para>Oppositional defiant disorder and separation anxiety are common comorbid conditions.
DIAGNOSIS
HISTORY
Diagnosis is based on DSM-V criteria:
- Criterion A: exposure to trauma ( ≥1 of the following):
- Direct experience of a traumatic event
- In-person witnessing of a traumatic event
- Learning of a traumatic event involving a close friend or family member
- Repeated exposure to details of a traumatic event
- Criterion B: intrusive symptoms associated with the traumatic event ( ≥1 of the following):
- Recurrent, involuntary, and intrusive distressing memories of the event
- Recurrent distressing dreams related to the event
- Dissociative reactions that simulate a recurrence of the event
- Intense or prolonged distress to stimuli that resemble an aspect of the event
- Criterion C: avoidance of stimuli associated with the trauma ( ≥1 of the following):
- Avoidance of memories, thoughts, or feelings about the event
- Avoidance of external reminders that trigger memories, thoughts, or feelings about the event
- Criterion D: negative cognitive and mood changes associated with the trauma ( ≥2 of the following):
- Inability to remember aspects of event
- Persistent and exaggerated negative opinion of self, others, or the world
- Distorted beliefs about the cause or consequences of the event
- Negative emotional state
- Diminished interest in significant activities
- Feeling detached from others
- Inability to experience positive emotions
- Criterion E: hyperarousal ( ≥2 of the following):
- Difficulty sleeping/falling asleep
- Decreased concentration
- Hypervigilance
- Outbursts of anger/irritable mood
- Exaggerated startle response
- Self-destructive behavior
- Criterion F: duration of the relevant criteria symptoms should be >1 month
- Criterion G: clinically significant distress/impairment in functioning
- Criterion H: relevant criteria not attributed to substance effects or other medical conditions
Pediatric Considerations
Memories of the traumatic event may not appear distressing and may be seen as play reenactment.
Frightening dreams of children may not have content attributable to the traumatic event.
Reactions can include a fear of being separated from a parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions, excessive clinging, and regressive behavior.
Older children may show extreme withdrawal, disruptive behavior, and/or an inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger, fighting, somatic complaints with no medical basis, and decline in schoolwork performance are often seen. Furthermore, depression, anxiety, feelings of guilt, and emotional numbing are often present.
Parental posttraumatic stress has been shown to be a robust predictor of pediatric PTSD (5)[A].
PHYSICAL EXAM
- Patients may present with physical injuries from the traumatic event.
- Mental status examination:
- Thoughts and perceptions (e.g., hallucinations, delusions, suicidal ideation, phobias)
- General appearance: disheveled, poor hygiene
- Behavior: agitation; startle reaction extreme
- Psychological numbness
- Orientation may be affected.
- Memory: forgetfulness, especially concerning the details of the traumatic event
- Poor concentration
- Poor impulse control
- Altered speech rate and flow
- Mood and affect may be changed: depression, anxiety, guilt, and/or fear
Pediatric Considerations
Elevated heart rate immediately following trauma is associated with development of PTSD (5)[A].
DIFFERENTIAL DIAGNOSIS
- Acute stress disorder (symptoms <4 weeks)
- Generalized anxiety disorder
- Adjustment disorder
- Obsessive-compulsive disorder
- Schizophrenia
- Major depressive disorder
- Mood disorder with psychotic features
- Substance abuse
- Personality disorders
- Dissociative disorders
- Conversion disorder
TREATMENT
Better prognosis if treated with a combination of psychotherapy and pharmacotherapy, initiated soon after the trauma.
