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Post-traumatic stress disorder

Definition
  • Post-traumatic stress disorder (PTSD) can occur after any major traumatic event.
  • Symptoms include upsetting thoughts and nightmares about the traumatic event, avoidance behaviour, numbing of general responsiveness, increased irritability, and hypervigilance.[1]
  • To fulfil the Diagnostic and Statistical Manual-IV (DSM-IV) criteria for PTSD:
    • An individual must have been exposed to a traumatic event
    • Have at least one re-experiencing, three avoidance, and two hyperarousal phenomena
    • Have had the symptoms for at least 1 month
    • The symptoms must cause clinically important distress or reduced day-to-day functioning.
  • It is labelled as acute for the first 3 months and chronic if it lasts beyond 3 months.[1]
  • People with subsyndromal PTSD have all the criteria for PTSD except one of the re-experiencing, avoidance, or hyperarousal phenomena.
  • Acute stress disorder occurs within the first month after a major traumatic event and requires the presence of symptoms for at least 2 days.
  • Treatments for PTSD may have similar effects, regardless of the traumatic event that precipitated PTSD.
  • However, great caution should be applied when generalising from one type of trauma to another.
Risk Factors
  • Major trauma (such as rape)
  • A history of psychiatric disorders
  • Acute distress and depression after the trauma
  • Lack of social support
  • Personality factors.
Differential diagnosis

Epidemiology
  • One large cross-sectional study in the USA found that 1/10 (10%) women and 1/20 (5%) men experience PTSD at some stage in their lives.[2]
Aetiology
  • The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body’s response to stress.
  • It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters).
  • Having been exposed to trauma in the past may increase the risk of PTSD.
Clinical features
  • Repeated "reliving" of the event, which disturbs day-to-day activity
    • Flashback episodes, where the event seems to be happening again and again
    • Recurrent distressing memories of the event
    • Repeated dreams of the event
    • Physical reactions to situations that remind you of the traumatic event
  • Avoidance
    • Emotional "numbing," or feeling as though you don’t care about anything
    • Feelings of detachment
    • Inability to remember important aspects of the trauma
    • Lack of interest in normal activities
    • Less expression of moods
    • Staying away from places, people, or objects that remind you of the event
    • Sense of having no future
  • Arousal
    • Difficulty concentrating
    • Exaggerated response to things that startle you
    • Excess awareness (hypervigilance)
    • Irritability or outbursts of anger
    • Sleeping difficulties
  • May also feel a sense of guilt about the event (including "survivor guilt"), and the following symptoms, which are typical of anxiety, stress, and tension:
    • Agitation, or excitability
    • Dizziness
    • Fainting
    • Feeling your heart beat in your chest (palpitations)
    • Fever
    • Headache
    • Paleness
Pathophysiology
  • Low cortisol levels may predispose individuals to PTSD
    • Because cortisol is normally important in restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.
  • There is considerable controversy within the medical community regarding the neurobiology of PTSD.
    • A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD.
    • Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.[27]
  • Three areas of the brain whose function may be altered in PTSD have been identified
  • In human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories.
    • The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus particularly during extinction.[33]
    • This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.[33][34]
    • Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.
Investigations
  • There are no tests that can be done to diagnose PTSD.
  • The diagnosis is made based on a set of symptoms that continue after extreme trauma.
Management

a) conservative
b) medical
Symptom class Symptom Medication
Reexperiencing
  intrusive recall amitriptyline; fluoxetine; imipramine; lamotrigine; sertraline
intrusive reexperiencing amitriptyline; fluoxetine; imipramine; nefazodone; sertraline (women only); topiramate;
sleep disturbance, nightmares benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; prazosin; topiramate; trazodone; zolpidem
dissociative recall risperidone
intense psychological distress (anger, anxiety) when exposed to reminders of traumatic event(s) benzodiazepines; buspirone; carbamazepine; lithium (not for anxiety); nefazodone; trazodone
Avoidance
  avoidance amitriptyline; fluoxetine; lamotrigine; nefazodone; sertraline
feelings of detachment or estrangement from others amitriptyline; risperidone
restricted range of affect (numbing) amitriptyline; lamotrigine; sertraline (women only)
Hyperarousal
  general hyperarousal amitriptyline; nefazodone; phenelzine; sertraline (women only)
sleep disturbance, nightmares benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; trazodone; zolpidem
irritability, anger (and impulsiveness) carbamazepine; nefazodone; valproic acid
anger buspirone; fluoxetine; lithium; trazodone
aggression risperidone
exaggerated startle response; general autonomic hyperexcitability benzodiazepines; buspirone; carbamazepine; clonidine; propranolol; valproic acid
Secondary symptom Medication
depression nefazodone; phenelzine
dream content distortions nefazodone
relapse of symptoms carbamazepine;
self-mutilation clonidine; buprenorphine
sexual function reduction nefazodone
sleep hours reduction nefazodone

c) surgical
  • n/a
Prognosis
  • One large cross-sectional study in the USA found that over a third of people with previous PTSD continued to satisfy the criteria for PTSD 6 years after initial diagnosis.[2]
  • However, cross-sectional studies provide weak evidence about prognosis.
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