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PTSD-Diagnosis and Treatment Options

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Contact Hours: 2

This online independent study activity is credited for 2 contact hours at completion.

Course Purpose

To provide healthcare professionals with an overview of posttraumatic stress disorder (PTSD), assessment tools currently used, and psychotherapies and common medications used to improve symptoms.

Overview

Posttraumatic stress disorder (PTSD) is a syndrome that results from exposure to real or threatened death, serious injury, or sexual assault. The symptoms of PTSD include persistently re-experiencing the traumatic event, intrusive thoughts, nightmares, flashbacks, dissociation, intense negative emotions such as sadness and guilt, and physiological reactions when exposed to the traumatic reminder. Having awareness regarding the signs and symptoms of PTSD is essential for healthcare professionals to start early treatment and limit the burden of the illness on the person who suffers from PTSD.

Objectives

Upon completion of the independent study, the learner will be able to:

  1. Define posttraumatic stress disorder (PTSD)
  2. Describe the symptoms of PTSD
  3. Identify diagnostic tools for PTSD that may be used by healthcare professionals and mental health experts.
  4. Review various psychotherapies and medication classifications to treat PTSD

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PTSD: Diagnosis and Treatment Case Study

Mike is a military veteran who has been working in the outpatient building of your local hospital for the last year. While at work, a patient diagnosed with bipolar disorder became agitated and aggressive, and attempted to throw a chair at a staff member. The sound of the chair hitting the floor was extremely loud, and startled patients in the waiting area.
After checking to see if everyone was ok, you notice Mike standing away from other staff members, and his hands are clenched. In previous conversations, Mike shared with you that he suffers from PTSD. What are the symptoms of PTSD? How is PTSD diagnosed, and what are some of the treatments that are used to improve the symptoms of PTSD? The responses to these questions will be answered during the review of posttraumatic stress disorder.

Definitions
Acute stress disorder (ASD)An intense, unpleasant, and dysfunctional reaction beginning shortly after a traumatic event and lasting less than one month.
Diagnostic and Statistical Manual of Mental Disorders(DSM-5)A handbook that is widely used by clinicians and psychiatrists to diagnose psychiatric illnesses. The DSM covers all categories of mental health disorders for both adults and children.
Posttraumatic Stress Disorder (PTSD)A syndrome that results from exposure to real or threatened death, serious injury, or sexual assault that lasts longer than one month.
Introduction

Posttraumatic stress disorder (PTSD) is a syndrome that results from exposure to real or threatened death, serious injury, or sexual assault.¹ Following the traumatic event, PTSD is common and is one of the serious health concerns that is associated with comorbidity, functional impairment, and increased mortality with suicidal ideations and attempts. The Diagnostic and Statistical Manual of Mental Disorders(DSM-5) has included PTSD in the new category of Trauma- and Stress-related Disorders.

The symptoms of PTSD include persistently re-experiencing the traumatic event, intrusive thoughts, nightmares, flashbacks, dissociation(detachment from oneself or reality), intense negative emotions such as sadness and guilt, and physiological reactions when exposed to the traumatic reminder.⁹ Furthermore, problems with sleep and concentration, irritability, increased reactivity, increased startle response, hypervigilance, avoidance of traumatic triggers also occur. There is a significant impairment in social, occupational, and other areas of functioning. However, the symptoms of PTSD overlap with acute stress disorder (ASD).⁵ The symptoms of ASD and PTSD are the same, however there is a variation in the duration of the symptoms. Acute stress disorder occurs in no less than three days and no longer than four weeks, in comparison to PTSD, which lasts longer than four weeks and can persist for years.

The development of posttraumatic stress disorder in individuals is linked to a large number of factors. These include experiencing a traumatic event such as a severe threat or a physical injury, a near-death experience, combat-related trauma, sexual assault, interpersonal conflicts, child abuse, or after a medical illness. Chronic PTSD occurs in people who are unable to recover from the trauma due to maladaptive responses.¹²

The risk factors for the development of PTSD include biological and psychological factors such as gender (more prevalent in women), childhood adversities, pre-existing mental illness, low socioeconomic status, less education, and lack of social support.

