Definition
A.Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways.
1.Directly experiencing the traumatic event(s).
2.Witnessing, in person, the event(s) that occurred to a close family member or close friend, resulting in actual or threatened death.
3.Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4.Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
B.Presence of one (or more) of the following intrusive symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred.
1.Recurrent, involuntary, and intrusive distressing stories or memories of the traumatic event(s).
2.Recurrent distressing dreams in which the content and/or affect of the dream related to the traumatic event(s) are expressed.
3.Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
4.Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5.Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C.Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following.
1.Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2.Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that trigger distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D.Negative alterations in cognition and mood associated with the traumatic event(s) beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following.
1.Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not the other factors such as head injury, alcohol, or drugs).
2.Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
3.Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4.Persistent negative emotional state (horror, fear, anger, guilt, shame).
5.Markedly diminished interest or participation in significant activities.
6.Feelings of detachment or estrangement from others.
7.Persistent inability to experience positive emotions.
E.Marked alterations in arousal and reactivity associated with the traumatic event(s) beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following.
1.Irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward others/objects.
2.Reckless or self-destructive behavior.
3.Hypervigilance.
4.Exaggerated startle response.
5.Problems with concentration.
6.Sleep disturbances (falling/staying asleep or restless sleep).
F.Duration of the disturbance is more than 1 month.
G.The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H.The disturbance is not attributed to the physiological effects of a substance or another medical condition.
Incidence
A.9% to 15% lifetime incidence, and lifetime prevalence is about 8% of the general population.
B.Lifetime prevalence is 10% in women and 4% in men and is more common in young adults.
C.More common in single, divorced, widowed, and socially withdrawn individuals.
D.Risk factor is severity, duration, and proximity of the person’s exposure to the trauma.
E.Symptoms usually develop within the first 3 months of the trauma, but a delay can exist.
Pathogenesis
A.Activation of the amygdala, increase in epinephrine and norepinephrine, and changes in cortisol production.
B.Activation of the hypothalamus–pituitary–adrenal axis (HPA) and reduction of the hippocampus/frontal cortex.
Predisposing Factors
A.Childhood trauma.
B.Intimate partner violence.
C.Personality disorder.
D.Female.
E.Genetic vulnerability.
F.Recent life change.
G.Perception of external locus of control.
H.Alcohol and substance use.
I.Rape, military combat, and ethnically motivated genocide.
J.Medical rule out: Posttraumatic stress disorder (PTSD) commonly exists with chronic pain syndromes and irritable bowel syndrome.
K.Other psychiatric disorders commonly coexist with PTSD and all other disorders.
Subjective Data
A.Common symptoms.
1.Patients who have PTSD have considerable stress that interferes with their ability to interact in society.
B.Common or typical scenario.
1.May involve the patient withdrawing from society, job loss, divorce, or even substance abuse.
C.Family/social history.
1.Ask about family situation, support system, or use of any drugs or alcohol.
D.Review of systems.
1.Psychiatric: Ask about depression, anxiety, constant fear, suicidal thoughts, or complaints of chronic pain.
Mental State Examination
A.General.
1.Agitated.
2.Anxious.
3.Irritable.
B.Attitude.
1.Describe if patient is friendly, cooperative, hostile, or defensive.
C.Mood.
1.General mood of patient.
D.Affect.
1.Can be described as expansive, euthymic, constricted, or blunted.
E.Speech.
1.Quantity, rate, and volume.
F.Thought process and content.
1.How is the patient thinking?
Diagnostic Tests
A.Screening instruments.
1.Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) (PCL-S).
2.Clinician-Administered PTSD Scale for PTSD (CAPS-5).
3.Trauma Screening Questionnaire (TSQ).
4.Short Screening Scale for PTSD.
5.Short Form of the PTSD Checklist.
Differential Diagnosis
A.Adjustment disorder.
B.Acute stress disorder—Distinguished from PTSD based on time frame: Duration is restricted to 3 days to 1 month.
C.Anxiety/obsessive-compulsive disorder.
D.Major depression.
E.Personality disorders.
F.Conversion disorder.
G.Psychotic disorders.
H.Traumatic brain injury.
Evaluation and Management Plan
A.General plan.
1.Psychotherapy.
a.Trauma-focused therapy.
b.Cognitive behavioral therapy (CBT).
c.Exposure therapy.
d.Eye movement desensitization and reprocessing (EMDR).
B.Pharmacotherapy.
1.Selective serotonin reuptake inhibitors (SSRIs) are the only Food and Drug Administration (FDA) approved treatment for PTSD and have the strongest evidence: Paroxetine (Paxil) and sertraline (Zoloft) are the only medications with FDA approval.
2.Benzodiazepines are not indicated in the treatment of PTSD.
3.Serotonin norepinephrine reuptake inhibitors (SNRIs) like venlafaxine XR (Effexor SR) and mirtazapine (Remeron) have been shown to be helpful.
4.Prazosin has been studied to treat nightmares: Starting dose 1 mg with range up to 40 mg.
Follow-Up
A.Coordination with a psychiatric specialist for ongoing treatment and follow-up.
B.Trauma-informed care and interventions have the best outcomes.
Consultation/Referral
A.Consider referral for integrative treatments (Confusion Assessment Method [CAM]): Mindfulness, yoga, acupuncture, and massage.
Special/Geriatric Considerations
A.Adaptive coping in elderly patients may be impaired and lead them to engage in substance abuse to manage PTSD symptoms.
B.Older adults may not identify symptoms in the context of a psychological framework, making them less likely to seek treatment.
C.There may be a stigma in older adults about seeking psychological assistance.
Bibliography
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Pliszka, S. R. (2016). Neuroscience for the mental health clinician (5th ed.). New York, NY: Guilford Press.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014). Stahl’s essential psychopharmacology: Prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.