Description :
- anxiety disorder
- 3 major features
- reexperiencing of trauma - dreams or waking thoughts
- emotional numbing of other life experiences
- symptoms of autonomic instability, depression, cognitive difficulties (e.g. poor concentration)
- post-traumatic stress disorder considered a valid and useful diagnostic entity (BMJ 2001 Sep 8;323(7312):561), commentary can be found in BMJ 2002 Apr 13;324(7342):914
ICD-9 Codes :
- 309.81 prolonged posttraumatic stress disorder
ICD-10 Codes :
- F43.1 post-traumatic stress disorder
Who is most affected :
- any age including children
- females 2x
Incidence/Prevalence :
- 0.75% prevalence - 1.2% females, 0.5% males
- 8.6% prevalence in 15 US primary care clinics 2004-2005 based on 965 randomly sampled patients who completed self-report questionnaire and follow-up telephone interview (Ann Intern Med 2007 Mar 6;146(5):317), editorial can be found in Ann Intern Med 2007 Mar 6;146(5):390, commentary can be found in Evid Based Med 2007 Oct;12(5):149, Am Fam Physician 2007 Nov 1;76(9):1376
- acute PTSD common in people living in Manhattan after World Trade Center attacks; telephone survey of 1,008 adults living in Manhattan 5-8 weeks after the attacks, 7.5% had symptoms consistent with current PTSD related to the attacks, 20% prevalence among those living closest to the World Trade Center (N Engl J Med 2002 Mar 28;346(13):982)
- 12.7% prevalence of PTSD among adults in India affected by December 2004 tsunami (Am J Public Health 2007 Jan;97(1):99)
- incidence of PTSD 10-13 cases per 1,000 person-years among United States military
- based on prospective cohort study
- 50,184 participants who enrolled in United States military from July 2001 to June 2003 completed PTSD checklist questionnaire in 2004-2006
- new onset of self-reported PTSD symptoms or PTSD diagnosed in
- 7.6-8.7% of personnel who were deployed and reported combat exposure
- 1.4-2.1% of personnel who were deployed but did not report combat exposure
- 2.3-3% of non-deployed personnel
- Reference - BMJ 2008 Feb 16;336(7640):366 full-text
- PTSD uncommon in children and adolescents in general population
- longitudinal study of 1,420 children aged 9-13 years followed until age 16 years
- 68.2% had traumatic events
- 9.1% had painful recall
- 2.2% had subclinical PTSD
- 0.4% had PTSD
- Reference - Arch Gen Psychiatry 2007 May;64(5):577
- PTSD common in children and adolescents after traumas of various types
- 30.6% rate of PTSD and 13.6% rate of sub-syndromal PTSD in 447 children and adolescents after super-cyclone in Orissa, India (BMC Psychiatry 2007 Feb 14;7:8 full-text)
- 27% rate of PTSD in 401 trauma patients aged 12-19 years followed for 2 years (J Trauma 2005 Apr;58(4):764)
- 16.3% of 104 adolescents aged 12-20 years surveyed at least 1 year after liver, heart or kidney transplant met all PTSD symptom criteria, another 14.4% met 2 of 3 symptom-cluster criteria (Pediatrics 2005 Jun;115(6):1640)
- 11-13% prevalence of PTSD reported in 266 children ages 7-14 years living in villages affected by tsunami in southern Thailand, not significantly different from 6% prevalence of PTSD in 105 children living in unaffected villages (JAMA 2006 Aug 2;296(5):549), editorial can be found in JAMA 2006 Aug 2;296(5):576
- in children 3-18 seen in an urban pediatric trauma center for traffic-related injuries, follow-up at 7-12 months found diagnostic criteria for PTSD met in 25% children and 15% parents (Pediatrics 1999 Dec;104(6):1293)
- 21%-30% of 309 parents of childhood cancer survivors have PTSD (J Pediatr Psychol 1997 Dec;22(6):843)
- 27% of 165 parents of children receiving organ transplants met DSM-IV criteria for PTSD (Pediatrics 2003 Jun;111(6):e725 full-text)
- 10% of 145 Vietnamese boat refugees in Norway had or developed PTSD during 3 years of prospective follow-up (J Nerv Ment Dis 1994 Feb;182(2):85)
- PTSD very common in war survivors who experienced trauma
- 62% prevalence of PTSD reported in study of 490 Cambodian refugees more than 20 years after resettlement in United States, 99% of study subjects had near-death due to starvation and 90% had family member or friend murdered (JAMA 2005 Aug 3;294(5):571)
- 22% current and 33% lifetime prevalence of PTSD reported in 1,358 war survivors in former Yugoslavia who experience at least one war-releated stressor of combat, torture, internal displacement, refugee experience, siege and/or aerial bombardment (JAMA 2005 Aug 3;294(5):580)
Pathogenesis :
- repression, regression, denial, undoing
Likely risk factors :
- refugees resettled in western countries may be 10x more likely to have PTSD than general population in western countries
- high lifetime risk of mental disorders in post-conflict communities
- based on sampling of 3,048 respondents from Algeria, Cambodia, Ethiopia and Palestine
