Updated: 8/27/2020

Post-Traumatic Stress Disorder (PTSD)

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Snapshot
  • A 40-year-old man presents to his psychiatrist for a follow-up appointment. He had been in the army for 10 years and had post-traumatic stress disorder (PSTD). He started seeing his psychiatrist 1 month ago and had been treated with cognitive behavioral therapy and sertraline. He reports that while this has helped with his thoughts during the day, he continues to have nightmares almost every night. His psychiatrist adds prazosin.
Introduction
  • Overview
    • PSTD is a condition resulting from exposure to real, threatened, or perceived serious injury or sexual assault with symptoms lasting > 1 month
      • often long latency (e.g., childhood abuse may appear as PTSD as an adult)
  • Epidemiology
    • incidence
      • lifetime prevalence of 8%
    • demographics
      • female > male
    • risk factors
      • trauma
  • Pathogenesis
    • mechanism
      • may be due to alterations in amygdala, hippocampus, prefrontal cortex, and hypothalamic pituitary axis
  • Associated conditions
    • other mood disorders
  • Prognosis
    • prognostic variable
      • resilience
Presentation
  • Symptoms
    • diagnosis according to DSM-5 requires
      • exposure to actual or threatened death, injury, or assault
      • persistent re-experience of event 
        • intrusive thoughts, nightmares or related dreams, recurrent memories, dissociative experiences such as flashbacks, and negative feelings due to triggers
      • avoidance of potential triggers or of talking/thinking about the event
      • negative alterations in cognition and mood
        • inappropriate blaming of oneself or others
        • persistent negative emotions
        • loss of interest
        • detachment from others
      • hyperarousal
        • irritability
        • insomnia
        • difficulty concentrating
        • self-harming acts
        • recklessness
      • symptoms last > 1 month
      • symptoms cause significant distress or dysfunction
      • symptoms are not attributable to anything else such as medications or medical condition
  • Physical exam
    • physiological signs of arousal
      • tremor, sweating, or agitation
    • decreased range of emotions
Differential
  • Acute stress disorder
    • key distinguishing factor
      • onset of similar symptoms after traumatic event that lasts 3 days to 1 month
      • treatment is cognitive behavioral therapy (CBT)
Treatment
  • Lifestyle
    • cognitive behavioral therapy (CBT)
      • indications
        • all patients
  • Medical
    • beta-blocker
      • indications
        • may prevent PTSD
    • SSRI (selective serotonin reuptake inhibitor)
      • indications
        • first-line
      • drugs
        • sertraline and paroxetine are FDA-approved
    • SNRI (serotonin-norepinephrine reuptake inhibitor)
      • indications
        • first-line along with SSRIs above
      • drugs
        • venlafaxine
    • clonidine and guanfacine
      • indications
        • agitation
    • prazosin
      • indication
        • reduce nightmares and insomnia
Complications
  • Mood disorders
  • Panic and other anxiety disorders
  • Substance abuse disorders
  • Headaches

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Questions (2)
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(M2.PY.17.4682) A 28-year-old male presents with a recent onset of upsetting dreams, anxiety, and disturbing flashbacks. The patient reports that he returned from active duty in Iraq 3 months ago and was adjusting to life back at home until about 7 weeks ago when he began having intense fear of loud noises and seeing sudden flashbacks to bombing attacks he endured during his time in Iraq. He had to take a leave from his army instructor duties as he was not able to handle the familiar settings of practice shooting ranges and sudden loud explosions during battalion training. After refusing to leave his house, he was finally persuaded by his wife to visit your clinic. What is the most likely diagnosis?

QID: 107301
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Acute stress disorder

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Performance anxiety

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Schizophrenia

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Posttraumatic stress disorder

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Panic attack

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