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Anxiety Disorders - Post-Traumatic Stress Disorder (PTSD)

The human suffering that followed the terrorist attacks of September 11, 2001, is a grim reminder of the impact of PTSD on the health of individuals and populations exposed to traumatic events. PTSD is the 4th most common psychiatric disorder in the United States. Not surprisingly, PTSD is a worldwide disorder particularly prevalent in countries torn by war and violence. Symptoms of PTSD often persist for years and are accompanied by significant social and work impairment, substance abuse, and other mental disorders. The core symptoms of PTSD include re-experiencing of the traumatic event with intrusive thoughts and dreams, avoidance of reminders of the event, emotional numbing, hypervigilance, excessive startle response, and chronic autonomic arousal. In some settings, such as subsequent to the World Trade Center attacks or after rape, the diagnosis is evident. In primary care, however, PTSD may go unrecognized (Davidson). The possibility of PTSD should be considered in cases of somatization, unexplained abdominal pain, hypervigilance to bodily symptoms, and in patients who complain of chronic tension, dysphoria, irritability, angry outbursts, and difficulty with concentration. Physicians should inform patients that physical and emotional symptoms are common in people who have experienced traumatic events and inquire specifically if this might be the case for them. The opportunity to disclose the event to the physician validates the patient's experience and is a first step in treatment.

The psychobiology of PTSD is not completely understood but has features that differ from acute stress (Yehuda). In PTSD there appears to be a failure of normal adaptive responses to contain and resolve the psychological and autonomic responses to acute stress. Overwhelming fear, horror, autonomic arousal and emotions such as guilt and anger may lead patients to avoid thinking about the traumatic event and thus impair psychological resolution and the development of effective coping mechanisms. Unlike symptoms of acute stress, symptoms of PTSD gradually increase for months after the trauma (for example, exaggerated startle response begins to appear more than 1 month after the trauma) suggesting progressive central nervous system sensitization and impaired extinction of newly acquired autonomic responses. In contrast to patients with acute stress, patients with PTSD have low levels of circulating cortisol and increased sensitivity of the hypothalamic-pituitary-adrenal axis to feedback inhibition by circulating cortisol. Biochemical and anatomic changes have been noted in the amygdala and hippocampus of PTSD patients, brain regions involved in memory and emotion. Debriefing after an acute trauma has not been shown to decrease the development of PTSD. However, referral of patients after a severely traumatic event for more specific psychological interventions such as cognitive-behavioral therapy or exposure therapy may reduce the risk of developing PTSD. These psychological modalities are also of benefit in treating established PTSD but unfortunately are not widely available. SSRIs are beneficial in managing symptoms of PTSD and may decrease the incidence of chronic PTSD if initiated in patients with severe acute stress reactions (Stein et al.; Brady et al.). Predictors of response are unknown. An expert panel recommended that if there is no response to SSRI therapy after 8 weeks, switching to nefazodone or venlafaxine should be considered. A mood stabilizer such as valproic acid can be added for partial responders. Benzodiazepines may be used for brief periods after an acute stress but are ineffective and should be avoided in chronic PTSD.

References

1. Davidson JRT. Recognition and treatment of posttraumatic stress disorder. JAMA. 2001;286:584-8. [PMID:11476661]

2. Yehuda R. Post-traumatic stress disorder. N Engl J Med. 2002;346:108-14. [PMID:11784878]

3. Stein DJ, Zungu-Dirwayi N, van Der Linden GJ, Seedat S. Pharmacotherapy for posttraumatic stress disorder. Cochrane Database Syst Rev. 2000;CD002795. [PMID:11034765]

4. Brady K, Pearlstein T, Asnis GM, Baker D, Rothbaum B, Sikes CR, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA. 2000;283:1837-44. [PMID:10770145]

Reproduced from: MKSAP 12 Update. Ambulatory Medicine. October 2002, American College of Physicians--American Society of Internal Medicine.

Author: Peter R. Lichstein, MD, FACP
Professor of Medicine
Wake Forest University
Winston Salem, North Carolina

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