- lifetime prevalence based on DSM-IV criteria 1
- 5.8-37.4% for PTSD
- 5.2-22.7% for mood disorder
- 9.6-40% for anxiety disorder
- 1.6-8.3% for somatoform disorder
- 23.6-60.5% for any common disorder
- Reference -Lancet 2003 Jun 21;361(9375):2128
- risk factors for PTSD in adolescent trauma patients
- perceived threat to life (odds ratio OR 2.2)
- death of a family member at the scene (OR 4.7)
- no control over injury event (OR 1.7)
- violence-related injury (OR 2.2)
- female gender
- older age
- low socioeconomic status
- drug and alcohol abuse
- other adolescent behavioral problems
- Reference - 27% rate of PTSD in 401 trauma patients aged 12-19 years followed for 2 years (J Trauma 2005 Apr;58(4):764 in AHRQ Research Activities 2005 Sep;301:7)
Possible risk factors :
- biological vulnerability
- rape
- Vietnam veteran
- sexual violence exposure increased rates of PTSD and major depressive disorder and decreased social functioning in combatants
- based on cross-sectional survey of 1,666 adults ≥ 18 years old who were former combatants in Liberia
- Reference - JAMA 2008 Aug 13;300(6):676
- lower pretrauma cognitive ability associated with risk for PTSD in co-twin study with 2,386 male Vietnam-era twin veterans (Arch Gen Psychiatry 2007 Mar;64(3):361)
- history of childhood physical abuse associated with depression symptoms and post-traumatic stress disorder symptoms in telephone survey of 298 men, 51% of whom had history of childhood physical abuse (Ann Intern Med 2005 Oct 18;143(8):581)
- sudden unexpected death of loved one appears to be most important cause of PTSD due to high prevalence and moderate risk of PTSD, while traditional "traumas" have higher risk of PTSD but overall lower prevalence; based on telephone survey of 2,181 persons 18-45 in Detroit area (Arch Gen Psychiatry 1998 Jul;55:626)
- being a child soldier associated with increased risk for PTSD and depression after adjustment for trauma exposure
- based on cohort study with 141 former child soldiers and 141 never-conscripted matched controls in Nepal
- Reference - JAMA 2008 Aug 13;300(6):691
- risk for PTSD from subsequent trauma exposure higher in persons with prior PTSD
- based on cohort study
- 1,200 persons aged 21-30 years with and without previous trauma exposure randomly selected from health maintenance organization in Michigan were interviewed and followed for 10 years
- 990 (82.5%) completed follow-up interview
- at first follow-up
|
Prior exposure and PTSD |
Prior exposure without PTSD |
No prior exposure |
| Number of participants |
92 |
294 |
604 |
| Rate of exposure |
42.4% |
33.3% |
24% |
| PTSD if exposed |
18% |
12.2% |
8.3% |
- at second follow-up
|
Prior exposure and PTSD |
Prior exposure without PTSD |
No prior exposure |
| Number of participants |
105 |
386 |
419 |
| Rate of exposure |
60% |
41.5% |
27.4% |
| PTSD if exposed |
19.1% |
6.3% |
6.1% |
- Reference - Arch Gen Psychiatry 2008 Apr;65(4):431
- traffic accidents in children
- traffic accidents in children may increase risk of PTSD in children; 119 children aged 5-18 years involved in road traffic accidents and 66 children had sports injuries were assessed for PTSD 6 weeks after injury, 34.5% children involved in road traffic accidents and 3% who had sports injuries met diagnostic criteria for PTSD; presence of post-traumatic stress disorder was not related to type of accident, age of child, or nature of injuries but was significantly associated with female sex, previous experience of trauma, and subjective appraisal of threat to life (BMJ 1998 Dec 12;317(7173):1619)
- higher heart rate at emergency department visit associated with higher risk of PTSD; prospective study of 190 children aged 8-17 years hospitalized for traffic-related injury and followed for 6 months, mean heart rate at emergency department triage was 110 beats/minute among children who developed partial or full PTSD and 100 beats/minute among those who did not (Arch Gen Psychiatry 2005 Mar;62(3):335 in JAMA 2005 May 25;293(20):2450)
- mild traumatic brain injury associated with increased risk of post-traumatic stress disorder (PTSD) in US soldiers
- based on cohort study
- 2,525 US soldiers returning from year-long deployment to Iraq
- 124 (4.9%) reported injuries with loss of consciousness
- 260 (10.3%) reported injuries with altered mental status
- 435 (17.2%) reported other injuries
- rate of soldiers meeting criteria for PTSD
- 43.9% of those reporting loss of consciousness
- 27.3% of those reporting altered mental status
- 16.2% with other injuries
- 9.1% with no injury
- soldiers with mild traumatic brain injury (primarily with loss of consciousness) significantly more likely to report poor general health, missed workdays, medical visits, and increased somatic and postconcussive symptoms