Pathophysiology Related to PTSD

Posttraumatic stress disorder occurs in approximately 5% to 10% of the population who has a traumatic experience, and the percentage is higher in women than in men.¹⁷ Studies have shown that the rates vary depending on the specific population being considered. ¹⁷

The pathophysiology of posttraumatic stress disorder involves alterations in the neurotransmitter and neurohormonal functioning. Individuals with PTSD have shown to have normal to low levels of cortisol and elevated levels of corticotropin-releasing factor (CRF) despite their ongoing stress.⁶ Corticotropin-releasing factor stimulates the release of norepinephrine by the anterior cingulate cortex, leading to an increased sympathetic response, which manifests as increased heart rate, blood pressure, increased arousal, and startle response. Also, some studies have shown altered functioning of other neurotransmitter systems such as GABA, glutamate, serotonin, neuropeptide Y, and other endogenous opioids in patients with PTSD. ¹² There is a decrease in GABA activity and an increase in the glutamate, which fosters dissociation and derealization. Serotonin concentration is also decreased in dorsal/median raphe, which likely changes the dynamic between the amygdala and the hippocampus. Plasma neuropeptide Y concentration is also reduced.¹⁴ 

Posttraumatic stress disorder is also associated with a change in the neurophysiology and anatomy of the brain. The size of the hippocampus is reduced, and the amygdala, which processes emotions and modulating fear response, is overly reactive in individuals with PTSD. The medial prefrontal cortex which causes inhibitory control over the emotional reactivity of amygdala also appears to be smaller and less responsive in patients with PTSD.

Diagnosing PTSD

The initial step in the diagnosis of posttraumatic stress disorder is to obtain a detailed history. It may be challenging for the individual to describe the nature and severity of the traumatic event, and they may choose to avoid mentioning it. However, the presentation and the duration of the symptoms are useful in making an accurate diagnosis. The healthcare professional must inquire about any depressive or anxiety symptoms, suicidal ideation or previous attempts of suicide, substance abuse, and access to firearms.

The initial step in the diagnosis of posttraumatic stress disorder is to obtain a detailed history. It may be challenging for the individual to describe the nature and severity of the traumatic event, and they may choose to avoid mentioning it. However, the presentation and the duration of the symptoms are useful in making an accurate diagnosis. The healthcare professional must inquire about any depressive or anxiety symptoms, suicidal ideation or previous attempts of suicide, substance abuse, and access to firearms.

The Diagnostic Criteria for the Diagnosis of PTSD as per DSM-5 include²:

Criterion A: Stressor

Exposure to real or threatened death, injury, or sexual violence in one or more of the following ways:

  • Being directly exposed to the traumatic event.
  • Having indirect exposure to distressing details of the traumatic event; for instance, when professionals are repeatedly exposed to the details of child abuse, collecting human remains, or pieces of evidence. This does not include exposure through television, movies, electronic devices, or pictures.
  • Learning about a close family relative or close friend who was exposed to actual or threatened trauma, or accidental or violent death.
  • Witnessing at traumatic event as it occurred to someone else.

Criterion B: Intrusion Symptoms

Presence of one or more of the following symptoms related to the traumatic event that began after the trauma occurred:

  • Dissociative reactions, as flashbacks, in which the person may feel or act as though the traumatic event is happening again. These reactions may occur as a continuum ranging from brief reactions to complete loss of awareness of oneself or their surroundings. Children may re-enact events during play.
  • Distressing nightmares that may be repetitive where the content of the dream is related to the traumatic event. Children may have frightening dreams where they may or may not recognize the content.
  • Intense or prolonged psychological distress on exposure to traumatic reminders.
  • Marked physiological reactivity such as increased heart rate, blood pressure on exposure to traumatic reminders.
  • Recurrent, involuntary, and intrusive thoughts associated with the traumatic event. In children older than 6 years, this may be expressed using repetitive play in which the aspects of the trauma are expressed.

