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Post-Traumatic Stress Disorder
Aka: Post-Traumatic Stress Disorder, Posttraumatic Stress Disorder, PTSD
- See Also
- Acute Stress Disorder
- Anxiety Disorder
- Anxiety Secondary Cause
- Anxiety Symptoms
- Generalized Anxiety Disorder
- Obsessive Compulsive Disorder
- Body Dysmorphic Disorder
- Panic Disorder
- Social Anxiety Disorder (Social Phobia)
- Excessive Worry
- Anxiety Non-pharmacologic Management
- Anxiety Pharmacologic Management
- Pathophysiology
- See Spectrum of Trauma Response
- Causes: Trauma triggers for PTSD
- See Posttraumatic Stress Disorder Triggers
- Risk Factors
- See Posttraumatic Stress Disorder Risk Factors
- Symptoms
- Intrusive re-experiencing the Trauma
- Recurrent intrusive thoughts, images, dreams
- Intense distress when remembering Trauma
- Avoidance of reminders of Trauma
- Increased autonomic arousal
- Insomnia
- Angry outbursts or other anti-social behaviors
- Hyper-vigilance and suspiciousness
- Exaggerated startle response
- Change in activity, appetite, sleep, sex and social functioning
- Unable to rest (pacing)
- Cognitive symptoms
- Poor concentration, memory decision making, problem solving or attention
- Intrusive images or Nightmares
- Emotional symptoms
- Agitation or irritability
- Anxiety, apprehension or fear
- Depressed mood or guilt
- Denial or blaming
- Emotional numbing or dissociation
- Physical symptoms
- Chills or sweats
- Dizziness, Faintness or weakness
- Muscle Tremors or twitching
- Dyspnea
- Bruxism
- Increased Blood Pressure
- Tachycardia (or Palpitations)
- History
- Reexperiencing
- Times that you relive event when it is not happening?
- Think about event when you do not want to (e.g. Nightmares)?
- Fear and anxiousness when reminded of event?
- Avoidance
- Avoid specific places, people, conversation topics or situations since the event?
- Avoid previously pleasurable activities?
- Less connected with family and friends?
- Others notice you are unhappy or detached?
- Change in life goals?
- Increased Arousal
- Insomnia since the event?
- Prone to anger, arguments or Violence since the event?
- Difficulty maintaining attention or completing tasks?
- Are there places you feel safe or are you always on guard?
- Are you startled by certain triggers, new since the event?
- Associated Conditions
- Major Depression
- Substance Abuse
- Aggressive outbursts
- Panic Attacks or Panic Disorder
- Profound demoralization and low self esteem
- Pervasive guilt, grief or suspiciousness
- Suicidal Ideation
- Somatic complaints
- Interpersonal and work related Impairment
- Sexual Dysfunction
- Diagnosis: Screening
- Primary Care PTSD Screen (PC-PTSD)
- DREAMS Mnemonic
- SPAN Questionnaire
- Diagnosis: DSM-V Criteria
- See Spectrum of Trauma Response
- More than 1 MONTH of the following criteria
- Results in significantly impaired function
- Not due to other conditions
- Actual or threatened EXPOSURE to risk of death, serious injury or Sexual Violence (1 or more required)
- Includes witnessing events where other people were at risk
- Includes Hearing of a serious event affecting close friends or family
- Exposure to extreme Trauma-related details or after-effects (only includes media if related to work)
- RE-EXPERIENCING the Trauma (1 or more required)
- Distressing, intrusive, recurrent event memories (or play themes in children over age 6 years)
- Recurrent related Nightmares
- Flashbacks in which the event is re-lived
- Intense emotional distress or physiologic reaction in response to associated triggers
- AVOIDANCE (1 or more required)
- Avoid related distressing memories, thoughts or feelings
- Avoid external reminders of event (e.g. people, places, situations or activities)
- NEGATIVE MOOD or Thought Process since the event (2 or more of the following)
- Key details of the event are not remembered
- Persistent negativity about self and others since the event
- Distorted thoughts about causes and consequences of the Traumatic event
- Persistent negative emotions (e.g. fear, guilt or anger)
- Avoidance of previously pleasurable activities
- Detachment from others (family, friends)
- Inability to experience happiness, satisfaction or other positive emotions
- Increased AROUSAL or reactivity since event (2 or more)?