- after adjustment for PTSD and depression, mild traumatic brain injury not significantly associated with physical health outcomes or symptoms, except for headache
- Reference - N Engl J Med 2008 Jan 31;358(5):453, editorial can be found in N Engl J Med 2008 Jan 31;358(5):525, commentary can be found in N Engl J Med 2008 May 15;358(20):2177
- heart rate > 95 beats per minute in emergency department associated with higher risk of PTSD in prospective study of 161 acutely injured surgical inpatients followed for 12 months (Biol Psychiatry 2005 Jan 1;57(1):91 in AHRQ Research Activities 2005 Jun;298:30)
- PTSD symptoms may occur following mechanical ventilation
- based on prospective study of mechanically ventilated ICU patients
- 30 of 114 patients (26%) surveyed at hospital discharge reported symptoms consistent with PTSD
- no significant association with age
- PTSD at 6 months (out of 43 patients evaluated)
- 7 (16%) had PTSD symptoms
- reported in 22% of patients < 65 years old and no elderly patients
- Reference - meeting abstract in J Am Geriatr Soc 2005 Apr;53(S1):S1,B109
- long-term PTSD symptoms may occur after secondary peritonitis
- many factors affect psychological response to national trauma
- based on US national survey of 3,496 persons 9-23 days after September 11 terrorist attack
- of 1,069 randomly selected subjects outside of New York City, 933 completed follow-up surveys at 2 months and 787 at 6 months
- 17% of US population outside of New York City reported symptoms of September 11-related posttraumatic stress 2 months after the attacks, and 5.8% at 6 months
- high levels of posttraumatic stress symptoms associated with
- female sex
- marital separation
- pre-September 11 physician-diagnosed depression or anxiety disorder
- severity of exposure to the attacks
- early disengagement from coping efforts
- global distress associated with severity of loss due to attacks and early coping strategies (increased with denial and giving up, decreased with active coping)
- Reference - JAMA 2002 Sep 11;288(10):1235
- PTSD identified in mothers of children suffering life-threatening illnesses (Psychosomatics 1996 Mar-Apr;37(2):116)
Complications :
- posttraumatic stress disorder (PTSD) symptoms associated with increased risk for coronary heart disease in prospective cohort of 1,946 US military veterans followed for 11-15 years (Arch Gen Psychiatry 2007 Jan;64(1):109)
Associated conditions :
- aggression, violence, poor impulse control, substance abuse
- prior PTSD associated with risk for drug abuse or dependence in young adults
- based on prospective cohort study
- 988 young adults aged 19-24 years without clinical features of DSM-IV drug use disorders followed for 1 year
- 75 (7.6%) young adults had prior PTSD and 714 (72.3%) young adults exposed to trauma only (without PTSD) at first assessment
- prior PTSD associated with excess risk for drug abuse or dependence
- adjusted relative risk 4.9 (95% CI 1.6-15.2) compared to no-trauma group
- adjusted relative risk 2 (95% CI 1.1-3.8) compared to trauma-exposed group
- prior PTSD associated with emerging dependence problems (adjusted relative risk 4.9, 95% CI 1.2-20.1) compared to no-trauma group
- Reference - Arch Gen Psychiatry 2007 Dec;64(12):1435
- post-traumatic stress disorder (PTSD) may be common in fibromyalgia patients; questionnaire study of 77 fibromyalgia patients, 57% had PTSD symptoms, prevalence of PTSD higher than general population but no control group studied (Semin Arthritis Rheum 2002 Aug;32(1):38 in JAMA 2003 Jan 15;289(3):278)
- PTSD incidence appears increased in women with chronic pelvic pain
- based on observational study
- 713 consecutive women were seen in referral-based pelvic pain clinic
- 31.3% had positive PTSD screening
- 46.8% reported history of sexual or physical abuse
- Reference - Obstet Gynecol 2007 Apr;109(4):902
- PTSD associated with many adverse health outcomes in young girls in case-control study including 647 girls and 1,025 adolescents with PTSD diagnosis (Pediatrics 2005 Dec;116(6):e767 full-text)
- PTSD and depressive symptoms are associated with adolescent functional impairment during the year after physical injury based on prospective cohort of 108 injury survivors aged 12-18 years in surgical inpatient units (Arch Pediatr Adolesc Med 2008 Jul;162(7):642)
History of Present Illness (HPI) :
- sense of foreshortened future
- onset can be delayed decades after stressor
- prevalence of delayed-onset PTSD averaged 15.3% civilian cases and 38.2% military cases among PTSD cases in systematic review of 19 group studies, but definitions and prevalence rates varied across studies (Am J Psychiatry 2007 Sep;164(9):1319)
Social History (SH) :
- reduced involvement with normal activities, detachment