Criterion C: Avoidance

Persistent avoidance of the stimuli related to the traumatic event, as evidenced by one or both of the following:

Criterion D: Negative Alterations in Mood

Negative alterations in mood and cognition that began or worsened after the traumatic event, as evidenced by two or more of the following:

  • Feeling alienated, estranged, or detached from others.
  • Inability to recall important aspects of the traumatic event. This can be due to dissociative amnesia, not due to head injury, drugs, or alcohol.
  • Markedly diminished interest in significant activities that used to be enjoyable.
  • Persistent and distorted negative beliefs or expectations about oneself or the world, such as “I am bad,” or “The world is completely dangerous.”
  • Persistent distorted cognition that leads the individual to blame themself or others for causing the traumatic event.
  • Persistent inability to experience a positive emotion such as happiness, satisfaction, or love.
  • Persistent negative emotional state, including fear, guilt, anger, or shame.

Criterion E: Alterations in Arousal and Reactivity

Trauma-related alterations in reactivity and arousal that began or worsened after the traumatic event, as evidenced by two or more of the following:

  1. Irritable or aggressive outbursts with little or no provocation
  2. Reckless or self-destructive behavior
  3. Hypervigilance
  4. Exaggerated startle response
  5. Problems in concentration
  6. Sleep disturbances (difficulty falling or staying asleep, restless sleep)

Criterion F: Duration

     Persistence of symptoms in Criterion B, C, D, and E for more than one month

Criterion G: The disturbance causes significant functional impairment or distress in various areas of life, such as social or occupational.

Criterion H: The disturbance is not attributable due to substance use, medication, or another medical illness.

Conducting a Mental Health Exam

Posttraumatic stress disorder is a complex phenomenon, and it is necessary to evaluate for any co-existing psychiatric illnesses that an individual may have. After a detailed history is obtained, the next step is to have a thorough mental status examination, which helps confirm the behavioral, emotional, and cognitive aspects of PTSD. On the mental status examination, the individual would likely mention poor sleep, concentration, frequent nightmares, flashbacks related to the event, guilt, or negative emotions that are associated with the reminder of the event, resulting in avoidance and increased vigilance.  There are several self-assessment tools that can be utilized to assess for PTSD. Some of the options are as follows¹⁰:

The Primary Care PTSD Screen for DSM-5 

The Primary Care PTSD Screen for DSM-5  (PC-PTSD-5) is a 5-item screen that is used in primary care settings to identify people who may have PTSD. The measure begins with an item that assesses whether an individual has had any exposure to traumatic events by stating:

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

  • A physical or sexual assault or abuse
  • A serious accident or fire
  • A war
  • An earthquake or flood
  • Having a loved one die through homicide or suicide
  • Seeing someone be killed or seriously injured

Have you ever experienced this kind of event?

If an individual denies exposure, the PC-PTSD-5 is complete with a score of 0. However, if an individual indicates that they have experienced a traumatic event over the course of their life, the respondent is instructed to respond to five additional yes/no questions about how that trauma exposure has affected them over the past month:

            In the past month, have you…

  1. Had nightmares about the event or thought about the event when you did not want to?
  2. Tried hard not to think about the event or went out of your way to avoid situations that reminded you of the event?
  3. Been constantly on guard, watchful, or easily startled?
  4. Felt numb or detached from people, activities, or your surroundings?
  5. Felt guilty or unable to stop blaming yourself or others for the event or any problems the event(may have caused?

Individuals who screen positive to the questions require further assessment with a structured interview, such as the Clinician-Administered PTSD Scale for DSM-5. The administration of a clinical interview is not always possible due to time and availability of mental health experts. In these cases, an additional assessment should be conducted using a validated self-report measure such as the PTSD Checklist for DSM-5.

SPAN  Self-Report Screen

The SPAN (startle, physically upset by reminders, anger, and numbness) Self-Report Screen is a four-item screen that assists in identifying PTSD. The four items are ranked on a Likert scale to assess levels of distress within a 7 day period, and anyone who has a positive screen result should then be assessed with a structured interview for PTSD by a mental health expert. The self-report screen can be obtained by request at https://www.ptsd.va.gov/professional/assessment/screens.

