25-04: Psychiatric Trauma & Stressor-Related Disorders

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.

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.

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 for trauma exposure.

A. Psychotherapy

Psychotherapy should be initiated as soon as possible after the traumatic event, and it should be brief (typically 8–12 sessions), once the individual is in a safe environment. Cognitive processing therapy, cognitive behavioral therapy, and prolonged exposure therapy have demonstrated the greatest evidence in improving symptoms of PTSD. Evidence also shows that these psychotherapies may be more beneficial than medications alone for PTSD. In these approaches, the individual confronts the traumatic situation and learns to view it with less reactivity. Posttraumatic stress syndromes respond to interventions that help patients integrate the event in an adaptive way with some sense of mastery in having survived the trauma. 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.

Treatment of any comorbid substance abuse is an essential part of the recovery process for patients with PTSD. In patients with comorbid substance use disorders, there is evidence for better outcomes when substance abuse treatment is delivered alongside trauma-focused psychotherapy. Support groups and 12-step programs such as Alcoholics Anonymous are often very helpful.

Video telepsychiatry for psychotherapy or medication management allows for access to these resources that some patients, such as those in rural settings, may not otherwise have. There is similar efficacy in reduction of PTSD symptoms in women veterans with video teletherapy as with in-person therapy, and the practice of telepsychiatry is becoming more widely available.

B. Pharmacotherapy

SSRIs are helpful in ameliorating depression, panic attacks, sleep disruption, and startle responses in PTSD. Sertraline and paroxetine are approved by the US Food and Drug Administration (FDA) for this purpose, and the SSRIs are the only class of medications approved for the treatment of PTSD. They are, therefore, considered the pharmacotherapy of choice for PTSD. Early treatment of anxious arousal with beta-blockers (eg, propranolol, 80–160 mg orally daily) may lessen the peripheral symptoms of anxiety (eg, tremors, palpitations) but has not been shown to help prevent development of PTSD. Similarly, 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. The alpha-adrenergic blocking agent prazosin (2–10 mg orally at bedtime) has mixed evidence for decreasing nightmares and improving quality of sleep in PTSD, with a recent negative randomized control trial. Benzodiazepines, such as clonazepam, are generally thought to be contraindicated in the treatment of PTSD. The risks of benzodiazepines, including 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. Second-generation antipsychotics have not demonstrated significant utility in the treatment of PTSD, but agents such as quetiapine 50–300 mg/day may have a limited role in treating agitation and sleep disturbance in PTSD patients. Work with novel agents such as MDMA (methylenedioxymethamphetamine; also called Ecstasy) have shown early promise in the treatment of PTSD and are under investigation.

The sooner therapy is initiated after the trauma, 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, and have lower self-reported PTSD, depression, and anxiety symptoms. Approximately half of patients with PTSD experience chronic symptoms. Prognosis is best in those with good premorbid psychiatric functioning. Individuals experiencing an acute stress disorder typically do better long-term 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, rape or combat).