Trauma & Stressor-Related Disorders

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 the new 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

• Persons with comorbid chronic pain tend to have heightened PTSD symptoms compared to persons without chronic pain

Demographics

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

• Veterans

  • Data indicate that 53.4% of male and 48.1% of female Vietnam War veterans experienced some symptoms of PTSD, with approximately 60% of these affected 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 veterans who served in Iraq and 6% of those who served in Afghanistan have experienced PTSD

• Many individuals with PTSD (20–40%) experience other problems, including divorce, parenting problems, difficulties with the law, and substance abuse

• Studies using cross-sectional surveys have indicated a higher risk for PTSD among frontline workers during the COVID-19 pandemic

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

• 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

• MDMA (methylenedioxymethamphetamine; also called Ecstasy) significantly enhanced the treatment effects associated with manualized cognitive behavioral therapy for severe PTSD

• Early treatment of anxious arousal with β-blockers (eg, propranolol, ...