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ESSENTIALS OF DIAGNOSIS

  • Exposure to a traumatic or life-threatening event.

  • Flashbacks, intrusive images, and nightmares, often represent reexperiencing the event.

  • Avoidance symptoms, including numbing, social withdrawal, and avoidance of stimuli associated with the event.

  • Increased vigilance, such as startle reactions and difficulty falling asleep.

  • Symptoms impair functioning.

GENERAL CONSIDERATIONS

Posttraumatic stress disorder (PTSD) has been reclassified from an anxiety disorder to a trauma and stressor-related disorder in the DSM-5. PTSD is a syndrome characterized by “reexperiencing” a traumatic event (eg, sexual assault, severe burns, military combat) and decreased responsiveness and avoidance of current events associated with the trauma. The National Veterans Vietnam Readjustment Survey indicated that 53.4% of male and 48.1% of female Vietnam War veterans experienced some symptoms of PTSD, with approximately 60% of these affected veterans experiencing the full syndrome. Of the male veterans with PTSD, 44.7% experienced a lifetime prevalence of alcohol or drug abuse, with 13% experiencing current abuse or dependence. Data indicate that 13% of US veterans who served in Iraq and 6% of those who served in Afghanistan have experienced PTSD. The lifetime prevalence of PTSD among adult Americans has been estimated to be 6.8% with a point prevalence of 3.6% and with women having rates twice as high as men. Many individuals with PTSD (20–40%) have experienced other associated problems, including divorce, parenting problems, difficulties with the law, and substance abuse.

CLINICAL FINDINGS

The key to establishing the diagnosis of PTSD lies in the history of exposure to a perceived or actual life-threatening event, serious injury, or sexual violence. This can include serious medical illnesses, and the prevalence of PTSD is higher in people who have experienced serious illnesses such as cancer. The symptoms of PTSD include intrusive thoughts (eg, flashbacks, nightmares), avoidance (eg, withdrawal), negative thoughts and feelings, and increased reactivity. Patients with PTSD can experience physiologic hyperarousal, including startle reactions, illusions, overgeneralized associations, sleep problems, nightmares, dreams about the precipitating event, impulsivity, difficulties in concentration, and hyperalertness. The symptoms may be precipitated or exacerbated by events that are a reminder of the original traumatic event. Symptoms frequently arise after a long latency period (eg, child abuse can result in later-onset PTSD). DSM-5 includes the requirement that the symptoms persist for at least 1 month. In some individuals, the symptoms fade over months or years, and in others they may persist for a lifetime.

DIFFERENTIAL DIAGNOSIS

In 75% of cases, PTSD occurs with comorbid depression or panic disorder, and there is considerable overlap in the symptom complexes of all three conditions. Acute stress disorder has many of the same symptoms as PTSD, but symptoms persist for only 3 days to a month after the trauma. The other major comorbidity is alcohol and substance abuse. The Primary Care-PTSD Screen and the PTSD Checklist are two useful screening instruments in primary care clinics or community settings with populations at risk ...

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