Anxiety
Post-Traumatic Stress Disorder
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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
Nightmare
s
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
Tremor
s or twitching
Dyspnea
Bruxism
Increased
Blood Pressure
Tachycardia
(or
Palpitation
s)
History
Reexperiencing
Times that you relive event when it is not happening?
Think about event when you do not want to (e.g.
Nightmare
s)?
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?
Screening
DREAMS Mnemonic
SPAN Questionnaire
Associated Conditions
Major Depression
Substance Abuse
Aggressive outbursts
Panic Attack
s or
Panic Disorder
Profound demoralization and low self esteem
Pervasive guilt, grief or suspiciousness
Suicidal Ideation
Soma
tic complaints
Interpersonal and work related
Impairment
Sexual Dysfunction
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
Nightmare
s
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
Trauma
tic 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
Gene
ral 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 -
Gene
ral 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
Higher doses are typically required
Treat for at least 6 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
Nightmare
s of
Trauma
Prazosin
(
Minipress
)
Cyproheptadine
(
Periactin
) 4 mg PO qhs
Trazodone
Sedative-Hypnotic
s (short-term)
Zolpidem
(
Ambien
)
Zaleplon
(
Sonata
)
Hallucination
s 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
)
Benzodiazepine
s 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
Trauma
tic Stress Network
http://www.nctsnet.org
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]
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