traumatic [Disease/Finding], Post-Traumatic Stress Disorder, post traumatic stress syndrome, post-traumatic stress disorder (PTSD), Disorder;post traumatic stress, post-traumatic stress disorders, post traumatic stress disorders, post-traumatic stress syndrome, posttraumatic stress disorders, Post-traumatic stress disorder (disorder), -- Post Traumatic Stress Disorder, Post-traumatic stress disorder, Traumatic neurosis, PTSD - Post-traumatic stress disorder, Post-traumatic stress syndrome, Posttraumatic stress disorder (disorder), Posttraumatic stress disorder, disorder, post-traumatic stress, disorder; post-traumatic stress, disorder; stress, post-traumatic, neurosis; traumatic, post-traumatic stress; disorder, stress; disorder, post-traumatic, traumatic; neurosis, Posttraumatic stress disorder, NOS, Posttraumatic Stress Disorder, Traumatic Neurosis, Posttraumatic stress disorder NOS, post traumatic stress disorder
Italian Disturbo post-traumatico da stress, Neurosi post-traumatiche, PTSD, Disturbi da stress post-traumatico
Russian СТРЕСС ПОСТТРАВМАТИЧЕСКИЙ, СТРЕССОВЫЕ РАССТРОЙСТВА ПОСТТРАВМАТИЧЕСКИЕ, POSTTRAVMATICHESKIE STRESSOVYE RASSTROISTVA, STRESSOVYE RASSTROISTVA POSTTRAVMATICHESKIE, STRESS POSTTRAVMATICHESKII, NEVROZY TRAVMATICHESKIE, НЕВРОЗЫ ТРАВМАТИЧЕСКИЕ, ПОСТТРАВМАТИЧЕСКИЕ СТРЕССОВЫЕ РАССТРОЙСТВА
German Posttraumatische Neurosen, Posttraumatische Stressfolgen, Post-traumatische Neurosen, Posttraumatische Belastungsstörung, Post-traumatische Belastungsstörung, Post-traumatische Stressfolgen, Posttraumatische Belastungsstörungen, Post-traumatische Belastungsstörungen, Post-traumatische Streßfolgen, Posttraumatische Belastungsstoerung, post-traumatisches Stresssyndrom, Neurosen, posttraumatische, PTSD, Belastungsstörungen, posttraumatische, Posttraumatische Streßfolgen
French SSPT, Stress post-traumatique, Névroses post-traumatiques, Syndrome de stress post-traumatique, Troubles de stress post-traumatique, ESPT, TSPT, États de stress post-traumatique
Swedish Stressyndrom, posttraumatiskt
Czech neurózy posttraumatické, Posttraumatická stresová porucha, PTSD, stresové poruchy posttraumatické, posttraumatická stresová porucha, posttraumatický stresový syndrom
Finnish Posttraumaattiset stressihäiriöt
Japanese ストレス性障害-心的外傷後, ストレス障害-心的外傷後, 外傷後神経症, ｼﾝﾃｷｶﾞｲｼｮｳｺﾞｽﾄﾚｽｼｮｳｶﾞｲ, ストレス性障害-外傷後, 外傷後の神経症, 外傷後ストレス性障害, 外傷後ストレス障害, 外傷後ノイローゼ, 外傷性神経症, 心的外傷後ストレス障害, ストレス障害-外傷後, 心的外傷後ストレス性障害, 神経症-外傷後
Korean 외상후 스트레스 장애
Croatian POSTTRAUMATSKI STRESNI POREMEĆAJ
Polish Zespół stresu pourazowego, Nerwice pourazowe
Hungarian Posttraumás stress-betegség
Norwegian Posttraumatisk stress, Posttraumatiske nevroser, Posttraumatiske stressforstyrrelser, Posttraumatisk stressyndrom, Stressforstyrrelser, posttraumatiske, Stressyndrom, posttraumatisk
Spanish Trastornos de Estrés Postraumático, Estrés Postraumático, trastorno por estrés postraumático (trastorno), trastorno por estrés postraumático, trastorno por stress postraumático, trastorno por tensión postraumática, Trastorno por estrés postraumático, TEPT, Neurosis Postraumática, Trastornos por Estrés Postraumático, Trastornos Postraumáticos de Estrés
Portuguese Stress Pós-Traumático, Transtornos Pós-Traumáticos de Stress, Estresse Pós-Traumático, Transtornos de Stress Pós-Traumáticos, Perturbações Pós-Estresse Traumático, Perturbação de stress pós-traumático, PTSD, Neurose Pós-Traumática, Transtornos de Estresse Pós-Traumáticos, Transtornos Pós-Traumáticos de Estresse
Dutch Posttraumatische stressstoornis, neurose; traumatisch, posttraumatische stress; stoornis, stoornis; posttraumatische stress, stoornis; stress, posttraumatisch, stress; stoornis, posttraumatisch, traumatisch; neurose, posttraumatische stressstoornis, Neurosen, posttraumatische, PTSD, Posttraumatische stress-stoornissen, Stress-stoornis, posttraumatische, Stress-stoornissen, posttraumatische
Derived from the NIH UMLS (Unified Medical Language System)

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