Diagnosis and management of post-traumatic stress disorder.

American Family Physician
Dec 15, 2003 v68 i12 p2401
Page 1
Diagnosis and management of post-traumatic stress disorder.
by Bradley D. Grinage
Although post-traumatic stress disorder (PTSD) is a debilitating anxiety disorder that may cause
significant distress and increased use of health resources, the condition often goes undiagnosed.
The lifetime prevalence of PTSD in the United States is 8 to 9 percent, and approximately 25 to 30
percent of victims of significant trauma develop PTSD. The emotional and physical symptoms of
PTSD occur in three clusters: re-experiencing the trauma, marked avoidance of usual activities,
and increased symptoms of arousal. Before a diagnosis of PTSD can be made, the patient’s
symptoms must significantly disrupt normal activities and last for more than one month.
Approximately 80 percent of patients with PTSD have at least one comorbid psychiatric disorder.
The most common comorbid disorders include depression, alcohol and drug abuse, and other
anxiety disorders. Treatment relies on a multidimensional approach, including supportive patient
education, cognitive behavior therapy, and psychopharmacology. Selective serotonin reuptake
inhibitors are the mainstay of pharmacologic treatment.
© COPYRIGHT 2003 American Academy of Family
The Vietnam War significantly influenced the current
Physicians
concept of PTSD. In 1980, the Diagnostic and Statistical
Manual of Mental Disorders, 3d ed. (DSM-III) (4)
Post-traumatic stress disorder (PTSD) is an anxiety
established criteria for the diagnosis of PTSD.
disorder that occurs following exposure to a traumatic
Modifications were made in subsequent editions. (5,6) This
event. The disorder has not been extensively studied in
article reviews the current diagnostic criteria for PTSD as
primary care; however, the events of September 11, 2001, contained in the 4th edition, text revision (DSM-IV-TR) (7)
raised both public and professional awareness of PTSD.
and focuses on diagnosis and management, including the
Many more cases may now be diagnosed in family
detection and treatment of comorbidities.
practice patients, because they are more apt to disclose
information to their physicians and because physicians are Diagnosis
more aware of the diagnosis. One study (1) estimated that
11.8 percent of patients presenting to a primary care clinic A precipitating traumatic event is necessary, but not
met the diagnostic criteria for PTSD.
sufficient, to make the diagnosis of PTSD. The criteria for
diagnosis specify factors concerning the victim’s
Patients with PTSD use health care resources more often
perception of the trauma as well as the duration and
than patients without PTSD, including those who have
impact of associated symptoms, including persistent
other anxiety disorders. (1,2) Because of frustrations in
re-experiencing of the traumatic event, marked avoidance
diagnosing and managing their patient’s recurrent medical of usual activities, and symptoms of increased arousal
complaints, some physicians characterize patients with
(Table 1). (7)
PTSD as "difficult" or "heart-sink" patients--that is, patients
who evoke "an overwhelming mixture of exasperation,
Before a diagnosis of PTSD can be made, symptoms must
defeat, and sometimes plain dislike." (3) Prompt
last for at least one month and must significantly disrupt
recognition and effective treatment of PTSD can greatly
normal activities. In persons who have survived a
benefit these patients, their families, and those who work
traumatic event, an anxiety syndrome that lasts for less
with them.
than one month is termed "acute stress disorder"; this
condition requires three or more dissociative symptoms in
Background
addition to the persistent symptoms associated with PTSD.
Symptoms of PTSD that last less than three months
The psychologic effects of trauma have been described
indicate an acute condition. A delayed picture occurs in
throughout military history. Da Costa syndrome ("soldier’s
patients who begin experiencing symptoms six months or
heart"), which is characterized by cardiac symptoms
more after the traumatic event. (7)
associated with irritability and increased arousal, was
described in veterans of the American Civil War. During
The diagnosis of PTSD may be difficult to make for many
World War I, it was hypothesized that "shell shock"
reasons. Patients may not recognize the link between their
resulted from brain trauma caused by exploding shells.
symptoms and an experienced traumatic event; patients
During World War II, terms such as "combat neurosis" and may be unwilling to disclose the event; or the presentation
"operational fatigue" were used to describe combat-related may be obscured by depression, substance abuse, or
symptoms.
other comorbidities. (8) Direct, empathic, and
nonjudgmental questioning is recommended when
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American Family Physician
Dec 15, 2003 v68 i12 p2401
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Diagnosis and management of post-traumatic stress disorder.
