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posttraumatic stress disorder (PTSD); includes acute stress disorder

Aliases: soldier's heart, fright neurosis, combat neurosis, war neurosis, shell shock, survivor syndrome, nuclearism, operational fatigue, compensation neurosis Etiology: 1) experiencing or witnessing a traumatic event a) combat b) rape, assault, battery c) trauma, motor vehicle accidents d) disaster 2) also see risk factors for posttraumatic stress disorder Epidemiology: 1) prevalence a) 1-14% in community-based studies (DSM IV) b) women 10.4%, men 5.0% with 30% of these developing chronic form c) 25% of US veterans 2) 4th most-common psychiatric disorder History: - history of exposure to trauma Clinical manifestations: 1) also see DSM IV criteria for posttraumatic stress disorder 2) also see Primary Care PTSD Screen (PC-PTSD) [6] 3) persistent re-experiencing the traumatic event(s) - avoidance of stimuli associated with the traumatic event(s) [1] 4) dreams or intrusive thoughts, emotional numbing & autonomic arousal lasting > 3 months 5) pelvic or abdominal pain often present 6) increased incidence of periodic limb movement disorder 7) World War II veterans a) insomnia (80%) b) nightmares (75%) c) irritability (65%) d) social isolation (50%) e) flashbacks (45%) 8) Pearl Harbor survivors a) intrusive memories (65%) b) survivor guilt (42%) c) avoidance & hyperarousal (33%) 9) sleep disturbance & memory impairment more common in elderly 10) other common symptoms [6] - distrust - anger, irritability, rage - anxiety - chronic depression - vigilence, constantly on gaurd, startle reaction, easily startled - intrusive throughts - sleep disorders & nightmares - sexual problems - inability to feel emotions - alcohol &/or substance abuse - suicidal ideation Special laboratory: - A 5-item tool (the PC-PTSD-5) is recommended for primary care screening [35] - a set of 28 biomarkers might aid in diagnosing PTSD [28] Complications: 1) comorbidities a) depression (37%) b) alcohol & substance abuse (53%) c) domestic abuse d) somatoform disorders e) anxiety disorders (50%) 1] panic disorder 2] obsessive-compulsive disorder 3] generalized anxiety disorder 4] agoraphobia f) complex PTSD/disorder of extreme stress not otherwise specified g) obesity (women) [16] 2) hypercoagulabitity, cardiovascular events [6,15] 3) stress-related disorders including PTSD are associated with increased risk for life-threatening infections [29] Differential diagnosis: - psychosocial stress (not associated with exposure to trauma) Management: 1) treat pain aggressively [12] 2) behavioral therapy/psychotherapy a) life-review technique b) debriefing sessions c) cognitive behavioral therapy (CBT)/cognitive processing therapy (CPT) [35] 1] very effective for patients who show PTSD symptoms soon after trauma [14] 2] effective if therapy is delayed until patients want it [14] 3] CBT/EMDR (eye movement desensitization & reprocessing) 6 45 minute sessions useful for children [22] 4] durable effects lasting > 12 months [30] 5] 2 CBT for PTSD, cognitive processing therapy &/or prolonged exposure are recommended as 1st-line treatments in all PTSD practice guidelines [33] d) 8 sessions of psychotherapy recommended within 14 weeks [18] e) exposure therapy [25] f) mindfulness of benefit [35] g) 3 psychotherapies with equal but low efficacy [24] h) psychotherapy is superior to pharmacotherapy in the long term [27,35] 3) group therapy - individual therapy more effective than group therapy in active-duty military personnel [19] - not recommended [35] 4) smart phone application (PTSD Coach) reduces symptoms of PTSD [20] 5) pharmaceutical agents a) analgesics as needed for pain b) antidepressants 1] selective-serotonin reuptake inhibitors (SSRIs) [5] a] 1st line therapy for PTSD b] FDA-approved for PTSD c] reduce core symptoms d] may help with depression & anxiety e] ref [17] suggests immediate treatment with an SSRI for bereavement-associated PTSD 2] SNRIs alternative 1st line therapy [12] 3] atypical antidepressant if SSRI or SNRI ineffective [12] - nefazodone [1] 4] tricycic antidepressants may help [5] - imipramine, amitryptiline 5] ketamine may be useful for co-morbid depression [35] c) prazosin may or may not mitigate nightmares (weak recommendation) [35] 1] start 1 mg PO QHS; titrate to effect up to 10 mg QHS [12] 2] of no benefit for chronic PTSD in military veterans [23] d) anxiolytics - avoid benzodiazepines [12] - NOT effective when used alone - adjunctive therapy for anxiety &/or insomnia e) anticonvulsants 1] may be useful for flashbacks [5] 2] not useful [12] f) atypical antipsychotics 1] added to an antidepressant to decrease hyperarousal & re-experiencing symptoms 2] not helpful when used alone [12] 3] may be no better than placebo as adjunct to SSRI [13] g) addition of MDMA to psychtherapy appears promising [32] h) do not prescribe benzodiazepine for PTSD [1] 6) acupuncture of benefit for combat veterans [34] 7) transcranial magnetic stimulation, direct current stimulation & electroconvulsive therapy not recommended Notes: - about 50% veterans with PTSD diagnosis receive recommended 8 sessions of psychotherapy within 14 weeks - outcome data rarely collected [18]

Interactions

disease interactions

Related

assessment measures for PTSD classification of traumatic events for PTSD DSM IV criteria for posttraumatic stress disorder risk factors for posttraumatic stress disorder

Specific

dyssynergic defecation

General

anxiety disorder stress disorder

References

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  8. deprecated reference
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  11. Prescriber's Letter 14(1): 2007 Propranolol for Post-traumatic Stress Disorder Detail-Document#: 230111 (subscription needed) http://www.prescribersletter.com
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