Chronic impairing disorder that is characterized by re-experience and avoidance symptoms as well as negative alternations in cognition and arousal.
Etiology
Traumatic events:
The prevalence of traumatic events in the lives of individuals ranges from 61-80%. After the trauma, posttraumatic stress disorder occurs in approximately 5-10% of the population and is higher in women than in men.
- Severe threat or a physical injury
- Near-death experience
- Combat-related trauma
- Sexual assault, interpersonal conflicts, child abuse
- After a medical illness.
Chronic PTSD:
Occurs in patients who are unable to recover from the trauma due to maladaptive responses.
Risk factors:
Risk factors for the development of PTSD include several biological and psychological factors. The nature and the severity of the trauma are also accountable while determining the risk factors for PTSD.
- Gender (more prevalent in women)
- Childhood adversities
- Pre-existing mental illness
- Low socioeconomic status
- Less education
- Lack of social support
Pathophysiology
The pathophysiology of posttraumatic stress disorder involves alterations in the neurotransmitter and neurohormonal functioning.
Alterations in neurohormonal functioning:
- Normal/↓ cortisol & ↑ Corticotropin-releasing factor (CRF): Stimulates release of norepinephrine by anterior cingulate cortex, which leads to an increased sympathetic response:
- Increased heart rate, blood pressure
- Increased arousal, and startle response
Alterations in neurotransmitter systems:
- ↓ GABA & ↑ glutamate activity: Fosters dissociation and derealization
- ↓ Serotonin (dorsal/median raphe): Changes the dynamic between the amygdala and the hippocampus.
- ↓ Plasma neuropeptide-Y concentration
Changes in neurophysiology and anatomy of the brain:
- ↓ Hippocampus size
- Overly active amygdala (processing emotions and modulating fear response)
- Smaller & less responsive medial prefrontal cortex (inhibitory control over the emotional reactivity of amygdala)
Clinical features
Diagnostic criteria:
According to the DSM-5, in order to fulfill the criteria for a diagnosis of PTSD, the person must have experienced or witnessed a traumatic event that involved “actual or threatened death, serious injury, or sexual violence”. Whereas according to the ICD-11, the event or events must have been “extremely threatening or horrific”.
Core symptoms:
There are 3 groups of symptoms that are common to both the ICD-11 and the DSM-5 criteria. These are considered to be the core symptoms of PTSD.
- Intrusions or re-experiencing of the event (such as intrusive memories, repetitive play in which the events or aspects of it are expressed, nightmares, flashbacks, distress triggered by reminders of the event or events).
- Avoidance (such as avoiding thoughts, feelings or memories of the event or events, or avoiding people, places, conversations or situations that are associated with the event or the events).
- Dissociative/psychogenic amnesia (aka hysterical/functional amnesia): Severe retrograde amnesia with minimal or no anterograde amnesia
- Arousal and reactivity or sense of current threat (such as irritability, being overly vigilant, being easily startled, concentration problems, sleep problems).
Case studies:
Diagnosis
Posttraumatic stress disorder is a complex phenomenon, and it is necessary to evaluate for any co-existing psychiatric illness in the patient.
Mental status examination:
A thorough mental status examination helps confirm the behavioral, emotional, and cognitive aspects of PTSD.
- Poor sleep and concentration
- Frequent nightmares and flashbacks related to the event
- Guilt or negative emotions associated with the reminder, avoidance, and increased vigilance.
Self-report scales for screening or management:
- PTSD Checklist for DSM-5 (PCL-5)
- Trauma Symptom Checklist – 40 (TSC-40)
Differential diagnosis
- Acute stress disorder: The symptoms of PTSD and acute stress disorder mostly overlap. The onset and duration of the symptoms help in making the final diagnosis. Acute stress disorder is diagnosed if the symptoms are present for less than one month.
- Depression: At times, the patient has underlying depression that may co-exist and needs to be evaluated before formulating a treatment plan. Patients with PTSD also have a lifetime increased risk for depression and suicidal ideation/attempts.
- Adjustment disorder: The patient is diagnosed with adjustment disorder when the criteria for PTSD or any other psychiatric illness are not met.
- Anxiety disorders: The patient’s increased negative emotional and physiological responses may be confused with panic attacks or other specified anxiety disorder.
- Traumatic brain injury (TBI): Cognitive impairment and dissociative symptoms may be due to traumatic brain injury
Management
Posttraumatic stress disorder is a disabling consequence after a traumatic event, and early detection and intervention are necessary for planning the management.
Trauma-focussed psychotherapy:
First-line treatment effective in adults as well as children. The therapy has shown to shortens the course of those who will recover. However, it does not change the long-term outcome. It includes the following components:
- Ttrauma-focused CBT (cognitive-behavioral therapy)
- Eye movement desensitization and reprocessing (EMDR)
- Cognitive processing therapy
- Imaginal exposure
Sleep management:
Insomnia is common in patients with PTSD, which may be treated by educating the patient regarding following adequate sleep hygiene.
- Trauma-related nightmares:
- Prazosin: Peripherally active α-adrenoceptor antagonist
- Clonidine: Centrally active α-adrenoceptor agonist
- Trazodone can also be used for treating insomnia.
Pharmacological management:
SSRIs or SNRIs or trauma-focused psychotherapy or a combination of both are effective in the treatment of PTSD.
- Selective serotonin reuptake inhibitors (SSRI)
- Serotonin-norepinephrine reuptake inhibitors (SNRI)
- Adding antipsychotics (risperidone) to the standard antidepressant regimen can significantly improve the outcome of patients with PTSD