physicians take a patient history. For example, the
patients with mental health problems have a high risk of
physician might ask, "Have you ever been attacked or
PTSD. One study (18) noted that 72.2 percent of patients
threatened?" or, "Have you ever been in a severe accident
in community mental health centers had been exposed to
or natural disaster?" (8)
physical or sexual assault or were family members of
homicide victims. (18) Similarly, persons who abuse
Making a connection between a patient’s symptoms and a
alcohol or drugs are approximately 1.5 times more likely to
trauma that occurred in childhood may be particularly
experience traumatic events than nondrug users and have,
difficult to establish. An appropriate question to establish
therefore, an increased risk of developing PTSD. A history
this connection is, "Many people are troubled by
of behavior problems before the age of 15 years, as
frightening events that occurred in their childhood. Do you
occurs in patients with antisocial personality disorder, also
have this problem?" (9)
increases the risk of PTSD. (18)
A screening questionnaire for PTSD reportedly has a
Although PTSD is the least studied anxiety disorder, data
sensitivity of 80 percent and a specificity of 97 percent for
suggest that genetic factors may increase vulnerability to
the diagnosis of PTSD. (10) Examples of the questions
PTSD if the person is exposed to an adequate threat. (13)
include: "Do you have diminished interest in activities"; "Do
Age and ethnicity do not appear to affect morbidity. (12,19)
you have problems sleeping?"; and "Do you find it hard to
feel or show affection for others?" (10)
Etiology
Epidemiology
Although the etiology of PTSD is unknown, most
investigators believe that a personal predisposition is
PREVALENCE
necessary for symptoms to develop after a traumatic
event. Clinically significant symptoms following a traumatic
The overall lifetime prevalence of PTSD in the United
event occur in a minority of persons. Those likely to
States is approximately 8 to 9 percent, and the condition is
develop PTSD tend to have a pre-existing depression or
twice as common in women. (7,11,12) Symptoms that do
anxiety disorder, or a family history of anxiety and
not meet the full criteria for PTSD appear to be common in
neuroticism. (20)
the general population and can be quite common in groups
at high risk of PTSD. (13) For example, although the
From a biologic perspective, the body’s failure to return to
lifetime prevalence of PTSD in veterans of the Vietnam
its pretraumatic state differentiates PTSD from a simple
War is around 30 percent, about 50 percent of Vietnam
fear response. In a normal fear response, the immediate
veterans had some clinically significant symptoms of
sympathetic discharge activates the "fight-or-flight"
PTSD. (14)
reaction. Increases in both catecholamines and cortisol
occur relative to the severity of the stressor. Cortisol
RISK FACTORS
release stimulated by corticotropin-releasing factor via the
hypothalamic-pituitary-adrenal (HPA) axis acts in a
The epidemiology of PTSD is directly linked to the
negative feedback loop to suppress sympathetic activation
epidemiology of trauma. (11) The likelihood of developing
and cause further release of cortisol.
PTSD varies with severity, duration, and proximity of the
experienced trauma. (4) Approximately 25 to 30 percent of
In patients with PTSD, ambient cortisol levels are lower
victims of traumatic events develop symptoms of PTSD;
than normal; this state has been attributed to chronic
however, response to trauma varies with the severity and
"adrenal exhaustion" from inhibition of the HPA axis by
the subjective experience associated with the trauma.
persistent severe anxiety. However, recent data (21) note
(12,15,16) In men, exposure to military combat and
that cortisol levels in the immediate aftermath of a motor
witnessing someone being badly injured or killed are the
vehicle wreck were significantly lower in persons who went
types of trauma most commonly associated with a
on to develop PTSD. In a related study, (22) cortisol levels
diagnosis of PTSD. The most common traumatic events
immediately after rape were lower in women with a
associated with PTSD in women are rape and sexual
previous history of rape. Some investigators have
molestation. (11)
hypothesized that the HPA axis and the sympathetic
nervous system are disassociated in persons who develop
Persons who have been victimized previously are at
PTSD, which may allow for an uncontrolled catecholamine
greater risk of being victimized again. A history of
release that affects formation of memories during the
childhood abuse increases the risk for victimization and
trauma and perhaps exacerbates symptoms when that
PTSD in adults. (17) Because there is a strong relationship
person is exposed to cues after the trauma. (15)
between mental disorders and victimization by assault,
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American Family Physician
Dec 15, 2003 v68 i12 p2401
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Diagnosis and management of post-traumatic stress disorder.
Comorbidities
the patient and mitigate the impact of the traumatic event.
Local and national support groups may help to
PTSD is associated with increased rates of affective
destigmatize the mental health diagnosis and reaffirm that
disorders, anxiety disorders, and substance abuse. Data
symptoms of PTSD involve more than just a reaction to
from the National Comorbidity Survey (12) indicate that at
stress and require treatment. Support from family and
least one additional psychiatric disorder is present in 88.3
friends encourages understanding and acceptance that
percent of men and 79.0 percent of women who have a
may alleviate survivor guilt. However, the mainstay of
history of PTSD. In addition, 59 percent of men and 44
treatment is psychopharmacologic and psychotherapeutic
percent of women who have PTSD meet the criteria for
intervention (Figure 1).
three or more psychiatric diagnoses. Women who have
PTSD are 4.1 times as likely to develop a major
[FIGURE 1 OMITTED]
depression and 4.5 times as likely to develop mania as
women who do not have PTSD. Men who have PTSD are
PSYCHOTHERAPY
6.9 times as likely to develop depression and 10.4 times
as likely to develop mania as men who do not have PTSD.