The SPRINT Self-Report Screen

The SPRINT Self-Report Screen (Short Post-Traumatic Stress Disorder Rating Interview) is an eight-item self-report measure that assesses the core symptoms of PTSD (intrusion, avoidance, numbing, arousal), somatic malaise, stress vulnerability, and role and social functional impairment. The symptoms are rated on a 4 point Likert scale. A positive result can identify PTSD illness, and people who have a positive result on the screen should then be assessed with a structured interview for PTSD by a mental health expert. The self-report screen can be obtained by request at https://www.ptsd.va.gov/professional/assessment/screens.

Trauma Screening Questionnaire

The Trauma Screening Questionnaire (TSQ) is a 10-item symptom screen that used for survivors of traumatic events. The TSQ has five re-experiencing items and five arousal items. Individuals who answer the questionnaire should endorse any symptoms that they have experienced at least twice within a 7 day period. It is recommended that the TSQ be used four weeks after the traumatic event as this is likely when PTSD will begin. Individuals who answer the questionnaire and have a positive result should be assessed with a structured interview for PTSD by a mental health expert. The self-report screen can be obtained by request at https://www.ptsd.va.gov/professional/assessment/screens.

A positive response to any of the screens does not necessarily indicate that an individual has Posttraumatic Stress Disorder. However, a positive response does indicate that an individual may have PTSD or trauma-related problems, and further investigation of trauma symptoms by a structured clinical interview with  a mental health professional is warranted.

The gold standard for diagnosing PTSD is a structured clinical interview. The mental health professional can efficiently use self-report scales for screening or management such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), PTSD measure for DSM-5 (PCL-5), or the Trauma Symptom measure – 40 (TSC-40).²

Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

The CAPS is the gold standard in PTSD assessment.¹⁰  The CAPS-5 is a 30-item structured interview that can be used to:

  • Make current (past month) diagnosis of PTSD
  • Make lifetime diagnosis of PTSD
  • Assess PTSD symptoms over the past week

In addition to assessing the 20 DSM-5 PTSD symptoms, questions target the onset and duration of symptoms, subjective distress, impact of symptoms on social and occupational functioning, improvement in symptoms since a previous CAPS administration, overall response validity, overall PTSD severity, and specifications for the dissociative subtype (depersonalization and derealization).

Standardized questions and probes are provided for each symptom.

Sample questions include:

  • How does it happen that you start remembering the trauma?
  • If the answer is not clear – Are these unwanted memories, or are you thinking about the trauma on purpose?
  • How much do these memories bother you?
  • Are you able to put them out of your mind and think about something else?
  • How often have you had these memories in the past month?

The CAPS should be administered by mental health experts, but it can also be administered by other appropriately trained healthcare professionals who are familiar with PTSD. The full assessment can be requested from the Veterans Affairs at www.ptsd.va.gov.

PTSD Checklist for DSM-5

The PTSD Checklist for DSM-5 (PCL-5) is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including²:

Interpretation of the PCL-5 should be made by a mental health professional who is able to  evaluate the responses to 20 questions on a four-point Likert scale. The questions on the PCL-5 include the following:

In the past month, how much were you bothered by:

  1. Repeated, disturbing, and unwanted memories of the stressful experience?
  2. Repeated, disturbing dreams of the stressful experience?
  3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
  4. Feeling very upset when something reminded you of the stressful experience?
  5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
  6. Avoiding memories, thoughts, or feelings related to the stressful experience?
  7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
  8. Trouble remembering important parts of the stressful experience?
  9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
  10. Blaming yourself or someone else for the stressful experience or what happened after it?
  11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
  12. Loss of interest in activities that you used to enjoy?
  13. Feeling distant or cut off from other people?
  14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
  15. Irritable behavior, angry outbursts, or acting aggressively?
  16. . Taking too many risks or doing things that could cause you harm?
  17. Being “super alert” or watchful or on guard?
  18. Feeling jumpy or easily startled?
  19. Having difficulty concentrating?
  20. Trouble falling or staying asleep?

