Identifying and Managing Posttraumatic Stress Disorder



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Am Fam Physician. 2013 Dec 15;88(12):827-834.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/post-traumatic-stress-disorder.html.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Posttraumatic stress disorder (PTSD) occurs in an estimated 8% of men and 20% of women who are exposed to traumatic events. PTSD is a trauma- and stress-related disorder associated with significant psychosocial morbidity, substance abuse, and other negative physical health outcomes. The hallmarks of PTSD include exposure to a traumatic event; reexperiencing the event or intrusion symptoms; avoidance of people, places, or things that serve as a reminder of the trauma; negative mood and thoughts associated with the trauma; and chronic hyperarousal symptoms. Self-report questionnaires can assist clinicians in identifying anxiety problems associated with traumatic events. For patients who meet criteria for PTSD, trauma-focused psychotherapy and pharmacotherapy improve symptoms. Benzodiazepines and atypical antipsychotics are not recommended because studies have shown that adverse effects outweigh potential health benefits. Primary care physicians should monitor patients with PTSD for comorbid conditions such as substance abuse, mood disorders, and suicidality, and should refer patients to behavioral health specialists and support groups when appropriate.

Posttraumatic stress disorder (PTSD) is a trauma- and stress-related disorder that has historically been diagnosed in combat veterans, but also occurs after many other types of traumatic events (Figure 1). It is under-recognized and undertreated in primary care practices.1,2 To improve outcomes in patients with PTSD, this article provides a practical approach to the recognition, diagnosis, and multidisciplinary treatment of PTSD.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendations Evidence rating References

New patients with a history of trauma exposure should be screened for symptoms of PTSD initially, and then on an annual basis or more frequently if clinically indicated.

C

14

Trauma-focused psychotherapy and pharmacotherapy with selective serotonin reuptake inhibitors or serotonin–norepinephrine reuptake inhibitors are first-line treatment options for PTSD.

A

14, 20, 21

Monotherapy for PTSD should be optimized before prescribing additional agents.

C

14

Adjunctive treatment with prazosin (Minipress) is recommended for patients with PTSD who have sleep disturbance.

B

14, 31

Benzodiazepines should be avoided in the treatment of PTSD.

B

14, 30, 35

Atypical antipsychotics should generally be avoided in the treatment of PTSD.

C

14


PTSD = posttraumatic stress disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendations Evidence rating References

New patients with a history of trauma exposure should be screened for symptoms of PTSD initially, and then on an annual basis or more frequently if clinically indicated.

C

14

Trauma-focused psychotherapy and pharmacotherapy with selective serotonin reuptake inhibitors or serotonin–norepinephrine reuptake inhibitors are first-line treatment options for PTSD.

A

14, 20, 21

Monotherapy for PTSD should be optimized before prescribing additional agents.

C

14

Adjunctive treatment with prazosin (Minipress) is recommended for patients with PTSD who have sleep disturbance.

B

14, 31

Benzodiazepines should be avoided in the treatment of PTSD.

B

14, 30, 35

Atypical antipsychotics should generally be avoided in the treatment of PTSD.

C

14


PTSD = posttraumatic stress disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Assessment and Management of PTSD

Figure 1.

Algorithm for assessment and management of posttraumatic stress disorder (PTSD).

View Large

Assessment and Management of PTSD


Figure 1.

Algorithm for assessment and management of posttraumatic stress disorder (PTSD).

Assessment and Management of PTSD


Figure 1.

Algorithm for assessment and management of posttraumatic stress disorder (PTSD).

Diagnostic Criteria

PTSD is characterized by exposure to a traumatic event and the subsequent development of four general symptom domains: reexperiencing the event or intrusion symptoms; avoidance of people, places, or things that serve as a reminder of the trauma; negative changes

The Authors

CHRISTOPHER H. WARNER, MD, is deputy commander for clinical services and chief of medical staff at Bassett Army Community Hospital and the U.S. Army Medical Department Activity–Alaska in Fort Wainwright.

CAROLYNN M. WARNER, MD, is a primary care physician in the Warrior Transition Unit at the U.S. Army Medical Department Activity–Alaska.

GEORGE N. APPENZELLER, MD, is an emergency medicine physician and the Hospital Commander of Blanchfield Army Community Hospital in Fort Campbell, Ky.

CHARLES W. HOGE, MD, is a research consultant for the U.S. Army Office of the Surgeon General and a staff psychiatrist at the Walter Reed Army Institute of Research in Silver Spring, Md.

Address correspondence to Christopher H. Warner, MD, 650 Joel Dr., Fort Campbell, TN 37043 (e-mail: Christopher.h.warner.mil@mail.mil). Reprints are not available from the authors.

The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, the U.S. Department of Defense, or the U.S. government.

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