Posttraumatic Stress Disorder

History

• The experience of trauma includes exposure to threatened death, serious bodily injury, or sexual violence; such an event is required for the diagnosis, although witnessing (rather than personally experiencing) the traumatic event may also result in PTSD ^{r1c1c2c3c4c5c6}
  • Because patients may not associate current symptoms with a traumatic event, especially if a lot of time has passed, it is important to ask any patients who repeatedly report to primary care with unexplained physical symptoms about traumatic event(s)
  • Patients may give negative responses to all-inclusive questions (eg, "Have you ever been abused?"); specific questions (eg, "Have you ever been hit, beaten, or choked?") may be better ^r8
  • Males most often report combat experience, physical assault, witnessing death or assault, or being threatened with a weapon ^{r6c7c8c9c10c11}
  • Females more often report rape, sexual molestation, physical abuse, and childhood neglect ^{r6c12c13c14c15}
• Symptoms typically begin within 3 months of the traumatic event(s) ^r1
  • If duration of symptoms is less than 1 month, diagnosis cannot yet be made; however, if patient otherwise appears to have symptoms of PTSD, consider diagnosis of acute stress disorder ^r1
  • Symptoms fall within 4 groups: intrusion, avoidance, negative changes in cognition and mood, and alterations in arousal ^r1
    • Intrusion symptoms
      • Recurrent, intrusive, and involuntary memories of the event(s) ^r1c16c17
        • Memories typically involve sensory, emotional, or physiologic components
        • Often manifests as distressing dreams that replay the event or that thematically represent the event ^c18
      • Reliving the experience through flashbacks that may last from seconds to hours or days ^r1c19
        • Flashbacks range from brief sensory intrusions to complete loss of reality and awareness of surroundings
        • Patient may act as if the event(s) were occurring at that moment
      • Intense distress or physiologic reactivity after exposure to triggering people, places, or events or physical sensations ^c20
    • Avoidance symptoms
      • Patient will attempt to avoid all triggers that are reminders of the event ^c21
      • Avoids talking about the event in detail
    • Changes in cognitions and mood ^c22c23
      • Emotional numbing ^c24
        • Loss of interest in participating in activities once enjoyed ^r1c25
        • A feeling of detachment from other individuals ^c26
        • A persistent inability to feel positive emotions ^r1c27
      • Persistent negative feelings ^c28
        • About self, including shame or guilt, which may manifest in statements such as "I am a bad person" or "My nervous system is permanently ruined"
        • About the outside world, which may manifest in statements such as "the world is a terrible and dangerous place" or "I cannot trust anyone"
      • Negative changes in cognition ^r1
        • Difficulty concentrating, remembering daily events, or attending to focused tasks ^c29c30c31
        • Loss of memory for significant parts of the event(s) ^c32
        • Distorted thoughts and reasoning about the cause or consequences of the event(s) ^r1c33
      • Difficulty regulating emotions or maintaining interpersonal relationships (particularly for those with severe, repetitive, or prolonged trauma) ^r1c34c35
    • Altered arousal ^c36
      • Heightened sensitivity to perceived threats, both those related and not related to the traumatic event(s), and increased reactivity to unexpected stimuli ^r1c37c38
      • Aggression with little or no provocation or a quick temper ^r1c39c40
      • Participation in reckless or self-destructive behavior ^r1c41c42
      • Difficulty falling or staying asleep or having nightmares ^r1c43c44
• Symptoms manifest differently by age group
  • Children ^r1
    • Distressing dreams ^c45
      • Dream content may not be obviously related to the traumatic event(s)
    • Flashbacks can be experienced differently than in adults
      • May be manifested through play
      • Fear may not be expressed during the reexperiencing
    • Avoidance behaviors
      • In addition to avoiding people, places, and things that remind them of the trauma, school-aged children may avoid participation in new activities ^c46
    • Emotional and cognitive changes
      • Loss of positive expressions of emotion with increased expression of negative emotions (eg, sadness, shame, guilt) ^c47c48c49
      • Withdrawal from playing with friends ^c50
      • Developmental regression, including loss of language, may occur ^c51c52
    • Alterations in arousal
      • Angry outbursts or temper tantrums ^c53c54
  • Adolescents
    • May view themselves as cowardly ^c55
    • May view themselves as being changed in ways that make them undesirable to their peers ^c56
    • Reluctance to pursue developmental opportunities (eg, dating, driving) ^c57
    • May lose aspirations for the future ^c58
  • Older adults
    • May experience more avoidance, hyperarousal, sleep problems, and crying spells than younger people exposed to the same trauma ^{r1c59c60c61c62}
      • If PTSD begins in younger adulthood but continues into older age, symptoms of hyperarousal, avoidance, and negative cognition and moods may be reduced ^r1
    • Negative health perceptions are common, accompanied by increased using of primary care services ^c63
    • May have suicidal ideation ^c64
• Patients with untreated PTSD may use primary care services frequently, with a variety of unexplained somatic concerns