Trauma Symptom Checklist – 40 (TSC-40)

The TSC-40 is a 40-item self-report measure of symptomatic distress in adults arising from childhood or adult traumatic experiences. It measures aspects of post-traumatic stress as well as other symptoms found in some traumatized people, children, and their families through evaluation on a Likert scale.¹⁰ The TSC-40 should only be used by qualified mental health professionals. In addition to yielding a total score (ranging from 0 to 120), the TSC-40 has six sub-scales: Anxiety, Depression, Dissociation, Sexual Abuse Trauma Index, Sexual Problems, and Sleep Disturbances. The score for each subscale is the total of the relevant items listed.

  • Dissociation – 7, 14, 16, 25, 31, 38
  • Anxiety – 1, 4, 10, 16, 21, 27, 32, 34, 39
  • Depression – 2, 3, 9, 15, 19, 20, 26, 33, 37
  • SATI (Sexual Abuse Trauma Index) – 5, 7, 13, 21, 25, 29, 31
  • Sleep Disturbance – 2, 8, 13, 19, 22, 28
  • Sexual Problems – 5, 9, 11, 17, 23, 29, 35, 40

The questions on the TSC-40 include the following:

  1. Headaches 
  2. Insomnia
  3.  Weight loss (without dieting)
  4. Stomach problems
  5. Sexual problems
  6. Feeling isolated from others
  7. “Flashbacks” (sudden, vivid, distracting memories)
  8. Restless sleep
  9. Low sex drive
  10. Anxiety attacks
  11. Sexual overactivity
  12. Loneliness
  13. Nightmares
  14.  “Spacing out” (going away in your mind)
  15. Sadness
  16. Dizziness
  17. Not feeling satisfied with your sex life
  18. Trouble controlling your temper
  19. Waking up early in the morning
  20. Uncontrollable crying
  21. Fear of men
  22. Not feeling rested in the morning
  23.  Having sex that you did not enjoy
  24. Trouble getting along with others
  25.  Memory problems
  26. Desire to physically hurt yourself
  27. Fear of women
  28. Waking up in the middle of the night
  29. Bad thoughts or feelings during sex
  30. Passing out
  31. Feeling that things are “unreal”
  32. Unnecessary or over-frequent washing
  33. Feelings of inferiority
  34. Feeling tense all the time
  35.  Being confused about your sexual feelings
  36. Desire to physically hurt others
  37. Feelings of guilt
  38. Feeling that you are not always in your body
  39. Having trouble breathing
  40. Sexual feelings when you should not have them

The use of the CAPS-5, PCL-5 and TSC 40 provides an accurate assessment for PTSD. In addition to the mental health assessment, a physical examination should also be completed as a part of the total workup to rule out any medical or neurological disorders. Routine laboratory testing like complete blood count, urine toxicology, TSH, vitamin B12, folate levels should also be checked. People may present with physical injuries relating to the traumatic event, and accordingly, neuroimaging studies like CT scan and MRI scan of the brain should be considered based on the history and presentation of the individual.

Treatment Considerations for PTSD

Posttraumatic stress disorder is a disabling consequence after a traumatic event, and early detection and intervention is necessary for planning the appropriate treatment. Studies have shown that both psychotherapy and pharmacotherapy are effective. ⁹˒¹³Trauma-focused psychotherapy is considered a first-line treatment that is effective in adults as well as children. Trauma-focused psychotherapy includes trauma-focused cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), cognitive processing therapy, and imaginal exposure. The following provides a brief overview of each of the therapies:

Trauma-Focused Cognitive Behavioral Therapy

Trauma-Focused Cognitive Behavioral Therapy, or TF-CBT, is an evidence-based treatment program intended to help children and their families deal with the aftermath of a traumatic experience.⁹˒¹³ Trauma-Focused Cognitive Behavioral Therapy is also relatively short-term, lasting no more than 16 sessions for most people receiving treatment. Trauma Focused Cognitive Behavioral Therapy uses the acronym PRACTICE to describe steps in treatment within the phases:

Phase One – Stabilization

  • P: Psycho-Education – The first phase that begins with learning about trauma.
  • R: Relaxation Skills – Skills that are intended to help a child/adult reverse the physiological arousal effects of the trauma they have suffered.
  • A: Affective Regulation Skills – Skills that help a child/adult learn helpful strategies, such as problem-solving, to help for identify, modulate, and regulate any upsetting situations that may occur.
  • C: Cognitive Processing Skills – help a child/adult build the skills necessary for coping with stress and achieving meaningful healing from their trauma.

