Posttraumatic Stress Disorder (PTSD)

Background

• PTSD is a condition induced by exposure to an event that results in psychological disturbances lasting ≥ 1 month.
• Common forms of trauma that result in PTSD include:
  • exposure to a personal life-threatening incident or combat
  • unexpected death of someone close
  • serious injury/illness of someone close
  • sexual assault
  • assault by a partner or caregiver
• Comorbid psychiatric conditions occur in about 75% of persons with PTSD and include anxiety, depression, bipolar and other mood disorders, substance use disorders, borderline personality disorder, oppositional defiant disorder, and attention deficit and hyperactivity disorder.
• PTSD is associated with increased impairments in quality of life and function, chronic pain, sleep disturbances, sexual dysfunction, cognitive dysfunction, alexithymia, suicide attempts, frequency and duration of hospitalization, and the use of mental healthcare.
• Approximately 33% of persons with PTSD develop chronic PTSD-related symptoms.

Evaluation

• Symptoms of PTSD have a variable onset and may develop > 6 months from the incident trauma.
• Patients who have experienced a significant trauma should be screened for PTSD using the Primary Care PTSD (PC-PTSD) Screen or Clinician Administered Posttraumatic Scale (CAPS) interview. Patients suspected to have PTSD should also be assessed for suicide risk.
• The diagnosis of PTSD is made by a clinical interview that directly elicits history which establishes:
  • exposure to an actual or threatened trauma
  • experiencing memories that are recurrent, involuntary, and intrusive, dreams that are distressing, reactions that are dissociative (such as flashbacks), and/or distressing psychological or physiologic reactions to reminders of the trauma
  • avoidance of stimuli associated with the trauma
  • 2 or more mood or cognitive changes associated with the trauma such as an inability to recall details of the trauma, detachment and estrangement from others, distorted blame, negative beliefs that are persistent, negative emotional state, and decreased interest in activity participation
  • 2 or more symptoms indicating a change in arousal and reactivity associated with trauma including aggressiveness or irritableness, recklessness, increased vigilance, increased startle response, concentration problems, and sleep disturbances
  • persistence of symptoms which cause significant functional impairment and distress for ≥ 1 month

Management

• Psychological therapy, antidepressants, and symptom-directed pharmacotherapy are the mainstays of treatment.
• Comorbid psychiatric conditions need to be concurrently managed.
• Trauma-focused cognitive behavioral therapy (CBT) is effective for reducing the symptoms of PTSD and its components include (VA/DoD Strong recommendation):
  • exposure to stimuli and feelings related to the traumatic event
  • restriction of a patient's usual anxiety-reducing behaviors such as escape or seeking reassurance so as to increase self-efficacy
  • cognitive strategies to reduce the existing exaggerated perception of threat
  • strategies to manage arousal levels such as breathing control
• Recommended individual, manualized trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring include:
  • Prolonged exposure therapy (usually through imaginal exposure) is effective at reducing PTSD symptoms (VA/DoD Strong recommendation).
  • Cognitive processing therapy (CPT) combines cognitive therapy with writing exercises and is effective for reducing symptoms and prolonging remission (VA/DoD Strong recommendation).
  • Eye-movement desensitization and reprocessing is effective and is an information processing therapy that includes elements of psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies (VA/DoD Strong recommendation).
  • Brief Eclectic Psychotherapy (BEP), Narrative Exposure Therapy (NET), and written Narrative Exposure (NE) are specific cognitive behavioral therapies for PTSD and are effective at reducing PTSD symptoms (VA/DoD Strong recommendation).
• First-line medications effective for PTSD include paroxetine 20-50 mg/day, sertraline 50-200 mg/day, venlafaxine extendend release (XR) 75-225 mg/day, or fluoxetine 20-80 mg/day (VA/DoD Strong recommendation).
• Nefazodone, imipramine, or phenelzine medications may be considered if first-line pharmacotherapy, trauma-focused psychotherapy, or non-trauma-focused psychotherapy ineffective, unavailable, or not appropriate (VA/DoD Weak recommendation).
• Specific symptoms of PTSD may be targeted with pharmacotherapy and include:
  • zolpidem, zaleplon, and trazodone for the management of insomnia
  • naltrexone and fluphenazine for the management of flashbacks
  • lithium, valproate, carbamazepine, lamotrigine, topiramate, or gabapentin adjunctive to selective serotonin reuptake inhibitors (SSRIs) for the management of mood swings, irritability, impulsivity, and related symptoms
• Benzodiazepines are not recommended as they may not reduce PTSD symptoms, may worsen nonhyperarousal PTSD symptoms, have a high potential for abuse, and may have dissociative effects and/or disinhibiting properties (Strong recommendation).
• Repetitive transcranial magnetic stimulation (rTMS) as monotherapy or adjunct to selective SSRIs may be effective at symptom reduction (Weak recommendation).
• Early intervention with psychological therapies following a trauma may help prevent the development of PTSD but evidence is conflicting.