Continuing Education Activity

Posttraumatic stress disorder (PTSD) is a disabling psychiatric disorder that results from being exposed to real or threatened injury, death, and sexual assault. It is associated with functional and cognitive impairment. Early diagnosis and intervention are necessary for effective treatment and to minimize the longterm outcomes associated with PTSD. This activity describes the evaluation and management of PTSD and highlights the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Describe the etiology of posttraumatic stress disorder.
• Summarize the pathophysiology of posttraumatic stress disorder.
• Review the treatment considerations for patients with posttraumatic stress disorder.
• Outlines the importance of collaboration and coordination among the interprofessional team to improve outcomes for patients affected by posttraumatic stress disorder.

Introduction

Posttraumatic stress disorder (PTSD) is a syndrome that results from exposure to real or threatened death, serious injury, or sexual assault. Following the traumatic event, PTSD is common and is one of the serious health concerns that is associated with comorbidity, functional impairment, and increased mortality with suicidal ideations and attempts. The Diagnostic and Statistical Manual of Mental Disorders(DSM-5) has included PTSD in the new category of Trauma- and Stress-related Disorders.

The symptoms of PTSD include persistently re-experiencing the traumatic event, intrusive thoughts, nightmares, flashbacks, dissociation(detachment from oneself or reality), and intense negative emotional (sadness, guilt) and physiological reaction on being exposed to the traumatic reminder.[1] Furthermore, problems with sleep and concentration, irritability, increased reactivity, increased startle response, hypervigilance, avoidance of traumatic triggers also occur. There is a significant impairment in social, occupational, and other areas of functioning. However, the symptoms of PTSD overlap with acute stress disorder.[2] For a patient to be diagnosed as PTSD, the duration of the symptoms must be more than one month. 

Etiology

The development of posttraumatic stress disorder in individuals is linked to a large number of factors. These include experiencing a traumatic event such as a severe threat or a physical injury, a near-death experience, combat-related trauma, sexual assault, interpersonal conflicts, child abuse, or after a medical illness. Chronic PTSD occurs in patients who are unable to recover from the trauma due to maladaptive responses.[3]

The risk factors for the development of PTSD include biological and psychological factors such as gender (more prevalent in women), childhood adversities, pre-existing mental illness, low socioeconomic status, less education, lack of social support. Nature and the severity of the trauma are also accountable while determining the risk factors for PTSD.

Epidemiology

The prevalence of traumatic events in the lives of individuals ranges from 61% to 80%.[4] After the trauma, posttraumatic stress disorder occurs in approximately 5% to 10% of the population and is higher in women than in men.[5] Studies have shown that the rates vary depending upon the specific population being considered. 

Pathophysiology

The pathophysiology of posttraumatic stress disorder involves alterations in the neurotransmitter and neurohormonal functioning. Individuals with PTSD have shown to have normal to low levels of cortisol and elevated levels of corticotropin-releasing factor (CRF) despite their ongoing stress. CRF stimulates the release of norepinephrine by the anterior cingulate cortex, which leads to an increased sympathetic response, which manifests as increased heart rate, blood pressure, increased arousal, and startle response. Also, some studies have shown altered functioning of other neurotransmitter systems such as GABA, glutamate, serotonin, neuropeptide Y, and other endogenous opioids in patients with PTSD. There is a decrease in GABA activity and an increase in the glutamate, which fosters dissociation and derealization. Serotonin concentration is also decreased in dorsal/median raphe, which likely changes the dynamic between the amygdala and the hippocampus. Plasma neuropeptide Y concentration is also reduced.[6][7] 

Also, PTSD is associated with the change in the neurophysiology and anatomy of the brain. The size of the hippocampus is reduced, and the amygdala(processing emotions and modulating fear response) is overly reactive in individuals with PTSD. The medial prefrontal cortex (inhibitory control over the emotional reactivity of amygdala) appears to be smaller and less responsive in patients with PTSD.

History and Physical

The initial step in the diagnosis of posttraumatic stress disorder is to obtain a detailed history. It is challenging for the patient at times to describe the nature and severity of the traumatic event, and they may choose to avoid mentioning it. However, the presentation and the duration of the symptoms are useful in making an accurate diagnosis. The health care workers must inquire about any depressive or anxiety symptoms, suicidal ideation or previous attempts, substance abuse, access to firearms. 

