Trauma & Stressor-Related Disorders

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

• 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 but 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

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

Laboratory Tests

• Thyroid-stimulating hormone

• Complete blood count

• Toxicology screen (if suspected)

• Glucose

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 beta-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

  • Now generally thought to be contraindicated in the treatment of PTSD

  • The risks of addiction and disinhibition are thought to outweigh the anxiolytic and sleep benefits in most patients

• Trazodone (25–100 mg orally at bedtime) is commonly prescribed as a non–habit-forming hypnotic agent

• Prazosin (2–10 mg orally at bedtime) has had mixed evidence for decreasing nightmares and improving quality of sleep in PTSD

• Second-generation antipsychotics

  • Have not demonstrated significant usefulness in the treatment of PTSD

  • However, quetiapine 50–300 mg/day may have a limited role in treating agitation and sleep disturbance

Therapeutic Procedures

• The therapeutic approach is to facilitate the normal recovery that was blocked at the time of the trauma

  • Therapy close to the event should be brief (8–12 sessions) and simple (catharsis and working through of the traumatic experience), expecting quick recovery and promoting a sense of mastery and acceptance over the traumatic event

• Cognitive processing therapy, cognitive behavioral therapy, and prolonged exposure therapy

  • Have demonstrated the greatest evidence in improving symptoms of PTSD

  • May be more beneficial than medications alone for PTSD

Prognosis

• The sooner that symptoms arise after the initial trauma and the sooner that therapy is initiated, the better the prognosis

• A study published in 2018 comparing sertraline and prolonged exposure therapy for patients with PTSD demonstrated that patients who received their preferred treatment were more likely to

  • Be adherent

  • Respond to treatment

  • Have lower self-reported PTSD, depression, and anxiety symptoms

• About 50% of patients experience chronic symptoms

• Prognosis is best in those with good premorbid psychological functioning

• Individuals experiencing an acute stress disorder typically do better than those experiencing a delayed posttraumatic disorder

• Individuals who experience trauma resulting from a natural disaster (eg, earthquake or hurricane) tend to do better than those who experience a traumatic interpersonal encounter (eg, sexual assault or combat)

When to Refer

• Partner relationship problems are a major area of concern, and it is important that the clinician have available a dependable referral source when marriage counseling is indicated