Review of Systems (ROS) :
- feelings of guilt, rejection, humiliation, dissociative states, panic attacks, illusions, hallucinations
- patients with post-traumatic stress disorder have more physical symptoms than control patients, based on retrospective/cross-sectional study (J Fam Pract 2001 Mar;40(3):247)
General Physical :
Neuro :
- impaired memory
- impaired attention
Making the diagnosis :
- DSM-IV-TR criteria
- exposed to traumatic event in which events involved actual or threatened death or serious injury, or threat to physical integrity of oneself or others
- response to traumatic event involved intense fear, helplessness or horror
- traumatic event persistently reexperienced in at least 1 of:
- recurrent and intrusive distressing recollections of event
- recurrent distressing dreams of event
- acting or feeling as if event were recurring
- intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of traumatic event
- physiological reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of traumatic event
- persistent avoidance of stimuli associated with trauma and numbing of general responsiveness (3 of 7 criteria, not present before trauma):
- efforts to avoid thoughts, feelings or conversations associated with trauma
- efforts to avoid activities, places or people that arouse recollections of trauma
- inability to recall important aspect of trauma
- markedly diminished interest or participation in significant activities
- feeling of detachment or estrangement from others
- restricted range of affect
- sense of foreshortened future
- persistent symptoms of increased (CNS) arousal (not present before trauma, 2 of 5 criteria):
- difficulty falling or staying asleep
- irritability or outburst of anger
- difficulty concentrating
- hypervigilance
- startle response
- duration of above symptoms > 1 month
- distress or impaired functioning
Rule out :
Imaging studies :
- sleep - increased REM latency, increased nightmares
- decreased REM amount, stage 4 sleep, and sleep efficiency
Other diagnostic testing :
Prognosis :
- tends to remit with time (30% recover, 10% no change), chronic course over several years
- no significant remission in 48% of 125 German adolescents and young adults ages 14-24 years with PTSD followed for 34-50 months (Am J Psychiatry 2005 Jul;162(7):1320 in BMJ 2005 Jul 30;331(7511):300)
- worse prognosis with preexisting psychopathology
Treatment overview :
- treatments proven to be beneficial
- cognitive behavior therapies
- exposure therapy
- treatments likely to be beneficial
- sertraline (Zoloft) 50-200 mg/day
- imagery rehearsal therapy in women with chronic nightmares
- eye movement desensitization and reprocessing
- treatments with unknown effectiveness
- supportive counseling
- affect management
- psychodynamic psychotherapy
- hypnotherapy
- inpatient programs
- drama therapy
- drugs other than sertraline
- other antidepressants - fluoxetine, brofaromine, amitriptyline
- anticonvulsants - lamotrigine, Carbamazepine, valproic acid, topiramate
- benzodiazepines
- antipsychotics
- clonidine or propranolol for autonomic hyperarousal
Counseling :
- some psychological treatments appear effective in PTSD (level 2 [mid-level] evidence)
- based on Cochrane review of trials with methodologic limitations
- systematic review of 33 randomized trials of psychological treatments for adults with traumatic stress symptoms for at least 3 months
- most trials did not report details of randomization or allocation concealment
- treatments with best evidence for supporting efficacy
- trauma-focused cognitive behavioral therapy/exposure therapy reduced clinician assessed PTSD symptoms compared to waitlist or usual care (14 trials with 649 patients) but not compared to stress management (6 trials with 239 patients)
- eye movement desensitization and reprocessing significantly better than waitlist or usual care (5 trials with 162 patients) but not compared to trauma-focused cognitive behavioral therapy (6 trials with 187 patients) or stress management (2 trials with 53 patients)
- stress management significantly better than waitlist or usual care (3 trials with 86 patients)
- other therapies (supportive therapy, non-directive counseling, psychodynamic therapy, hypnotherapy) were less effective than trauma-focused cognitive behavioral therapy/exposure therapy (3 trials with 120 patients) or stress management (1 trial with 25 patients) and no more effective than waitlist or usual care (2 trials with 72 patients)
- Reference - systematic review last updated 2007 May 23 (Cochrane Library 2007 Issue 3:CD003388)
- cognitive behavior therapies effective
- techniques include
- imaginal exposure
- real life exposure
- cognitive therapy - challenging distorted thoughts