MEDICATION
First Line
- SSRIs: depression, panic attacks, startle response, sleep disruption (6)[A]. All commonly used SSRIs have been shown to be effective in the treatment of PTSD and are the first-line treatment:
- Sertraline: 50 to 200 mg every day (FDA approved)
- Paroxetine: starting dose: 10 mg every day; may be increased in 10 mg increments at intervals ≥1 week (FDA approved)
- Fluoxetine: 20 mg every day/BID not to exceed 80 mg/day (demonstrates some efficacy for all three symptom clusters)
- Sleep disruption: Sleep disruption due to hyperarousal is ubiquitous in PTSD. Standard sedatives, such as trazodone 50 to 300 mg at bedtime, mirtazapine 7.5 to 30 mg qhs, or amitriptyline 25 to 100 mg qhs
- Nightmares/nighttime hyperarousal: prazosin 2 to 15 mg qhs (7)[A], clonidine 0.1 to 0.2 mg qhs, amitriptyline 25 to 100 mg qhs
Second Line
Refractory/residual symptoms: Consider augmentation with:
- Depression: mirtazapine 15 to 45 mg/day; consider switch to a serotonin-norepinephrine reuptake inhibitor (SNRI), such as venlafaxine XR 37.5 to 300 mg/day, duloxetine 60 to 120 mg/day or desvenlafaxine 50 to 100 mg/day. Nefazodone 300 to 600 mg/day in divided doses can be very effective, but requires quarterly LFTs.
- Reexperiencing/intrusive thoughts: first-/second-generation antipsychotic medications: aripiprazole 5 to 15 mg/day, risperidone 0.5 to 2 mg/day, olanzapine 2.5 to 10 mg/day, quetiapine 50 to 400 mg/day (8)[A]. 2nd-generation Rx less prone to extrapyramidal symptoms (EPS): cognitive dulling.
- Hyperarousal: clonidine, start 0.05 mg BID/TID; slowly titrate to as much as 0.45 mg/day divided doses; guanfacine 1 to 3 mg/day in divided doses (long-acting forms of both clonidine and guanfacine now available). Also consider 2nd-generation antipsychotics quetiapine, risperidone, and olanzapine as above. Divided doses often more helpful.
- Impulsivity/explosiveness: anticonvulsants: valproic acid 500 to 2,000 mg/day, carbamazepine 200 to 600 mg/day, topiramate 50 to 200 mg/day
- Anxiety: benzodiazepines (see "ALERT " ), including clonazepam, 1 to 4 mg/day in divided doses for a limited duration. Consider also hydroxyzine 25 to 50 mg TID/QID PRN or risperidone 0.25 to 0.5 mg TID PRN
ALERT
Given risk of substance abuse and questionable benefit in PTSD, recommended benzodiazepines be avoided (9)[A]. Short-acting benzodiazepines presents the greatest risk.
ADDITIONAL THERAPIES
- Psychotherapeutic interventions:
- Exposure therapies have shown the highest effectiveness for treatment of PTSD (10)[A]:
- Behavioral and cognitive-behavioral therapy (CBT): Early CBT has been shown to speed recovery. CBT is currently considered the standard of care for PTSD by the U.S. Department of Defense.
- One week intensive CBT was as effective as 3 months weekly CBT in one study (11)[A].
- Internet-based CBT has shown benefit in reduction of PTSD symptoms.
- Prolonged exposure therapy: Reexperience distressing trauma-related memories and reminders to facilitate habituation and successful emotional processing of memory.
- EMDR (eye movement desensitization and reprocessing) has been shown to benefit patients with PTSD (12)[A].
- Stress-reduction techniques:
- Immediate symptom reduction (e.g., rebreathing in a bag for hyperventilation)
- Early recognition and removal from a stress
- Relaxation, meditation, and exercise techniques are also helpful in reducing the reaction to stressful events.
- Telemedicine-based collaborative care (with nurse case manager, pharmacy, psychology, and psychiatry) is more effective than usual care (13)[A].
- Interpersonal psychotherapy:
- Supportive psychotherapy with an emphasis on the here and now
- Social:
- Establish the social framework of the problem. Clarifying this allows the patient to begin viewing it within the proper context (e.g., change of job/relocation of adult-dependent offspring)
INPATIENT CONSIDERATIONS
Inpatient care is necessary only if the patient becomes suicidal/homicidal or for treatment of comorbid conditions (e.g., depression, substance abuse).
