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Posttraumatic stress disorder

Definition
PTSD is a mental disorder resulting from exposure to a traumatic experience, which is typically characterized by intrusive, involuntary, and/or distressing recollection or re-experience of the traumatic events.
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Pathophysiology
PTSD is caused by traumatic exposure to death, injury, sexual assault, torture, or bodily disfigurement.
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Epidemiology
In the US, the estimated prevalence of PTSD, based on the Same Event definition of DSM-V for lifetime, past 12 months, and past 6 months, is 8.3%, 4.7%, and 3.8%, respectively.
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Disease course
The psychological impact of trauma leads to abnormalities in fear learning, threat detection, executive function, emotion regulation, and contextual processing. These neuroendocrine changes are linked to altered activity in the amygdala. PTSD is associated with mood, anxiety, substance abuse disorders, or suicidal ideation leading to serious disability, medical illness, and premature death. The relative risk of suicidal ideation in PTSD is similar to the relative risk of generalized anxiety disorder or alcohol dependence; however, is lower than that of depression.
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Key sources
The following summarized guidelines for the evaluation and management of posttraumatic stress disorder are prepared by our editorial team based on guidelines from the United States Department of Defense (DoD/VA 2023), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the World Health Organization (WHO 2023), the American Psychiatric Association (APA 2019), the Ontario Neurotrauma Foundation (ONF 2018), and the Anxiety Canada (AC 2014).
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Guidelines

1.Screening and diagnosis

Indications for screening: consider using the Primary Care PTSD Screen for DSM-5 for screening for PTSD.
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  • Diagnosis

2.Medical management

General principles
Offer individual psychotherapy over pharmacologic interventions for the treatment of PTSD.
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Avoid precluding psychotherapies from the treatment of PTSD in patients with comorbid substance use disorder and/or other disorders.
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  • Antidepressants

  • Antipsychotics

  • Anticonvulsants

  • Alpha-blockers

  • Other medications

  • Combination therapy

3.Nonpharmacologic interventions

Psychotherapy: as per VA 2023 guidelines, offer any of the following individual, manualized trauma-focused psychotherapies for the treatment of PTSD:
cognitive processing therapy
eye movement desensitization and reprocessing
prolonged exposure.
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  • Technology-based interventions

  • Alternative and complementary therapies

4.Therapeutic procedures

Therapies with no evidence for benefit: avoid offering electroconvulsive therapy or vagus nerve stimulation for the treatment of PTSD.
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5.Specific circumstances

Patients after traumatic brain injury: assess for symptoms of PTSD in the assessment of common post-concussive mental health symptoms in patients after concussion.
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6.Preventative measures

Prevention after acute stress: insufficient evidence to recommend for or against psychotherapy or pharmacotherapy in the immediate post-trauma period to prevent PTSD in persons exposed to trauma.
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7.Follow-up and surveillance

Assessment of treatment response: consider using a validated instrument, such as the PTSD Checklist for DSM-5, or a structured clinician-administered interview, such as the Clinician-Administered PTSD Scale, to detect changes in symptom severity over time.
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