Posttraumatic stress disorder is a condition that is usually seen after experiencing a severe traumatic event that threatens the individual’s life or physical integrity. The estimated prevalence of posttraumatic stress disorder in the United States is around 8—10 %. The diagnosis of the condition is based on the DSM-5 criteria. Laboratory and imaging studies might be performed for research purposes but are not clinically indicated. Treatment is mainly based upon cognitive behavioral therapy and eye movement desensitization and reprocessing therapy. Beta-blockers or anti-depressants might be indicated in some cases.

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Ptsd-brain

Image: “Ptsd-brain” by National Institutes of Health. License: Public Domain


Overview of Posttraumatic Stress Disorder

Posttraumatic stress disorder is defined as the anxiety disorder that usually occurs after someone experiences a severe trauma that is known to constitute a threat to one’s physical wellbeing or one’s own life. Posttraumatic stress disorder can also happen as a consequence to experiencing a traumatic event that affected another person who is important to the subject.

Epidemiology of Posttraumatic Stress Disorder

PTSD in both sexes

The estimated prevalence of posttraumatic stress disorder in the U.S. is around 8—10 %. Women are more likely to develop posttraumatic stress disorder compared to men. Additionally, the nature of the traumatic event is also different between men and women. Sexual assault is the most common trigger for posttraumatic stress disorder in women whereas trauma from combat is the most common cause of posttraumatic stress disorder in men.

A recent study suggested that the risk of posttraumatic stress disorder is more related to the duration and severity of the experienced trauma rather than the individual’s sex. Posttraumatic stress disorder can be diagnosed in all age groups. The estimated prevalence of posttraumatic stress disorder in adolescent males is around 3.7 % whereas the prevalence of the disorder in adolescent females is around 6.3 %.

The prognosis of PTSD

The prognosis of posttraumatic stress disorder in treated patients is good with complete or almost complete recovery in most cases. Rapid involvement with treatment, social support, avoidance of retraumatization, and the absence of other psychiatric disorders or substance abuse are good prognostic factors in posttraumatic stress disorder.

Etiology and Pathology of Posttraumatic Stress Disorder

Symptoms of posttraumatic stress disorder usually happen within three months after the traumatic event.

Note: The most common finding in research studies of fear conditioning and anxiety disorders in rodents showed that the amygdala, hypothalamus, locus ceruleus and the parabrachial nucleus to be involved in the pathology.

Many of the symptoms of posttraumatic stress disorder can be explained by the activation of these brain regions. The orbitoprefrontal cortex plays a critical role in inhibiting the over-activation of these brain regions in normal subjects. Patients with posttraumatic stress disorder show decreased inhibition by the orbitoprefrontal cortex.

Clinical Presentation of Posttraumatic Stress Disorder

The diagnosis of posttraumatic stress disorder is based on 8 criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):

  1. Patients should directly experience the traumatic event or should witness the traumatic event when it affected another person. Sometimes, patients might know about the traumatic event that a close family member has encountered but not witness it. In most cases of posttraumatic stress disorder, the exposure to the traumatic event is repeated and extreme.
  2. Patients should have persistent thoughts, images, dreams, hallucinations, dissociative flashback episodes, or intense distress after experiencing the traumatic event.
  3. Patients also show avoidance behavior where they avoid talking or feelings related to the traumatic event. Additionally, patients usually avoid places and people that might trigger the recollection of the traumatic event.
  4. Patients should also have two or more of the following symptoms to be diagnosed with posttraumatic stress disorder. Inability to remember an important aspect of the triggering event, persistent negative beliefs about oneself, distorted thoughts about the cause of the event, persistent negative emotional state, markedly diminished interest in participation in daily activities, and inability to experience positive emotions are included in this criterion.
  5. Patients should also have two or more symptoms that are suggestive of altered arousal. Examples of such symptoms include anger outbursts, self-destructive behavior, hypervigilance, concentration problems and sleep disturbances.
  6. The duration of these symptoms should be more than one month; the symptoms should significantly impair the quality of life for the patient and proper exclusion of medical conditions or drug abuse as causes of the symptoms are the three remaining criteria for the diagnosis of posttraumatic stress disorder.
  7. The risk of myocardial infarction has been previously shown to be higher in patients with posttraumatic stress disorder compared to subjects without previous history of posttraumatic stress disorder.
  8. The mental status examination in patients with posttraumatic stress disorder might reveal several abnormalities. Mood and concentration are usually impaired. Additionally, memory impairment has been observed in patients with posttraumatic stress disorder. The risk of concurrent major depressive disorder in women with posttraumatic stress disorder is high.

Diagnostic Workup for Posttraumatic Stress Disorder

Laboratory investigations

Laboratory investigations are not useful in the management of posttraumatic stress disorder but might be indicated for research purposes. Cortisol levels have been found to be decreased in patients with posttraumatic stress disorder. Elevated levels of norepinephrine and epinephrine are usually seen in patients with this disorder.

Endogenous opiates

Endogenous opiates were found to be elevated in patients with posttraumatic stress disorder and is thought to be related to the blunted emotions seen in patients with posttraumatic stress disorder.

Magnetic resonance imaging studies

Magnetic resonance imaging studies of the brain are also performed for research purposes and to exclude medical conditions that might cause similar symptoms. Hippocampal atrophy is commonly seen in patients with posttraumatic stress disorder. Some studies even suggest that the size of the hippocampus might be correlated with the risk of posttraumatic stress disorder later in life.

Treatment of Posttraumatic Stress Disorder

Note: The treatment of posttraumatic stress disorder should be initiated as soon as possible. The initial focus of the treatment plan for the patient should be to correct any form of substance abuse.

Eye movement desensitization and reprocessing (EDMR)

Eye movement desensitization and reprocessing (EDMR) is thought to activate the different brain regions that are related to information processing and the inhibition of the activated brain regions known to cause the symptoms of posttraumatic stress disorder. Therefore, trauma-oriented cognitive behavioral therapy when combined with EDMR has been shown to be successful in managing the symptoms of the condition.

Pharmacotherapy

Pharmacotherapy might be also indicated especially in the early stages to make it possible for the patient to go to work and still be integrated.

Beta-blockers

The medical treatment of choice for posttraumatic stress disorder that is not associated with depression is beta-blockers. Alpha-antagonists have also shown some efficacy. Benzodiazepines should be avoided if possible due to the increased risk of drug dependence. Patients with comorbid depression usually respond well to antidepressants combined with beta-blockers. Prazosin has been shown to decrease the rate of nightmares and lower the severity of the symptoms during the day.

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