Studies demonstrate that cognitive-behavior treatment is
(23)
effective in ameliorating the symptoms of PTSD. In a study
(27) of patients receiving various forms of
More than one half of men with PTSD also have a
cognitive-behavior treatment in nine sessions over a
comorbid alcohol problem, and a significant portion of men
six-week period, the percentage of patients who attained
and women who have PTSD have a comorbid
positive end-state function (defined as a 50 percent
illicit-substance use problem. (12) In patients who have
reduction in severity of PTSD symptoms) ranged from 21
PTSD, phobias tend to be more prevalent than generalized
to 46 percent. A similar study showed that 32 to 53 percent
anxiety disorder or panic disorder; the risk of almost all
of patients receiving 10 sessions of cognitive-behavior
anxiety disorders is increased markedly in these patients
treatment over a 16-week period achieved positive
(23) (Table 2). (12) The rate of attempted suicide in
end-state function. (27)
patients who have PTSD is estimated at 20 percent. (24)
Specific types of cognitive-behavior treatment include
Disease Course and Prognosis
cognition therapy, exposure therapy, and stress
inoculation training. These therapies focus on ways for
PTSD may occur at any age, even in childhood. Symptom
patients to confront fear and develop anxiety-management
duration is variable and is affected by the proximity,
tools. The different forms of cognitive-behavior treatment
duration, and intensity of the trauma, as well as
tend to be equally efficacious when used individually and
comorbidity with other psychiatric disorders. (7,20) The
in combination. Other therapies, such as group therapy,
patient’s subjective interpretation of the trauma also
eye movement desensitization, and reprocessing therapy,
influences symptoms. (18) In patients who are receiving
may have some role in the treatment of PTSD; however,
treatment, the average duration of symptoms is
because their efficacy has not been substantially
approximately 36 months. In patients who are not
demonstrated, cognitive-behavior treatment remains the
receiving treatment, the average duration of symptoms
primary mode of therapy. (26-28)
rises to 64 months. More than one third of patients who
have PTSD never fully recover. (12)
Approximately 14 percent of patients with PTSD
discontinue psychotherapy. The highest drop-out rates (up
Factors associated with a good prognosis include rapid
to 50 percent) occur with exposure therapy, indicating that
engagement of treatment, early and ongoing social
many patients have difficulty with re-experiencing the
support, avoidance of re-traumatization, positive premorbid
trauma. (26,27) The attending physician can provide solid
function, and an absence of other psychiatric disorders or
therapeutic intervention with good listening skills and
substance abuse. (19,25)
empathic support. If resolution of PTSD symptoms does
not occur with initial support and medication, referring the
Treatment
patient to a therapist may be warranted.
The treatment of patients with PTSD relies on a
Because PTSD can have devastating effects on family
multidimensional approach. (26) Treatment options include
members and those close to the patient, family and other
patient education, social support, and anxiety
group therapies may be indicated as adjuncts to individual
management through psychotherapy and
treatment of the patient with PTSD. (29)
psychopharmacologic intervention. Patient education and
social support are important initial interventions to engage
PHARMACOLOGY
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American Family Physician
Dec 15, 2003 v68 i12 p2401
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Diagnosis and management of post-traumatic stress disorder.
Recent interest in the treatment of PTSD has stimulated
in patients with PTSD. (33) A recent pilot study suggests
large, prospective, double-blind, placebo-controlled clinical
that propranolol, administered after an acute traumatic
trials of the efficacy of selective serotonin reuptake
event, may have a preventive effect on the subsequent
inhibitors (SSRIs) in the treatment of the symptoms of
development of PTSD. (35)
PTSD. Currently, paroxetine (Paxil) and sertraline (Zoloft)
are the only medications that have been approved by the
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Diagnosis and management of post-traumatic stress disorder.
propranolol. Biol Psychiatry 2002;51:189-92.
The author thanks Anne D. Walling, M.D., of the University
of Kansas School of Medicine-Wichita, and Angela Dudley
for assistance in the preparation of the manuscript.
The author indicates that he does not have any conflicts of
interest. Sources of funding for this article: none reported.
He serves as a lecturer for Pfizer, Bristol-Myers Squibb,
and Eli Lilly.
BRADLEY D. GRINAGE, M.D., is director of forensic
psychiatry and assistant professor at the University of
Kansas School of Medicine-Wichita. He received his
medical degree from the University of Kansas School of
Medicine, Kansas City. Dr. Grinage completed a residency
in general adult psychiatry in the United States Air Force
and a fellowship in forensic psychiatry at the University of
Missouri School of Medicine, Kansas City.
Address correspondence to Bradley D. Grinage, M.D.,
University of Kansas School of Medicine-Wichita,
Department of Psychiatry and Behavioral Sciences, 1010
N. Kansas, Wichita, KS 67214-3199 (e-mail:
bgrinage@kumc.edu) Reprints are not available from the
author.
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