Physical examination

• Findings are typically normal unless the trauma resulted in a persistent physical injury or scarring ^c65
• A mental status examination should be performed to assist with differential diagnosis ^r4

Causes

• Although the cause of PTSD is not fully known, it is thought to result from altered trajectory of recovery after exposure to a traumatic event ^r9c66
  • While many people experience a DSM-5-TR PTSD-qualifying traumatic event, most do not develop PTSD
  • A hypothesis is that altered memory mechanisms contribute to maintenances and repeated activation of traumatic memory, as opposed to processing and contextualization ^r10c67
  • May be associated with neurobiologic alterations in the central and autonomic nervous systems ^r11c68
    • Certain alterations in the brain have been associated with PTSD ^r11r12
      • Reduced brain volume in the hippocampus and anterior cingulate ^c69
      • Excessive amygdala activity ^c70
      • Reduced activation of the prefrontal cortex and hippocampus in response to trauma reminders

Risk factors and/or associations

Primary diagnostic tools

• Diagnosis is based on patient interview, which may be aided by a screening assessment tool at the initial diagnostic encounter and ideally is confirmed by a semistructured interview with a mental health professional ^r4c148c149
  • In the primary care setting, use a screening instrument to determine if patient appears likely to have PTSD
    • PC-PTSD-5 (Primary Care PTSD Screen for DSM-5) ^r14
      • 5-item screening measure
      • Screening test of choice per US Department of Veterans Affairs/Department of Defense PTSD guidelines ^r4
      • High diagnostic accuracy and patient acceptability ^r15
      • Available from the US Department of Veterans Affairs ^r14

  • DSM-5 diagnostic criteria for posttraumatic stress disorder (children older than 6 years and adults).

    Data from American Psychiatric Association: Posttraumatic stress disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association; 2022:301-15

    Category	Criteria
    Criterion A
    Exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:	1. Personally experiencing traumatic event(s)
    	2. Witnessing the event(s) in person as it occurred to others
    	3. Learning about the event(s) that occurred to a close friend or family member
    	4. Experiencing repeated or extreme exposures to details of event(s). (Does not include exposures through electronic media, television, movies, or pictures, unless work related.)
    Criterion B
    Presence of at least 1 intrusion symptom associated with and occurring after the traumatic event(s):	1. Recurrent, involuntary, and intrusive distressing memories of the event(s)
    	2. Recurrent distressing dreams related to the event(s)
    	3. Dissociative reactions (eg, flashbacks) in which the patient feels or acts as if the event(s) were recurring
    	4. Intense or prolonged psychological distress when exposed to internal or external cues related to an aspect of the event(s)
    	5. Marked physiologic reactions to these cues
    Criterion C
    Persistent avoidance of certain stimuli associated with the event(s):	1. Efforts to avoid distressing memories, thoughts, or feelings related to the event(s)
    	2. Efforts to avoid external reminders of those memories, thoughts, or feelings
    Criterion D
    Negative changes in cognitions and mood associated with the event(s), either starting or worsening after the event(s), as evidenced by at least 2 of the following:	1. Inability to recall key features of the traumatic event (due to dissociative amnesia; not due to head injury, alcohol, or drugs)
    	2. Persistent and exaggerated negative beliefs or expectations about self, others, or the world in general
    	3. Persistent distorted cognitions about the cause or consequence of the event(s), resulting in the patient blaming self or others
    	4. Persistent negative emotions, such as fear, horror, anger, guilt, or shame
    	5. Markedly diminished interest or participation in significant activities
    	6. Feeling of detachment or estrangement from others
    	7. Persistent inability to experience positive emotions, such as happiness, satisfaction, or love
    Criterion E
    Changes in arousal and reactivity beginning or worsening after the event(s), as indicated by 2 or more of the following:	1. Irritable behavior and angry outbursts (with little or no provocation)
    	2. Reckless or self-destructive behavior
    	3. Hypervigilance
    	4. Exaggerated startle response
    	5. Difficulty concentrating
    	6. Sleep disturbance(s)
    Criterion F
    Criteria B, C, D, and E must be met for more than 1 month after the traumatic event
    Criterion G
    The condition must cause clinically significant distress or impairment
    Criterion H
    The condition is not attributable to substance use or any other medical condition

