Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a mental disorder than can occur after a person is exposed to a major traumatic event. It is classified as a “trauma and stress-related disorder” in the DSM V. It used to be thought that PTSD only occurred in combat situations but it is now known that it can occur as a reaction to other traumas as well, in both children and adults. An example of a screening question for PTSD is: “In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you have had nightmares about it or thought about it when you did not want to?”

Most people who experience a traumatic event, however, do not develop PTSD, so it is important to be aware of the risk factors for someone to develop PTSD after a traumatizing event. There is a genetic susceptibility to developing PTSD. PTSD shares genetic variance with other anxiety disorders like panic disorder and generalized anxiety disorder. PTSD also shares genetic variance with substance abuse disorders. People who experience an interpersonal assault are more likely to develop PTSD compared to people who experience a non-assault based trauma. PTSD is commonly seen in patients with military experience but can also be seen as a result of sexual assault, physical abuse, and domestic violence, in children and adults. PTSD is more commonly seen in situations where someone is exposed to a repeated trauma rather than a single trauma.

People with smaller hippocampi (the part of the limbic system that plays a role in both memory and inhibitory control) are more likely to develop PTSD after a traumatic event.  The hippocampus is an area of the brain with high numbers of gluco-corticoid receptors, glucocorticoids being part of the physiologic response to stress.  In PTSD, there is an over-activation of the Hypothalamic-Pituitary-Adrenal (HPA) axis which results in an increase in the fight or flight response. This contributes to the symptoms that are seen in PTSD, including hyper-vigilance, avoidance of triggers, nightmares, intrusive flashbacks, experiencing distress with reminders of the trauma, sleep disturbance, irritability, anger outbursts, and exaggerated startle response. Children experiencing PTSD will display it in their play and might also exhibit aggression, regression in their development and hyperactivity and impulsivity.

Patients with PTSD are at higher risk for suicidal ideation and suicide. They are at higher risk for other mental health concerns like other anxiety disorders and major depression. They are at higher risk for substance abuse problems, in large part in an effort to “self-medicate”.

The mainstay of treatment for PTSD is therapy (individual and group) and medication if needed. Trauma focused CBT is an evidence-based therapy practice used for PTSD. Additionally some patients find EMDR (eye movement desensitization and reprocessing) helpful for their symptoms. The SSRIs and other antidepressants can be useful for the depressive and anxiety symptoms of PTSD. Additionally medications like Prazosin can be used adjunctively for nightmares and sleep disturbance. Benzodiazepines are not particularly helpful for PTSD and therefore are not generally a recommended treatment.

It is our hope that this primer on PTSD is helpful for primary care providers to be able to screen for PTSD appropriately and refer for a more thorough assessment as needed.

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