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Key Features

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) moved from among the Anxiety Disorders in DSM-IV to new the category Trauma and Stressor-Related Disorder in DSM-5

  • 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

  • Posttraumatic stress disorder (PTSD) is more common when the event is associated with physical injury than when it is not

  • 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 may persist for a lifetime

Demographics

  • The estimated lifetime prevalence of PTSD among adult Americans is 6.8% with a point prevalence of 3.6%, with women having rates twice as high as men

  • Data indicate that 13% of veterans who served in Iraq and 6% of those who served in Afghanistan have experienced PTSD

Clinical Findings

Symptoms and Signs

  • Physiologic hyperarousal

    • Startle reactions

    • Intrusive thoughts

    • Illusions

    • Overgeneralized associations

    • Sleep problems

    • Nightmares

    • Dreams about the precipitating event

    • Impulsivity

    • Difficulties in concentration

    • Hyperalertness

Differential Diagnosis

  • Anxiety disorders

  • Affective disorders

  • Personality disorders exacerbated by stress

  • Somatic disorders with psychic overlay

Diagnosis

Laboratory Tests

  • Thyroid-stimulating hormone

  • Complete blood count

  • Toxicology screen (if suspected)

  • Glucose

Treatment

Medications

  • Selective serotonin reuptake inhibitors (SSRIs)—in full dosage

    • Helpful in ameliorating depression, panic attacks, sleep disruption, and startle responses in chronic PTSD

    • Sertraline and paroxetine are FDA approved for this purpose

  • Early treatment of anxious arousal with β-blockers (eg, propranolol, 80–160 mg daily orally)

    • May lessen the peripheral symptoms of anxiety (eg, tremors, palpitations)

    • Has not been shown to help prevent the development of the disorder

  • Noradrenergic agents, such as clonidine (titrated from 0.1 mg orally at bedtime to 0.2 mg three times a day), have been shown to help with the hyperarousal symptoms of PTSD

  • Antiseizure medications such as carbamazepine (400–800 mg daily orally) often mitigate impulsivity and difficulty with anger management

  • Benzodiazepines (Table 25–1) such as clonazepam (1–4 mg daily orally divided into one or two doses)

    • Reduce anxiety and panic attacks when used in adequate dosage

    • Dependency problems are a concern, particularly when the patient has had such problems in the past

  • Trazodone (25–100 mg orally at bedtime) is commonly prescribed ...

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