The diagnostic criteria for the diagnosis of PTSD as per DSM-5 include:

Criterion A: Stressor

Exposure to real or threatened death, injury, or sexual violence in one or more of the following ways:

1. They are directly exposed to the traumatic event.
2. Witnessing in person as it occurred to someone else.
3. They learned about a close family relative or close friend been exposed to actual or threatened trauma, accidental or violent death.
4. Indirect exposure to distressing details of the traumatic event (professionals repeatedly exposed to the details of child abuse, collecting human remains, or pieces of evidence). This does not include exposure through television, movies, electronic devices, or pictures.

Criterion B: Intrusion Symptoms

Presence of one or more of the following symptoms related to the traumatic event and began after the trauma occurred:

1. Recurrent, involuntary, and intrusive thoughts associated with the traumatic event. In children older than 6 years, this may be expressed using repetitive play in which the aspects of the trauma are expressed.
2. Distressing nightmares that may be repetitive with the content of the dream is related to the traumatic event. Children may have frightening dreams where they may or may not recognize the content.
3. Dissociative reactions, as flashbacks, in which the individual may feel or act that the traumatic event is happening again. These reactions may occur as a continuum ranging from brief reactions to complete loss of awareness of oneself or the surrounding. Children may re-enact such events in the play.
4. Intense or prolonged psychological distress on exposure to traumatic reminders
5. Marked physiological reactivity such as increased heart rate, blood pressure on exposure to traumatic reminders

Criterion C: Avoidance

Persistent avoidance of the stimuli related to the traumatic event, as evidenced by one or both of the following:

1. Avoidance or efforts to avoid distressing memories, thoughts associated with the traumatic event.
2. Avoidance or efforts to avoid external reminders such as people, places, activities, conversations, or situations that arouse distressing memories or thoughts related to the traumatic event

Criterion D: Negative Alterations in Mood

Negative alterations in mood and cognition that began or worsened after the traumatic event, as evidenced by two or more of the following:

1. Inability to recall important aspects of the traumatic event. This can be due to dissociative amnesia, not due to head injury, drugs, or alcohol.
2. Persistent and distorted negative beliefs or expectations about oneself or the world, such as "I am bad," or "The world is completely dangerous."
3. Persistent distorted cognition that leads the individual to blame self or others for causing the traumatic event.
4. Persistent negative emotional state, including fear, guilt, anger, or shame
5. Markedly diminished interest in significant activities that used to be enjoyable.
6. Feelings alienated, estranged, or detached from others.
7. Persistent inability to experience a positive emotion such as happiness, satisfaction, or love

Criterion E: Alterations in Arousal and Reactivity

Trauma-related alterations in reactivity and arousal that began or worsened after the traumatic event, as evidenced by two or more of the following:

1. Irritable or aggressive outbursts with little or no provocation.
2. Reckless or self-destructive behavior.
3. Hypervigilance
4. Exaggerated startle response
5. Problems in concentration
6. Sleep disturbances (difficulty falling or staying asleep, restless sleep)

Criterion F: Duration

     Persistence of symptoms in Criterion B, C, D, and E for more than one month

Criterion G: The disturbance causes significant functional impairment or distress in various areas of life, such as social or occupational.

Criterion H: The disturbance is not attributable due to substance use, medication, or another medical illness.[8]

Evaluation

Posttraumatic stress disorder is a complex phenomenon, and it is necessary to evaluate for any co-existing psychiatric illness in the patient. After a detailed history is obtained, the next step is to have a thorough mental status examination, which helps confirm the behavioral, emotional, and cognitive aspects of PTSD. On the mental status examination, the patient would likely mention poor sleep and concentration, frequent nightmares and flashbacks related to the event, guilt or negative emotions associated with the reminder, avoidance, and increased vigilance.  

The health-care providers can efficiently use self-report scales for screening or management such as PTSD Checklist for DSM-5 (PCL-5), Trauma Symptom Checklist - 40 (TSC-40).[9][10] Physical examination should be done as a part of the total workup to rule out any medical or neurological disorder. Routine laboratory testing like complete blood count, urine toxicology, TSH, vitamin B12, folate levels are checked. Individuals may present with physical injuries in regards to the trauma, and accordingly, neuroimaging studies like CT scan and MRI scan of the brain is indicated as per the history and presentation.