• After initial screening, if PTSD is likely, conduct an in-depth assessment to establish diagnosis; this assessment requires more time to complete and should be administered by someone knowledgeable about PTSD and trained in administering the assessment (typically a psychologist, psychiatrist, or clinical social worker) ^r4r9
  • Several semistructured interviewing tools are available to guide assessment: ^r2
    • CAPS-5 (Clinician-Administered PTSD Scale for DSM-5) ^r16
      • 30-item interview ^r2
      • Can be obtained by request from the US Department of Veterans Affairs ^r16
    • CAPS-CA-5 (Clinician-Administered PTSD Scale for DSM-5: Child/Adolescent Version) ^r3
      • For children and adolescents aged 7 years and older
      • Includes age-appropriate items and picture response options
      • Can be obtained by request from the US Department of Veterans Affairs ^r3
    • PSS-I-5 (PTSD Symptom Scale Interview) ^r17
      • Updated to include DSM-5 diagnostic criteria
      • Available by request from the University of Pennsylvania; details are available on the US Department of Veterans Affairs National Center for PTSD website^r17

Procedures

Most common

• Adjustment disorders ^r1c151
  • Similar to PTSD, DSM-5-TR defines adjustment disorders as the presence of emotional or behavioral symptoms in response to identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)
  • Unlike PTSD, the stressor can be of any severity or type
  • Diagnose adjustment disorder over PTSD in 1 of 2 situations:
    • When a patient is exposed to a stressor that meets criterion A for PTSD but responds in a way that does not meet all other PTSD criteria
    • When a patient responds in a way that meets all criteria for PTSD to a stressor that does not meet criterion A
• Acute stress disorder ^r1c152
  • Similar to PTSD, acute stress disorder is a reaction to actual or threatened death, serious injury, or sexual violation resulting in symptoms related to intrusion, negative mood, dissociation, avoidance, and arousal that begin or worsen after the stressful event(s)
  • Diagnostic criteria are slightly different from those of PTSD, requiring at least 9 symptoms from any of the following categories: intrusion, negative mood, dissociation, avoidance, and arousal
  • Differentiate by symptom duration; commonly diagnosed within 1 month after the traumatic event when the symptom duration is not sufficient for PTSD diagnosis
• Major depressive disorder ^r1c153d1
  • Mood disorder characterized by persistent feelings of sadness or hopelessness or loss of interest in activities once enjoyed
  • When preceded by a traumatic event, this condition may be mistaken for PTSD
  • Unlike PTSD, does not include any criteria B or C symptoms
  • Differentiate from PTSD by absence of several PTSD criteria symptoms
• Personality disorder ^r1c154d2
  • Condition characterized by chronic, persistent (commonly since childhood or adolescence) impairments in personality functioning and pathologic personality traits
  • As with PTSD, patient may have difficulty maintaining interpersonal relationships
  • Differentiate by absence of readily identifiable actual or threatened death, serious injury, or sexual violation linked to emergence of symptoms
• Dissociative disorders ^r1c155
  • Disorders characterized by a loss of normal integration between memories, identity awareness and sensations, and body movements; include the following:
    • Dissociative amnesia ^r1c156
    • Dissociative identity disorder ^r1c157
    • Depersonalization-derealization disorder ^r1c158
  • Symptoms may be mistakenly classified as PTSD with dissociative symptoms ^r1
    • However, if all criteria for PTSD are met, then PTSD with dissociative symptoms should be diagnosed
  • Unlike PTSD, dissociative disorders do not always result from exposure to trauma ^r1
  • Differentiate from PTSD by absence of several PTSD criteria symptoms
• Obsessive-compulsive disorder ^r1c159
  • Psychological condition characterized by recurrent intrusive thoughts or repetitive stereotyped behaviors that last for at least 1 hour per day or interfere with normal functioning
  • Similar to PTSD, obsessive-compulsive disorder is characterized by intrusive thoughts
  • However, in obsessive-compulsive disorder, thoughts do not typically relate to a past traumatic event
  • Differentiate from PTSD by the presence of compulsions, urges to perform rituals in response to obsessions, and absence of criteria D and E symptoms