Phase Two – Trauma Narrative

  • T: Trauma Narration and Processing – A child’s/adult’s telling of their story of a traumatic experience.

Phase Three – Integration / Consolidation

  • I: In Vivo Mastery of Trauma Reminders – Stimuli a child/adult may experience that can cause intense, painful, and debilitating memories of the trauma suffered, helping them overcome their avoidance of reminders of the trauma.
  • C: Conjoint Child-Parent Sessions – Opportunities for a mental health expert to help families reconnect and plan for continued healing and growth.
  • E: Enhancing Safety – Taking the skills gained through therapy and applying it to family life going forward. Families can create their own safety plans for specific situations and continue to work on valuable skills, like problem-solving, refusing drugs, and general social skills.

Eye Movement Desensitization and Reprocessing (EMDR)

Eye movement desensitization and reprocessing (EMDR) is a treatment for PTSD as well as other mental health conditions. ⁶ The treatment combines one’s traumatic memories and positive thoughts and beliefs to help reduce the distress stemming from the traumatic event. With these thoughts and images in mind, the individual also pays attention to outside stimulus such as eye movements or finger tapping, which is guided by a mental health expert.

EMDR treatment focuses on the PTSD-related periods of an individual’s life, including:

Cognitive Processing Therapy

Cognitive processing therapy (CPT) is a specific type of cognitive behavioral therapy that has been effective in reducing symptoms of PTSD that have developed after experiencing a variety of traumatic events including child abuse, combat, rape ,and natural disasters. ⁹Cognitive processing therapy is usually delivered over 12 sessions and helps individuals learn how to challenge and modify unhelpful beliefs related to the trauma.

  • Treatment begins with psychoeducation regarding PTSD, thoughts, and emotions. The individual becomes more aware of the relationship between thoughts and emotions and begins to identify “automatic thoughts” that may cause PTSD symptoms.
  • Next, the individual begins more formal processing of the traumatic event by writing a detailed account of the experience, and reading it allowed to try to  break the pattern of avoiding thoughts and feelings associated with the trauma.
  • Finally, once the individual has developed skills to identify and address unhelpful thinking, they use the coping skills to continue evaluating and modifying beliefs related to traumatic events.

Imaginal Exposure

Exposure to a traumatic event through imaging allows the individual to re-experience the event in a safe, controlled environment while also carefully experiencing their reactions and beliefs in relation to that event.  In imaginal exposure, the main clinical issue is avoidance. Exposure therapy corrects the fear that is associated with the trauma by showing cause and effect to thoughts of the trauma to current behaviors. Using imaginal exposure is an important element of cognitive behavior therapy because it reduces anxiety from things most feared but are unlikely to materialize again.

Pharmacological Treatment

Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) are the first-line drug of choice for the treatment of PTSD.¹˒ ⁴

Serotonin Reuptake Inhibitors (SRIs)

Serotonin reuptake inhibitors (SRIs) include selective serotonin reuptake inhibitors (SSRIs)  that work by increasing serotonin levels in the brain, which influences emotions, mood, and sleep, and Serotonin and norepinephrine reuptake inhibitors (SNRIs) which work by reducing the absorption of serotonin and norepinephrine (neurotransmitters) in the brain cells, improving mood, and reducing anxiety and panic attacks. Serotonin reuptake inhibitors are the most studied medications for the treatment of PTSD with favorable results.¹˒⁴ For example, Paroxetine is FDA approved for the short treatment of PTSD and has shown significant treatment response compared to placebo in three randomized controlled trials.¹³ Three SSRIs (fluoxetine, sertraline, and paroxetine) and one SNRI (venlafaxine ) have the strongest evidence and are first-line pharmacotherapies for the treatment of PTSD.⁹ 

