Post-Traumatic Stress Disorder

1. See Also
   1. Acute Stress Disorder
   2. Anxiety Disorder
   3. Anxiety Secondary Cause
   4. Anxiety Symptoms
   5. Generalized Anxiety Disorder
   6. Obsessive Compulsive Disorder
   7. Body Dysmorphic Disorder
   8. Panic Disorder
   9. Social Anxiety Disorder (Social Phobia)
   10. Excessive Worry
   11. Anxiety Non-pharmacologic Management
   12. Anxiety Pharmacologic Management
2. Pathophysiology
   1. See Spectrum of Trauma Response
3. Causes: Trauma triggers for PTSD
   1. See Posttraumatic Stress Disorder Triggers
4. Risk Factors
   1. See Posttraumatic Stress Disorder Risk Factors
5. 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)
6. 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?
7. 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
8. Diagnosis: Screening
   1. Primary Care PTSD Screen (PC-PTSD)
   2. DREAMS Mnemonic
   3. SPAN Questionnaire
9. 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
10. 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]
11. 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)
12. 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
13. 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
14. 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]