Post-traumatic stress disorder

• Diagnosis
  • Exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:
    • Directly experiencing the traumatic event(s).
    • Witnessing, in person, the event(s) as it occurred to others.
    •  Learning that the traumatic event(s) occurred to a close family member or close friend. – In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. – first responders collecting human remains or police officers repeatedly exposed to details of child abuse).
  • Intrusion Symptoms
    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event
      • children: older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
      • children: there may be frightening dreams without recognizable content.
    • Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
      • may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings
      • children: trauma-specific reenactment may occur in play.
    • intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Avoidance
    • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
    • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  • Negative Cognition and Mood
    • Inability to remember an important aspect of the traumatic event
    • dissociative amnesia
    • Persistent and exaggerated negative beliefs/expectations about oneself, others, or the world
      • e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined
    • Persistent, distorted cognitions about the cause or consequences
    • individual to blame himself/herself or others.
    • Persistent negative emotional state
      • fear, horror, anger, guilt, or shame
    • diminished interest or participation in significant activities.
    • Feelings of detachment or estrangement from others.
    • Persistent inability to experience positive emotions
      • (e.g., inability to experience happiness, satisfaction, or loving feelings).
  • Changes in Arousal
    • Irritable behavior and angry outbursts = verbal or physical aggression toward people or objects.
    • Reckless or self-destructive behavior
    • Hypervigilance
    • Exaggerated startle response
    • Problems with concentration
    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

T – Traumatic event (experienced, witnessed, or was confronted, and the person experienced intense helplessness, fear, and horror)

R – Re-experiencing (intrusive thoughts, nightmares, flashbacks, or traumatic memories/images)

A – Avoidance (emotional numbing, detachment from others, flattening of affect, loss of interest, lack of motivation, and persistent avoidance of things associated with the traumatic experience)

U – Unable to function (symptoms cause negative mood, distress, or cause significant impairment in social, occupational, and interpersonal life)

M – 1 month of symptoms (at least)

A – Arousal increased (insomnia, poor concentration, irritable, angry, startle reflex, hypervigilance)

Prognosis

• PTSD can occur at any point in life, beginning after age 1.
• Symptoms usually begin within the first 3 months after trauma,
  • although for some there may be a delay of months or years before the criteria for a full diagnosis is met.
• PTSD symptoms can be chronic, lasting years to decades after the initial trauma.
  • However, individuals generally have substantially improved occupational functioning at work, relationships, and social interactions.
  • long-term employment disability related to PTSD is also rare.
• Functioning
  • functioning will improve significantly over the long term
  • even if posttraumatic stress symptoms remain.

Risks

• increased risk for suicidal ideation and suicide attempts
• the risk is increased by 2 to 3-fold

Comorbidity

• 80% will have another mental disorder, including
  • depressive disorders
  • anxiety disorders
  • substance use disorders
  • borderline personality disorder.
• In children with PTSD
  • oppositional defiant disorder
  • separation anxiety disorder

Treatment

1. Psychotherapy
   1. Cognitive processing therapy (CPT)
   2. trauma-focused CBT (TF-CBT)
   3. prolonged exposure (PE) therapy
   4. Eye movement desensitization and reprocessing therapy (EMDR) 

Following treatment with psychotherapy, benefits can be maintained between 1 to 10 years.

In children, art therapy, play therapy, and family therapy (without the perpetrators of the trauma) can also be helpful.^[

2. Pharmacotherapy
   1. should start with either a selective serotonin reuptake inhibitor or a serotonin norepinephrine reuptake inhibitor.
   2. For individuals with PTSD-associated nightmares:
      1. Prazosin can reduce trauma nightmares and improve sleep quality. However, one recent randomized control trial actually found no difference between prazosin and placebo in military veterans with PTSD-associated nightmares.
      2. Naltrexone may also reduce flashbacks, and that fluphenazine may improve, we experiencing the symptoms.

1st line	Monotherapy: fluoxetine, paroxetine, sertraline†, venlafaxine XR
2nd line	Monotherapy: fluvoxamine, mirtazapine, phenelzine
3rd line	Monotherapy: amitriptyline, aripiprazole, bupropion SR, buspirone, carbamazepine, desipramine, duloxetine, escitalopram, imipramine, lamotrigine, memantine, moclobemide, quetiapine, reboxetine, risperidone, tianeptine, topiramate, trazodone
Adjunctive therapy*	Second-line: eszopiclone, olanzapine, risperidone Third-line: aripiprazole, clonidine, gabapentin, levetiracetam, pregabalin, quetiapine, reboxetine, tiagabine Not recommended: bupropion SR, guanfacine, topiramate, zolpidem
Not recommended	Alprazolam, citalopram, clonazepam, desipramine, divalproex, olanzapine (as monotherapy), tiagabine

† = If there is a co-morbid substance use disorder, sertraline is recommended as the medication of choice, * = Adjunctive therapy is used in patients who have had an inadequate response to adequate antidepressant therapy, and can be considered for patients with treatment-resistant PTSD.

Doses of pharmacological agents in the treatment of PtsD

Antidepressants	Doses (mg/day)
Paroxetine	20–50
sertraline	50–200
fluoxetine	20–80
Venlafaxine	75–300
Mirtazapine	15–45
amitriptyline	50–300
imipramine	50–300
Phenelzine	15–75
Anticonvulsants	Doses (mg/day)
topiramate	25–500
lamotrigine	50–500
Carbamazepine	300–1000
Antiadrenergic	Doses (mg/day)
Prazosin	2–15
Clonidine	0.2–0.4
Antipsychotics	Doses (mg/day)
risperidone	0.5–6
olanzapine	5–20
Quetiapine	25–300