- Outbursts of anger or irritability with minimal provocation
- Reckless behavior
- Hypervigilance
- Increased startle reaction
- Difficult concentration
- Insomnia
- Variations
- Delayed expression (manifests >6 months after event)
- Dissociation
- Depersonalization
- Sense of detachment from self (feelings, body)
- As if observing self from another person's perspective
- Derealization
- Sense that surrounding world is unreal
- References
- (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA, Washington, DC, p. 271-2
- Management: General Approach
- Evaluate for Suicidality
- Requires immediate management
- Assess for associated conditions
- Chemical Dependency
- Mood Disorder (e.g. Major Depression)
- Traumatic Brain Injury
- Reassurance
- PTSD is a reaction to the stress of Trauma
- Predictable course and often resolves with treatment
- Anticipatory guidance
- Prepare patient for possible symptoms in future
- Be careful in somatizing or suggestible patients
- Cognitive behavioral approaches (individual or group therapy)
- Psychotherapy is a preferred first-line therapy with long lasting effects
- Medications, if needed, should only be adjunctive
- Cognitive processing therapy
- Challenge maladaptive beliefs about safety, trust, esteem
- Prolonged exposure therapy
- Breathing retraining to decrease arousal
- Repeated remembering of Trauma to teach memories are not dangerous
- Re-exposure to real world, feared situations
- References
- Coffey (2015) Am Fam Physician 92(9):807-12 [PubMed]
- Management: Medications - General Approach
- Efficacy
- SSRI and SNRI agents are effective, first-line therapies with the best evidence
- Reduce intrusive thoughts and flashbacks
- Decrease irritability, anger and hyperarousal
- Improve anxiety and depressed mood
- Other psychoactive agents have been used for more specific indications
- Precautions
- When SSRI and SNRI medications are stopped, relapse is common (taper off)
- Titrating to maximal doses is typically required
- Trial a medication for at least 2 months at maximal dose before excluding as ineffective
- Treat for at least 6-12 months before discontinuation
- Selective Serotonin Reuptake Inhibitor (SSRI)
- Sertraline (Zoloft) - FDA approved for PTSD
- Paroxetine (Paxil) - FDA approved for PTSD
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
- Venlafaxine (Effexor)
- Davidson (2006) Arch Gen Psychiatry 63:1158-65 [PubMed]
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Management: Medications - Specific Indications
- Dissociative flashbacks or intrusive memories
- Propranolol (Inderal) 10-20 mg PO qid prn
- Nightmares of Trauma
- Prazosin (Minipress)
- Cyproheptadine (Periactin) 4 mg PO qhs
- Trazodone
- Sedative-Hypnotics (short-term)
- Zolpidem (Ambien)
- Zaleplon (Sonata)
- Hallucinations of the Trauma
- Olanzapine (Zyprexa) 2.5 to 5 mg PO qd
- Avoidance, numbing Sensation or diminished interests
- Selective Serotonin Reuptake Inhibitor (SSRI)
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
- Hyperarousal or Irritability
- Propranolol (Inderal) 10-20 mg PO qid prn
- Buspirone (Buspar)
- Benzodiazepines are not recommended
- Risk of paraxodical worsening of PTSD symptoms
- No evidence of benefit and risk of dependence
- Marijuana is not recommended
- No evidence of benefit and may worsen symptoms
- Mixed PTSD Symptoms - Mood stabilizers (based on weak evidence)
- Divalproex (Depakote) 250-500 mg tid (or 750 mg qhs)
- Carbamazepine (Tegretol) 400-800 mg PO qd
- Lamotrigine (Lamictal)
- Topiramate (Topamax)
- Gabapentin (Neurontin)
- Lithium
- Resources
- National Center for PTSD
- http://www.ptsd.va.gov/public
- Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
- http://www.dcoe.mil/psychologicalhealth.aspx
- National Child Traumatic Stress Network
- http://www.nctsnet.org
- SAMHSA National Help Line (for patients, staffed 24/7)
- https://www.samhsa.gov/find-help/national-helpline
- References
- (2017) Presc Lett 24(10): 58
- Butler (1999) Am Fam Physician 60(2):524-30 [PubMed]
- Bowles (2000) Am Fam Physician 61(6):1689-96 [PubMed]
- Ursano (2004) Am J Psychiatry 161(11 suppl): 3-31 [PubMed]
- Warner (2013) Am Fam Physician 88(12): 827-34 [PubMed]