Admission criteria

• Suicidal or homicidal ideation ^r8
• Severe illness with lack of social support ^r8
• Significant functional impairment ^r8

Recommendations for specialist referral

• Refer to a mental health professional for definitive diagnosis and disease management ^r8
  • If managed in a primary care setting, the US Department of Veterans Affairs/Department of Defense guidelines recommend collaborative care to ensure that the veteran is receiving evidence-based care ^r4
• Collaborate with a specialist in substance use disorders for patients with severe drug or alcohol dependence
• Outpatient care is optimal for most patients; however, those with comorbid conditions may require inpatient care ^r8

Drug therapy

• Selective serotonin reuptake inhibitors
  • Paroxetine ^c160
    • Paroxetine Hydrochloride Oral tablet; Adults: 20 mg PO once daily, initially. May increase the dose by 10 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Max: 50 mg/day.
    • Paroxetine Hydrochloride Oral tablet; Older Adults: 10 mg PO once daily, initially. May increase the dose by 10 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Max: 40 mg/day.
  • Sertraline ^c161
    • Sertraline Hydrochloride Oral tablet; Adults: 25 mg PO once daily initially. May increase the dose by 25 to 50 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Usual dose: 50 to 200 mg/day. Max: 200 mg/day.
• Serotonin and norepinephrine reuptake inhibitors
  • Venlafaxine ^c162
    • Immediate release
      • Venlafaxine Hydrochloride Oral tablet; Adults: 25 mg PO 2 to 3 times daily, initially. May increase the dose if inadequate response and depending on tolerability. Dose range: 75 to 375 mg/day PO in 2 to 3 divided doses.
    • Extended release
      • Venlafaxine Hydrochloride Oral tablet, extended-release; Adults: 37.5 mg PO once daily, initially. May increase the dose if inadequate response and depending on tolerability. Dose range: 75 to 225 mg PO once daily.
• α₁-Antagonist
  • Prazosin
    • Prazosin Hydrochloride Oral capsule; Adults: 1 mg PO once daily at bedtime, initially. Titrate dose to clinical response. Dose range: 3 to 20 mg/day.

Nondrug and supportive care

• Educative and supportive care (most useful for managing the acute aftermath of a traumatic event) ^r8c163c164
  • Education should focus on the following:
    • Expected physiologic and emotional response to trauma
    • Strategies for decreasing secondary or continual exposure to trauma
    • Ways to reduce stress (eg, breathing, physical exercises)
    • Importance of remaining mentally active
    • Importance of self-care
• Prolonged exposure therapy ^r9c165
  • Consists of 8 to 15 sessions for 60 to 90 minutes per session either weekly or biweekly
    • First few sessions focus on teaching the patient relaxation breathing exercises and providing psychoeducation about the symptoms of PTSD and the role of avoidance in maintaining treatment
    • Next several sessions focus on imaginal exposure, during which time the patient describes the traumatic event out loud for a prolonged time (eg, 30-45 minutes)
    • Includes in vivo exposure, which involves teaching the patient how to manage trauma-related situations that were previously avoided
    • Between sessions, patients are expected to listen to recordings of sessions and practice in vivo exposures
  • Treatment application should be culturally informed ^r8
  • Dropout rate ranges from 10% to 38% ^r9
• Cognitive processing therapy ^r9c166
  • Typically 12 sessions in individual or group format
  • Similar to prolonged exposure therapy, includes psychoeducation and education about the role of avoidance in maintaining the disorder
  • Early in the process, the patient writes down and discusses the impact the traumatic event had on their life
  • Through discussion, the therapist probes the patient for potential maladaptive thinking patterns and helps to develop strategies for developing more effective thinking patterns
  • Dropout rates are approximately 20% ^r9
• Eye movement desensitization and reprocessing ^r9c167
  • Length of treatment depends on patient ability to manage emotions
  • Initially, patients are trained to manage negative emotions
    • Patient is asked to list emotionally significant experiences and the distorted beliefs related to those experiences and desired beliefs
    • Patient is asked to think about a visual representation of the experience and to focus specifically on the physical sensations of the memory while engaging bilateral/saccadic eye movements
    • Patient then practices thinking the desired belief with the visual image of the trauma
• Cognitive behavioral therapy ^r34c168c169
  • Generally consists of 12 to 16 sessions; may be provided in group or individual formats
    • May also be provided through a computer or mobile device facilitated by a therapist (internet-based cognitive behavioral therapy)
      • Some data suggest computer delivery may be as effective as in-person delivery ^r4
      • Expert opinion is divided owing to concerns of substantial selection bias in trials
  • Focuses on the relationship among the patient's thoughts, feelings, and behaviors with the goal of helping the patient maintain a sense of control and reducing avoidance behaviors
  • May include exposure to trauma narrative or reminders of the trauma and psychoeducation about how trauma may affect a person; may also include stress management techniques
• Present-centered therapy ^r35
  • Focuses on increasing adaptive responses to life stressors and difficulties that relate to PTSD symptoms
  • May be provided in group or individual formats; can range from 12 to 32 sessions in a group format and 10 to 12 sessions for individually delivered therapy
  • Initial sessions provide an overview and rationale for therapy; subsequent sessions focus on topics chosen by patients, with the final session devoted to review and reflection
  • Therapist provides close listening, reflection, validation, support, and encouragement
• Narrative exposure therapy ^r36c170
  • Based on the patient establishing a chronologic narrative of their life, focusing on the traumatic event but including positive experiences to contextualize memories of the trauma
  • Therapist concludes therapy by presenting the patient with a written biography of their life
  • Often used in community settings or for patients who experience a trauma related to political, cultural, or social forces ^r36

