Trauma and Stressor-Related Disorders

Post-Traumatic Stress Disorder (PTSD)

In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), post-traumatic stress disorder (PTSD) is recategorized as a trauma and stressor-related disorder.

Patients with a history of trauma may be at risk for PTSD. Such patients may have intrusive thoughts, flashbacks (vivid reexperiencing of the traumatic events), nightmares, hypervigilance to threat, and avoidance of situations or other stimuli likely to reactivate emotional experiences of the trauma. Symptoms may otherwise be subtle, including negative thoughts and depression, irritability, anger outbursts, and increased alcohol and substance misuse. PTSD may also manifest in the form of somatic symptoms with headache and back pain being the most common complaints.

In patients with new-onset anxiety, interpersonal conflicts, insomnia, or depression, screening for PTSD may be appropriate if symptoms are present for more than one month.

Diagnosis

The table below outlines the DSM-5 diagnostic criteria and features for PTSD. Patients must meet eight of these features to be diagnosed with PTSD.

(Source: Case 1-2019: A 34-Year-Old Veteran with Multiple Somatic Symptoms . N Engl J Med 2019.)

Treatment

Treatment approaches for PTSD generally incorporate psychotherapy and psychopharmacology. It is also important to address and treat somatic symptoms when possible within the therapeutic plan.

• Psychotherapies include cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and prolonged exposure therapy (PE). These therapies also utilize education and counseling to reduce distress and avoidance.

  • CPT is a type of cognitive behavioral therapy designed to help the individual examine and modify maladaptive thoughts or behaviors stemming from the traumatic event and work toward changing them.

• Psychopharmacologic agents commonly used in the treatment of PTSD include selective serotonin-reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Benzodiazepines have been shown to be ineffective for PTSD treatment and prevention and are associated with adverse effects, including worse overall severity and psychotherapy outcomes, disinhibition, and substance use.

Acute Stress Disorder

Acute stress disorder shares features with PTSD but refers to symptoms during the acute phase (3 days to 1 month) following a traumatic or extremely stressful event (threat of death, serious injury, or sexual violation). If post-traumatic symptoms persist beyond a month, assessment for PTSD is warranted. Diagnosis of PTSD cannot be made until at least 1 month after the experience of a traumatic event. Acute reactions include anxiety, negative mood, dissociative symptoms (e.g., an altered sense of reality or amnesia about the traumatic event), and intrusive symptoms (e.g., flashbacks, memories, or disturbing dreams), which can lead to avoidant behavior.

Although most acute stress disorder symptoms are self-limiting, treatment for acute symptoms is similar to treatment for PTSD (described above) and may involve anxiolytics such as benzodiazepines. However, anxiolytics should be prescribed with caution because patients can become over reliant on this class of medication.