ONGOING CARE
PATIENT EDUCATION
National Center for PTSD: www.ptsd.va.gov
PROGNOSIS
- Varies significantly from patient to patient
- In 50% of cases, the symptoms spontaneously remit after 3 months; however, in other cases, symptoms may persist, often for many years, and cause long-term impairment in life functioning.
- Factors associated with a good prognosis include:
- Rapid engagement of treatment
- Early and ongoing social support
- Avoidance of retraumatization
- Positive premorbid function
- Absence of other psychiatric disorders/substance abuse
COMPLICATIONS
- Increased risk for panic disorder, agoraphobia, obsessive-compulsive disorder, social phobia, specific phobia, major depressive disorder, somatization disorder; impulsive behavior, suicide, and homicide. Victims of sexual assault are at especially high risk for developing mental health problems and committing suicide.
- Benzodiazepines lead to abuse and dependence.
- Avoidance of stimuli associated with the trauma can generalize to wide-ranging avoidance. This leads to a far greater negative impact on the patient 's life.
REFERENCES
11 Alisic E, Zalta AK, van Wesel F, et al. Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. Br J Psychiatry. 2014;204:335 " 340.22 Amos T, Stein DJ, Ipser JC. Pharmacological interventions for preventing post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2014;(7):CD006239.33 Searcy CP, Bobadilla L, Gordon WA, et al. Pharmacological prevention of combat-related PTSD: a literature review. Mil Med. 2012;177(6):649 " 654.44 Rose S, Bisson J, Churchill R, et al. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002;(2):CD000560.55 Brosbe MS, Hoefling K, Faust J. Predicting posttraumatic stress following pediatric injury: a systematic review. J Pediatr Psychol. 2011;36(6):718 " 729.66 Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2006;(1):CD002795.77 Writer BW, Meyer EG, Schillerstrom JE. Prazosin for military combat-related PTSD nightmares: a critical review. J Neuropsychiatry Clin Neurosci. 2014;26(1):24 " 33.88 Han C, Pae CU, Wang SM, et al. The potential role of atypical antipsychotics for the treatment of posttraumatic stress disorder. J Psychiatr Res. 2014;56:72 " 81.99 Jeffreys M, Capehart B, Friedman MJ. Pharmacotherapy for posttraumatic stress disorder: review with clinical applications. J Rehabil Res Dev. 2012;49(5):703 " 715.1010 Korn ¸r H, Winje D, Ekeberg , et al. Early trauma-focused cognitive-behavioural therapy to prevent chronic post-traumatic stress disorder and related symptoms: a systematic review and meta-analysis. BMC Psychiatry. 2008;8:81.1111 Ehlers A, Hackmann A, Grey N, et al. A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. Am J Psychiatry. 2014;171(3):294 " 304.1212 Goodson J, Helstrom A, Halpern JM, et al. Treatment of posttraumatic stress disorder in U.S. combat veterans: a meta-analytic review. Psychol Rep. 2011;109(2):573 " 599.1313 Fortney JC, Pyne JM, Kimbrell TA, et al. Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72(1):58 " 67.
ADDITIONAL READING
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V). 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
CODES
ICD10
- F43.10 Post-traumatic stress disorder, unspecified
- F43.11 Post-traumatic stress disorder, acute
- F43.12 Post-traumatic stress disorder, chronic
ICD9
309.81 Posttraumatic stress disorder
SNOMED
- 47505003 Posttraumatic stress disorder (disorder)
- 192042008 Acute post-trauma stress state (disorder)
- 313182004 Chronic post-traumatic stress disorder (disorder)
- 318784009 Posttraumatic stress disorder, delayed onset (disorder)
- 699241002 Chronic post-traumatic stress disorder following military combat (disorder)
- 446175003 Acute posttraumatic stress disorder following military combat (disorder)
- 446180007 Delayed posttraumatic stress disorder following military combat (disorder)
CLINICAL PEARLS
- Treatment is often best accomplished with a combination of psychotherapy and pharmacotherapy.
- The sooner therapy is initiated after the trauma, the better the prognosis.