- stress inoculation - instruction in coping skills and some cognitive techniques such as restructuring
- prolonged imaginal exposure therapy reduces PTSD symptoms at 3 months in female veterans (level 1 [likely reliable] evidence)
- based on randomized trial
- 284 female veterans with current PTSD and clear memory of trauma that caused PTSD at least 3 months prior were randomized to prolonged exposure (a type of cognitive behavioral therapy) vs. present-centered therapy (a type of supportive therapy)
- both groups had sessions delivered by standard protocol in 10 weekly 90-minute sessions
- prolonged exposure used imaginal exposure in sessions 3-10
- present-centered therapy focused on current life problems as manifestations of PTSD
- primary outcome was Clinician-Administered PTSD Scale (CAPS) score
- outcome assessors were blinded
- 38 women (13%) lost to follow-up but all women included in intention-to-treat analysis
- comparing prolonged exposure vs. present-centered therapy
- 38% vs. 21% treatment dropout (p = 0.002)
- mean number of sessions attended 8 vs. 9.3 (p < 0.001)
- mean CAPS score at baseline 77.6 vs. 77.9
- mean CAPS score at 10 weeks 52.9 vs. 60.1 (p < 0.05)
- mean CAPS score at 3 months 49.7 vs. 56 (p < 0.05)
- mean CAPS score at 6 months 50.4 vs. 54.5 (not significant)
- 39% vs. 20.3% no longer met criteria for PTSD at 10 weeks (p = 0.002, NNT 6)
- 39% vs. 28% no longer met criteria for PTSD at 3 months (not significant)
- 39.7% vs. 32.9% no longer met criteria for PTSD at 6 months (not significant)
- Reference - JAMA 2007 Feb 28;297(8):820, commentary can be found in JAMA 2007 Jun 27;297(24):2694
- cognitive therapy effective for recent-onset PTSD (level 1 [likely reliable] evidence)
- based on randomized trial
- 97 motor vehicle accident survivors with PTSD in initial months and increased risk for persistent PTSD underwent 3-week self-monitoring phase
- 85 patients with no recovery during 3-week self-monitoring phase were randomized to cognitive therapy vs. self-help booklet (based on cognitive behavioral therapy) vs. repeated assessments with follow-up at 3 and 9 months (79 patients)
- cognitive therapy patients received average of 11 sessions, starting mean 4 months after traumatic event
- cognitive therapy most effective in reducing symptoms of PTSD, depression, anxiety, and disability
- 11% cognitive therapy vs. 61% self-help booklet vs. 55% control group had PTSD at follow-up
- Reference - Arch Gen Psychiatry 2003 Oct;60(10):1024, commentary can be found in Evidence-Based Medicine 2004 May-Jun;9(3):84 or in Evid Based Ment Health 2004 May;7(2):51
- Internet-based cognitive behavioral therapy associated with improvements in PTSD severity and other psychopathological symptoms (level 2 [mid-level] evidence)
- based on randomized trial without attention control
- 96 patients with PTSD were randomized to 10 sessions of Internet-based cognitive behavioral therapy vs. waiting list control for 5 weeks and followed for 3 months after treatment completion
- assessment conducted at treatment completion and 3 months after treatment
- severity of PTSD significantly reduced from baseline in intervention group at 5 weeks and sustained at 3 months after treatment
- co-morbid depression and anxiety significantly reduced in intervention group compared to control at 5 weeks and sustained at 3 months after treatment
- Reference - BMC Psychiatry 2007 Apr 19;7:13 full-text
- cognitive therapy appears to reduce symptoms and improve functioning in chronic PTSD in context of terrorism or civil conflict (level 2 [mid-level] evidence)
- imagery rehearsal therapy may reduce chronic nightmares, improve sleep quality and decrease PTSD symptoms severity (level 2 [mid-level] evidence)
- based on randomized trial using wait-list control
- trial participants were 168 female sexual assault survivors with nightmares, insomnia and post-traumatic stress symptoms
- Reference - JAMA 2001 Aug 1;286(5):537, editorial can be found in JAMA 2001 Aug 1;286(5):584
- discussion of cognitive behavior therapy and evidence base for psychotherapies can be found in BMJ 2002 Feb 2;324(7332):288, commentary can be found in BMJ 2002 Jun 22;324(7352):1522
- Internet-based, therapist-assisted self-management treatment may reduce PTSD symptoms and depression in military personnel (level 3 [lacking direct] evidence)
- based on small randomized trial with high dropout rate
- 41 military service members with PTSD randomized to Internet-based therapist-assisted self-management cognitive behavior therapy vs. supportive counseling
- 30% dropout rate unrelated to treatment group (considered similar to regular cognitive behavior therapy)
- self-management cognitive behavior therapy associated with greater decline in daily log-on ratings of PTSD symptoms and global depression in intention-to-treat analysis