Comorbidities

• Sleep disturbances ^c171
  • Present in nearly all veterans with PTSD ^r4c172
  • For patients with PTSD and insomnia, consider cognitive behavioral therapy for insomnia as first line treatment, with medication considered a second line intervention ^r4
  • Prazosin is an option for treatment of PTSD-associated nightmares and sleep disturbances ^r4
• Substance use disorders ^c173
  • Patients with PTSD and a substance use disorder (including nicotine/tobacco use disorder) can both tolerate and benefit from concurrent treatment for both conditions ^r4d3
  • Presence of a substance use disorder should not prevent concurrent treatment with evidence-based, trauma-focused therapy for PTSD ^r4
  • Combining medications and psychotherapy may be an effective strategy for treating PTSD and a co-occurring substance use disorder ^r4
• Other mental disorders, including depression and anxiety disorders ^c174c175c176
  • Patients are 80% more likely to meet criteria for another mental disorder compared with those without PTSD; screen patients for these disorders ^r1
• Traumatic brain injury ^c177
  • Among veterans deployed to the wars in Afghanistan and Iraq, co-occurrence of traumatic brain injury is 48% ^r1

Special populations

• Older adults
  • Symptoms of disease may be exacerbated in this population by declining health, decreasing cognitive function, and social isolation ^r1
  • These patients may be reluctant to report traumatic events or admit to emotional or psychological problems

At-risk populations

• Because of the availability of sound screening measures and the potential benefits of early identification of PTSD, the US Department of Veterans Affairs and Department of Defense recommend screening after separation from military service and during deployment ^r39
  • Department of Veterans Affairs recommends annual screening for the first 5 years after separation from service and every 5 years thereafter
  • Department of Defense recommends routine screening throughout cycles of deployment
  • A single screening is not recommended because the disorder can have a fluctuating course with periods of remission and recurrence
  • No screening method should be the sole basis for diagnosis; a more structured assessment is required

Screening tests

• PC-PTSD-5 ^r14r15c203
  • 5-item questionnaire with "yes"/"no" responses ^r15
    • Have you ever experienced an especially frightening, horrible, or traumatic event; for example, a serious accident or fire, physical or sexual assault or abuse, an earthquake or flood, war, seeing someone be killed or seriously injured, or having a loved one die through homicide or suicide?
      • If the patient answers "yes," move on; if "no," then the test result is negative
    • In the past month, have you:
      • 1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?
      • 2. Tried hard not to think about it or gone out of your way to avoid situations that reminded you of it?
      • 3. Been constantly on guard, watchful, or easily startled?
      • 4. Felt numb or detached from others, activities, or your surroundings?
      • 5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
    • Test result is positive if the patient answers "yes" to any 3 questions
      • Optimal sensitivity is reached if a 3-question cutoff is used
      • Optimal efficiency of the test is reached if a 4-question cutoff is used