Post-Traumatic Stress Disorder

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

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II. Epidemiology: Lifetime Prevalence

  1. U.S. General Population: 6%
    1. Women: 8%
    2. Men: 4%
  2. U.S. Veterans: 7%
    1. Women: 13%
    2. Men: 6%
    3. Age 18-29: 15%
    4. Age 30-65: 9-10%
    5. Age >65 years: 4%
  3. References
    1. Schnurr, Epidemiology and Impact of PTSD (US VA), accessed 3/138/2023
      1. https://www.ptsd.va.gov/professional/treat/essentials/epidemiology.asp
    2. Goldstein (2016) Soc Psychiatry Psychiatr Epidemiol 51(8):1137-48 +PMID: 27106853 [PubMed]
      1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980174/

III. Pathophysiology

  1. See Spectrum of Trauma Response

IV. Causes: Trauma triggers for PTSD

  1. See Posttraumatic Stress Disorder Triggers

V. Risk Factors

  1. See Posttraumatic Stress Disorder Risk Factors

VI. 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)
    8. Gastrointestinal upset

VII. 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?

VIII. 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

IX. Diagnosis: Screening

  1. Precautions
    1. PTSD Screening should include Suicidality screening
  2. Indications
    1. History of likely Posttraumatic Stress Disorder Triggers
    2. Undifferentiated Mood Disorder
    3. Military Veterans
      1. Screen yearly for 5 years after military seperation, then once every 5 years thereafter
      2. See Healthcare of the Military Veteran
  3. Screening Tools
    1. Primary Care PTSD Screen (PC-PTSD)
    2. DREAMS Mnemonic
    3. SPAN Questionnaire
  4. Diagnostic Tools
    1. Clinician Administered PTSD Scale for DSM-5 (CAPS-5)
      1. Thirty item diagnostic tool requiring up to one hour for clinician to administer
    2. PTSD Checklist for DSM-5 (PCL-5)
      1. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
      2. Self-reported 20 item questionnaire, validated for civilian and military patients
    3. DSM-5 Criteria for Posttraumatic Stress Disorder (DSM-5)
      1. https://www.mdcalc.com/calc/10211/dsm-5-criteria-posttraumatic-stress-disorder

X. Diagnosis: DSM-V Criteria (over age 6 years old)

  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 (dissociative reactions)
    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. Modifiers
    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

XI. Management: General Approach

  1. Evaluate for Suicidality
    1. Requires immediate management
  2. Assess for associated conditions
    1. Traumatic Brain Injury
    2. Chemical Dependency
      1. Up to 40% of PTSD patients meet criteria for Alcohol Use Disorder
      2. Chemical use significantly increases Suicide Risk
    3. Mood Disorder
      1. Major Depression is comorbid in up to 50% of PTSD patients
  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. Typically consists of weekly or twice weekly sessions, 60 to 90 minutes each, for 6 to 12 weeks
    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]

XII. 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)
  5. Other agents that may improve symptoms
    1. Mirtazapine
    2. Amitriptyline

XIII. 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)
      1. May decrease sympathetic tone during sleep (mixed efficacy)
      2. Raskind (2018) N Engl J Med 378(6): 507-17 [PubMed]
      3. Zhang (2020) Sleep Med 67:225-31 [PubMed]
  3. Sleep Disturbance or Insomnia
    1. Screen for Obstructive Sleep Apnea
      1. Obstructive Sleep Apnea is found in up to 75% of patients with PTSD (at least moderate in 50%)
      2. Zhang (2017) Sleep Med 36:125-32 [PubMed]
    2. Cognitive Behavioral Therapy for Insomnia (preferred longterm)
    3. Sedative-Hypnotics (short-term)
      1. Zolpidem (Ambien)
      2. Zaleplon (Sonata)
    4. Other medications that have been used
      1. Cyproheptadine (Periactin) 4 mg PO qhs
      2. Trazodone
  4. Hallucinations of the Trauma (or PTSD refractory to SSRI/SNRI therapy)
    1. Olanzapine (Zyprexa) 2.5 to 5 mg orally daily
    2. Risperidone
      1. Rothbaum (2008) J Clin Psychiatry 69(4): 520-5 [PubMed]
      2. Krystal (2011) JAMA 306(5): 493-502 [PubMed]
    3. Aripiprazole
      1. Robert (2009) Psychopharmacol Bull 42(1): 69-80 [PubMed]
      2. Richardson (2011) BMC Psychiatry 11:86 [PubMed]
  5. Avoidance, numbing Sensation or diminished interests
    1. Selective Serotonin Reuptake Inhibitor (SSRI)
    2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
  6. 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
  7. 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

XIV. Prevention

  1. See Acute Traumatic Stress Disorder

XV. 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
  5. PTSD Treatments (AHRQ)
    1. https://effectivehealthcare.ahrq.gov/products/ptsd-adult-treatment-update/research-2018

XVI. 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. Sartor (2023) Am Fam Physician 107(3): 273-81 [PubMed]
  5. Ursano (2004) Am J Psychiatry 161(11 suppl): 3-31 [PubMed]
  6. Warner (2013) Am Fam Physician 88(12): 827-34 [PubMed]
  7. Williams (2022) Cochrane Database Syst Rev (3): CD002795 [PubMed]

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