- Reference - Am J Psychiatry 2007 Nov;164(11):1676
- cognitive behavior therapy (CBT) may be effective in children with PTSD (level 2 [mid-level] evidence)
- based on small randomized trial without attention control
- 24 children aged 8-18 years with PTSD were randomized to 10-week course of individual CBT vs. waitlist
- 92% CBT group vs. 42% waitlist group no longer met criteria for PTSD at end of treatment (NNT 2)
- Reference - J Am Acad Child Adolesc Psychiatry 2007 Aug;46(8):1051
- other counseling therapies have appeared effective compared to wait list control in single randomized trials (level 2 [mid-level] evidence)
- psychodynamic psychotherapy, exposure therapy, and hypnotherapy were all equally effective and slightly better than wait list control in randomized trial of 112 patients (J Consult Clin Psychol 1989 Oct;57(5):607)
- affect management (group therapy focused on regulation of mood) for 15 weeks as adjunctive therapy to drug treatment controlled symptoms more than wait list control in randomized trial of 48 women (J Trauma Stress 1997 Jul;10(3):425)
- brief eclectic psychotherapy (components of cognitive behavior therapy and psychodynamic therapy) over 16 sessions more effective than wait list control in randomized trial of 42 police officers, criteria for PTSD were met by 9% vs. 50% after treatment and 4% vs. 65% at 3 months (J Trauma Stress 2000 Apr;13(2):333)
- psychosocial intervention for school children with post-disaster trauma symptoms may reduce PTSD symptoms (level 2 [mid-level] evidence)
- based on 2 randomized trials with methodologic limitations
- randomized trial of 4,258 children in 10 public elementary schools were screened 2 years after hurricane destroyed 71% of homes on Kauai Island (United States) in 1992
- study did not have intention-to-treat analysis
- 248 children with highest level of trauma-related symptoms were randomized to group intervention vs. individual intervention vs. wait-list control group; intervention was school-based, manual-guided and consisted of 4 weekly counselor-led sessions
- 214 children (86%) completed treatment, then 93% available at follow-up (except 25 sixth graders who matriculated)
- no differences between intervention groups, both interventions reduced trauma-related symptoms with sustained results at 1-year follow-up
- Reference - Arch Pediatr Adolesc Med 2002 Mar;156;211 in Pediatric Notes 2002 Mar 28;26(13);52
- cluster-randomized unblinded trial with 495 children (mean age 9.9 years) from political violence-affected communities in Indonesia
- children screening positively for trauma exposure randomized (by school) to school-based mental health intervention for 5 weeks vs. wait-list control
- intervention included 15 sessions of including trauma-processing activities, cooperative play, and creative-expressive elements
- intervention associated with significant improvement in DSM-IV defined PTSD symptoms and maintenance of hope
- no significant differences in changes in traumatic stress-related idioms (pains, fainting, dizziness, trembling, stiffness, and fevers), depressive symptoms, anxiety or functioning between groups
- Reference - JAMA 2008 Aug 13;300(6):655
Medications :
- medications can be effective in PTSD for reducing core symptoms, depression and disability; best evidence supports SSRIs
- systematic review of 35 randomized trials of pharmacotherapy for PTSD with 4,597 patients
- all trials were short-term, lasting 14 weeks or less
- medication reduced symptom severity compared to placebo in 17 trials with 2,507 patients
- response rates higher with medication than placebo in meta-analysis of 13 trials with 1,272 patients (NNT 5, 95% CI 4-7), response rates were 59.1% with medication vs. 38.5% with placebo
- medication less well tolerated than placebo
- evidence of treatment efficacy was most convincing for SSRIs
- Reference - systematic review last updated 2005 Oct 14 (Cochrane Library 2006 Issue 1:CD002795)
- antidepressants
- selective serotonin reuptake inhibitors (SSRIs) have been recommended as first-line agents, only drug class with multiple randomized trials showing efficacy
- sertraline (Zoloft) is an SSRI with specific indication for PTSD
- sertraline (Zoloft) now approved for long-term use in PTSD, based on 28-week placebo-controlled trial (Monthly Prescribing Reference 2001 Oct;A-11)
- sertraline significantly improves symptoms of PTSD, 187 outpatients from 14 centers underwent 2-week placebo run-in period then randomized to acute treatment with sertraline (25 mg/day for 1 week than flexible doses of 50-200 mg/day) vs. placebo for 12 weeks, 31% vs. 27% discontinued treatment (difference not significant), mean 150 mg dose in patients who completed the study, sertraline associated with significantly more improvement on 3 of 4 symptom scores, 53% vs. 32% response rate (p = 0.008, NNT 5), sertraline also associated with improved quality of life in analysis of patients who completed the study, 16% vs. 4.3% insomnia (p = 0.01, NNH 8) (JAMA 2000 Apr 12;283(14):1837), commentary can be found in JAMA 2000 Aug 2;284(5):563