Treatment / Management

Posttraumatic stress disorder is a disabling consequence after a traumatic event, and early detection and intervention are necessary for planning the management. Studies have shown that both psychotherapy and pharmacotherapy are effective.

Trauma-focussed psychotherapy is considered as the first-line treatment effective in adults as well as children, and it includes trauma-focused CBT (cognitive-behavioral therapy), eye movement desensitization and reprocessing (EMDR), cognitive processing therapy, and imaginal exposure. Studies have shown that daytime PTSD symptoms improve even after a single session of CBT. The therapy has shown to shortens the course of those who will recover. However, it does not change the long-term outcome.[11]

Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) are the first-line drug of choice for the treatment of PTSD. Sertraline and paroxetine are Food and Drug Administration(FDA)-approved medications for adults. However, their efficacy in children and adolescents is still to be proven. Insomnia is common in patients with PTSD, which may be treated by educating the patient regarding following adequate sleep hygiene. Clonidine and prazosin are useful in decreasing trauma-related nightmares.[12][13] Trazodone can also be used for treating insomnia. Studies have shown that adding an antipsychotic like risperidone to the standard antidepressant regimen can significantly improve the outcome of patients with PTSD. SSRIs or SNRIs or trauma-focused psychotherapy or a combination of both are effective in the treatment of PTSD.

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.[14]

Prognosis

The long-term outcome for patients with posttraumatic stress disorder depends on one's ability to cope up with stress, substance abuse, the nature of social support, and the ability to stay compliant with the treatment plan as devised individually. About 30% of people eventually recover, and another 40% get better with the treatment, although less-intense symptoms may remain. A few of the patients receive the support to make successful adjustments and develop the coping methods to overcome the symptoms of PTSD even without formal treatment. Comorbidities with PTSD worsen the health status of individuals.

Complications

Posttraumatic stress disorder has a devastating impact on those suffering and their families. Psychiatric and medical comorbidities are common with PTSD such as:

• Mood disorders
• Anxiety and panic disorders
• Neurological disorders including dementia
• Substance abuse disorder

Patients with PTSD are associated with substantial disability, and the presence of comorbidities can cause the chronicity of the condition. Studies have shown that 51.9% of men with PTSD concomitantly abuse alcohol and have reported early age of onset of alcohol dependence, increased cravings, and legal problems owing to alcohol abuse. There is an overall increased risk of suicide ideation and attempts. Dementia may also occur due to traumatic injury or alterations in the functioning of the brain.

Deterrence and Patient Education

The risk and recovery of the patient with posttraumatic stress disorder are highly dependent upon the social phenomenon. Studies have shown that individuals who have been exposed to human-generated traumatic events such as combat veterans are at increased risk of developing PTSD than the individuals who are exposed to other kinds of trauma. During childhood, the child's proximity with its caretaker modulates the coping skills and determines the sense of safety following the trauma.[15][16] It is challenging for the patients to open up about their trauma, mostly during the first visit. PTSD also affects the development and the course of many physical illnesses. Awareness about the signs and symptoms of PTSD is essential for patients and health-care providers to start early treatment and limit the burden of the illness on the patient and the families of the survivors.

Enhancing Healthcare Team Outcomes

Posttraumatic stress disorder often poses a diagnostic dilemma. A detailed history from the patient may suggest that the patient has PTSD; however, detailed mental status examination, cognitive testing, and laboratory investigations are essential to rule out any coexisting medical or psychiatric illness. Early diagnosis and timely intervention is essential and is a collaborative interprofessional effort.

An interprofessional team includes psychiatrists, psychologists, nurse practitioners, primary care providers, and social workers. The nurse monitors the patients, educates them regarding their illness, and informs the prescriber of any concerns associated with follow-up visits. The pharmacists review the dosage, checks for drug interaction, and educate the patient regarding the importance of compliance and the potential side effects. Social workers are assigned for the outpatient care of these patients, as many require support services. Communication is essential among the team to ensure effective patient care and to minimize the risk of medical errors. In case of side effects, appropriate referrals are made to make sure that the patients can maintain an adequate quality of life. Interprofessional teamwork is vital for successful diagnosis, management, and minimizing long-term outcomes associated with PTSD.