Second-Generation Antipsychotics (SGAs)

Second-Generation Antipsychotics (SGAs) can be used either as monotherapy or in combination with Serotonin reuptake inhibitors. Second-generation antipsychotics are mainly used to manage psychosis in someone who has lost touch with reality or is experiencing auditory or visual hallucinations, or delusions. These are not first-line medications, but are considered in individuals who have a limited response to SRIs and cognitive behavioral therapy, especially in the presence of associated anxiety and depression.⁹ Medications in this class include Aripiprazole, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Risperidone, and Ziprasidone.

 Alpha-1 Selective Adrenergic Blocker

Prazosin is an antihypertensive medication that works by blocking specific receptors on the vascular smooth muscle. It is thought that prazosin and its metabolites can reduce the overactivation of the sympathetic system in PTSD. Prazosin is mainly used as to minimize sleep disturbances.¹

Pharmacology Considerations

Serotonin Reuptake Inhibitors (SRIs) can cause rapid, chaotic heartbeats associated with long QT-syndrome, syndrome of inappropriate antidiuretic hormone secretion, hyponatremia, suicide ideation (especially in children), seizures, increased risk of bleeding, sexual dysfunction, gastrointestinal symptoms (such as nausea, vomiting, and diarrhea) and serotonin syndrome. SRIs Should be prescribed by a professional and per guidelines.

Sexual dysfunction in the form of decreased libido delayed ejaculation, and anorgasmia is common among women and men taking SSRIs.¹ Few people with sexual dysfunction due to SRIs therapy will improve with continued use of the SRI, and it is suggested to monitor symptoms for 8 weeks for improvement. In the case of persistence, careful dose reduction can be tried. If sexual dysfunction persists, another SRI should be considered.

SRIs should not be disconnected abruptly, as this may result in withdrawal symptoms.¹

SRIs can cause mania in patients with bipolar disorder and should not be used in individuals with a history of bipolar disorder. In the case of mania, the SRI should be discontinued, and appropriate bipolar disease therapy should be initiated.

Second-Generation Antipsychotics(SGAs) can cause long QT syndrome , metabolic syndrome, anticholinergic symptoms, and extrapyramidal symptoms (EPS). Risperidone can cause hyperprolactinemia.

Prazosin can cause first dose orthostatic hypotension, dizziness, fatigue, and headache. It should be used with caution in people with hepatic function impairment.

Conclusion

Posttraumatic stress disorder often poses a diagnostic dilemma. A detailed history from the individual may suggest that they have PTSD; however, detailed mental status examination, cognitive testing, and laboratory investigations are essential to rule out any coexisting medical or psychiatric illness. Early diagnosis and timely intervention are essential and is a collaborative interprofessional effort. An interprofessional team includes mental health experts, nurses, primary care providers, and social workers, and communication is essential among the team to ensure effective care is provided.

The long-term outcome for people with posttraumatic stress disorder depends on their ability to cope with stress, availability of social support, avoid substance abuse, and the ability to stay compliant with the treatment plan as recommended. Posttraumatic stress disorder has a devastating impact on those who suffer from it and their families. People diagnosed with PTSD are associated with substantial disability, and the presence of comorbidities can cause the chronicity of the condition. For instance, individuals diagnosed with PTSD often have other psychiatric and medical comorbidities such as anxiety and panic disorders, mood disorders, neurological disorders including dementia, or substance abuse disorder. There is also an overall increased risk of suicide ideation and attempts in those who are diagnosed with PTSD. Dementia may also occur due to traumatic injury or alterations in the functioning of the brain. Having awareness regarding the signs and symptoms of PTSD is essential for individuals  and healthcare professionals to start early treatment and limit the burden of the illness on the person who suffers from PTSD and their families.

PTSD-Diagnosis and Treatment Options Evaluation

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