- sertraline effective for PTSD; 208 outpatients randomized to sertraline 50-200 mg/day vs. placebo for 12 weeks, 60% vs. 38% response rate (p = 0.004, NNT 4.5), 9% vs. 5% discontinued due to adverse effects (NNH 25), 35% vs. 22% insomnia (NNH 7.7), 28% vs. 11% diarrhea (NNH 5.9), 23% vs. 11% nausea (NNH 8.3), 13% vs. 5% fatigue (NNH 12.5), 12% vs. 1% decreased appetite (NNH 9) (Arch Gen Psychiatry 2001 May;58(5):485 in JAMA 2001 Aug 1;286(5);515)
- sertraline may reduce combat-related PTSD symptoms; 42 Israeli military veterans with PTSD at least 6 months randomized to sertraline 50-200 mg/day vs. placebo for 10 weeks; 32 (76%) completed the study, 41% vs. 20% response rate among completers (NNT 5); results in intention to treat analysis were not statistically significant (J Clin Psychopharmacol 2002 Apr;22(2):190)
- maintenance sertraline effective over 28 weeks for sertraline responders; 96 adults with PTSD symptoms > 6 months who had responded to sertralien for 24 weeks were randomized to sertraline 50-200 mg/day vs. placebo for 28 weeks, 5.3% vs. 26% relapse rate (NNT 5), 16% vs. 46% relapse or discontinuation due to clinical deterioration (NNT 3), 16% vs. 52% acute exacerbation (NNT 3), 39% vs. 60% did not complete the study (NNT 5) (Am J Psychiatry 2001 Dec;158(12):1974 in ACP J Club 2002 Sep-Oct;137(2):69)
- paroxetine (Paxil)
- fluoxetine vs. placebo in 53 patients led to minimum symptoms and no disability in 41% vs. 4%, borderline statistical significance (Br J Psychiatry 1999 Jul;175:17)
- amitriptyline (1 trial with 40 patients) appeared effective but not statistically significant
- brofaromine (2 trials with 114 patients) did not appear effective
- venlafaxine extended-release associated with greater improvement in symptoms than placebo in 6-month randomized trial in 329 adults with PTSD for at least 6 months (Arch Gen Psychiatry 2006 Oct;63(10):1158), commentary can be found in Am Fam Physician 2007 Feb 1;75(3):397
- prazosin appears to reduce PTSD-related nightmares and other PTSD symptoms (level 2 [mid-level] evidence)
- based on 2 small randomized trials
- 40 veterans with chronic PTSD and distressing nightmares were randomized to prazosin vs. placebo for 8 weeks
- 10 Vietnam combat veterans with chronic PTSD and severe trauma-related nightmares randomized to prazosin vs. placebo
- topiramate (Topamax) reported to reduce nightmares and flashbacks (level 3 [lacking direct] evidence) in single uncontrolled retrospective series of 35 patients (J Clin Psychiatry 2002 Jan;63(1):15 in Annals of General Psychiatry 2005 Feb 16;4:5)
- medications not recommended as first line agents in APA guidelines due to adverse effects or insufficient evidence for efficacy
- guanfacine does not appear to improve PTSD symptoms (level 2 [mid-level] evidence)
- based on small randomized trial
- 63 veterans with chronic PTSD randomized to guanfacine (an alpha-2 agonist) vs. placebo for 8 weeks
- no significant differences in PTSD symptoms, subjective sleep quality or general mood disturbances
- Reference - Am J Psychiatry 2006 Dec;163(12):2186
Other management :
- brief inpatient treatment if severe
- group or family therapy, especially if chronic
- eye movement desensitization and reprocessing (EMDR)
- EMDR effective in systematic review with 16 randomized trials; EMDR involves asking patient to focus on traumatic event, a negative cognition associated with traumatic event and associated emotions, and then follow the therapist's finger; EMDR as effective as exposure therapy in 2 trials, EMDR more effective than relaxation therapy in 3 trials, EMDR more effective than waiting list in 3 trials; 5 trials assessed EMDR with vs. without eye movements, 3 found no differences, 2 found eye movements more effective than eyes fixed (Psychol Med 2000 Jul;30(4):863)
- EMDR may be an effective psychologic therapy but evidence very limited; EMDR consists of 8 steps which include desensitization and cognitive reprocessing, studies have shown that the "eye movement" component is not necessary; one trial by developer of EMDR had 21 volunteers with "traumatic memories" randomized to EMDR vs. placebo and reported successful desensitization and altered cognitive assessment after single session of EMDR with effects maintained over 3 months (J Traumatic Stress 1989;2;199); more rigorous trial with 36 subjects with PTSD randomized to EMDR vs. image habituation training vs. applied muscle relaxation vs. wait list found improvements with all 3 treatments compared to wait list control (J Behav Ther Exp Psychiatry 1994 Dec;25(4):283) (Alternative Medicine Alert 2001 Nov;4(11);121)
