Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 25-04: Psychiatric Trauma & Stressor-Related Disorders + Key Features Download Section PDF Listen +++ +++ 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 + Clinical Findings Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Laboratory Tests ++ Thyroid-stimulating hormone Complete blood count Toxicology screen (if suspected) Glucose + Treatment Download Section PDF Listen +++ +++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Guideline Development Panel for the Treatment of PTSD in Adults, American Psychological Association. Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Am Psychol. 2019 Jul–Aug;74(5):596–607. [PubMed: 31305099] + +Merz J et al. Comparative efficacy and acceptability of pharmacological, psychotherapeutic, and combination treatments in adults with posttraumatic stress disorder: a network meta-analysis. JAMA Psychiatry. 2019;76(9):904–13. [PubMed: 31188399] + +Raskind MA et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507–17. [PubMed: 29414272] + +Zoellner LA et al. Doubly randomized preference trial of prolonged exposure versus sertraline for treatment of PTSD. Am J Psychiatry. 2019 Apr 1;176(4):287–96. [PubMed: 30336702]