Post-Traumatic Stress Disorder (PTSD)

Snapshot

A 25-year-old woman presents for her annual exam. She appears easily startled and agitated. On further questioning, she reveals that she had a traumatic experience 3 months ago and since then has had nightmares, irritability, intrusive thoughts about it, and insomnia. She reports feeling “down” every day, but she wishes to avoid talking about the trauma explicitly. Her primary care doctor refers her to psychiatry who specializes in post-traumatic stress disorder (PSTD).

Introduction

Overview
- PSTD is a condition resulting from exposure to real, threatened, or perceived serious injury or sexual assault with symptoms lasting >1 month
  - often long latency (e.g., childhood abuse may appear as PTSD as an adult)
Epidemiology
- incidence
  - lifetime prevalence of 8%
- demographics
  - female > male
- risk factors
  - trauma
Pathogenesis
- mechanism
  - may be due to alterations in amygdala, hippocampus, prefrontal cortex, and hypothalamic pituitary axis
Associated conditions
- other mood disorders
Prognosis
- prognostic variable
resilience

Presentation

Symptoms
- diagnosis according to DSM-5 requires
  - exposure to actual or threatened death, injury, or assault
  - persistent re-experience of event
    - intrusive thoughts, nightmares or related dreams, recurrent memories, dissociative experiences such as flashbacks, and negative feelings due to triggers
  - avoidance of potential triggers or talking/thinking about the event
  - negative alterations in cognition and mood
    - inappropriate blaming of oneself or others
    - persistent negative emotions
    - loss of interest
    - detachment from others
  - hyperarousal
    - irritability
    - insomnia
    - difficulty concentrating
    - self-harming acts
    - recklessness
  - symptoms last > 1 month
  - symptoms cause significant distress or dysfunction
  - symptoms are not attributable to anything else such as medications or medical condition
Physical exam
- physiological signs of arousal
  - tremor, sweating, or agitation
decreased range of emotions

Differential

Acute stress disorder
- key distinguishing factor
  - onset of similar symptoms after traumatic event that lasts 3 days to 1 month
treatment is cognitive behavioral therapy (CBT)

Treatment

Lifestyle
- cognitive behavioral therapy (CBT)
  - indications
    - all patients
Medical
- beta-blocker
  - indications
    - may prevent PTSD
- SSRI (selective serotonin reuptake inhibitor)
  - indications
    - first-line
  - drugs
    - sertraline and paroxetine are FDA-approved
- SNRI (serotonin-norepinephrine reuptake inhibitor)
  - indications
    - first-line along with SSRIs above
  - drugs
    - venlafaxine
- clonidine and guanfacine
  - indications
    - agitation
- prazosin
  - indication
reduce nightmares and insomnia

Complications