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) ETIOLOGY Pathogenesis mechanism may be due to alterations in amygdala, hippocampus, prefrontal cortex, and hypothalamic pituitary axis Associated conditions other mood disorders Epidemiology Incidence lifetime prevalence of 8% Demographics female > male Risk factors trauma 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 Prognosis Prognostic variable resilience