- early intervention for PTSD and alcohol abuse can be effectively delivered after trauma; 120 injured surgical inpatients at level 1 trauma center randomized to collaborative care vs. usual care; collaborative care included continuous postinjury case management, motivational interviews regarding alcohol abuse and dependence, and drugs and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months; collaborative care reduced PTSD symptoms and rate of alcohol abuse/dependence over 1 year (Arch Gen Psychiatry 2004 May;61(5):498 in JAMA 2004 Aug 11;292(6):668), summary can be found in Am Fam Physician 2005 Feb 15;71(4):798
- Narrative Exposure Therapy tailored for children (KIDNET) reported to reduce PTSD and depression symptoms immediately and at 9 months (level 3 [lacking direct] evidence) in series of 6 Somali children aged 13-17 years living in Uganda refugee settlement (BMC Psychiatry 2005 Feb 3;5:7)
Prevention :
- individual psychotherapy
- cognitive behavioral therapy for acute stress disorder may prevent PTSD (level 2 [mid-level] evidence)
- based on small randomized trial with high drop-out rate
- 90 civilian patients with acute stress disorder after experiencing trauma randomized to 1 of 3 groups
- 5 weekly 90-minute sessions of exposure therapy
- 5 weekly 90-minute sessions of cognitive restructuring
- assessment at baseline and after 6 weeks (wait-list group)
- 77% completed treatment and 70% completed 6 month follow-up
- patients meeting diagnostic criteria for PTSD after treatment period with intention-to-treat analysis (p < 0.001)
- 33% with exposure therapy
- 63% with cognitive restructuring
- 77% with wait list
- full remission at 6 months of follow-up
- 47% with exposure therapy
- 13% with cognitive restructuring
- Reference -Arch Gen Psychiatry 2008 Jun;65(6):659
- single session debriefing ineffective
- no current evidence that single session psychological debriefing is useful for prevention of post traumatic stress disorder after traumatic incidents; 11 trials showed no benefit, 1 of which suggested increased risk of PTSD with debriefing; systematic review last updated 2001 Dec 3 (Cochrane Library 2002 Issue 2:CD000560), editorial commentary can be found in BMJ 2000 Oct 28;321(7268):1032
- single session debriefing does not improve natural recovery from psychological trauma, based on meta-analysis of 7 studies (Lancet 2002 Sep 7;360(9335):766), editorial can be found in Lancet 2002 Sep 7;360(9335):741, commentary can be found in Am Fam Physician 2003 Jan 15;67(2):419
- individual psychological debriefing after psychological trauma ineffective
- 236 adult survivors of recent traumatic event randomized to emotional ventilation debriefing vs. educational debriefing vs. no debriefing
- no significant differences in PTSD symptoms at 2 weeks, 6 weeks or 6 months
- Reference - Br J Psychiatry 2006 Aug;189:150
- propranolol shortly after trauma might reduce risk for developing PTSD (level 2 [mid-level] evidence)
- based on 2 small pilot trials
- 41 patients presenting to emergency department within 6 hours of acute traumatic event (and heart rate at least 80 beats/minute)
- were randomized to propranolol 40 mg vs. placebo 4 times daily for 10 days then tapered
- 31 patients (76%) completed treatment (61% propranolol, 87% placebo)
- 22 patients (54%) tested at 3 months (20% propranolol, 61% placebo)
- 0 propranolol vs. 6 (43%) placebo patients were physiologic responders during script-driven imagery of traumatic event at 3 months (p = 0.04)
- Reference - Biol Psychiatry 2002 Jan 15;51(2):189
- 19 patients presenting to emergency department 2-20 hours after assault or vehicular accident (and heart rate at least 90 beats/minute)
- Reference - Prescriber's Letter 2007 Jan;14(1):5
Screening :
- suggested screening questions
- initial screening questions
- Have you ever encountered an event that was life-threatening to you or someone else?
- Have you ever encountered an event where you feared for your safety or the safety of someone else?
- Have you ever experienced an event that deeply frightened you and left you feeling shocked or helpless?
- Have you ever been physically, sexually or emotionally abused?
- Have you ever been in a physically abuse relationship with an adult?
- further questions if any positive responses
- Do you have thoughts or images about the trauma that continue to bother you?
- Do you feel you do not care about things as much or feel numb as a result of the experience?
- Do you avoid certain people, places or situations since the trauma?
- Do you feel stressed, hyper, on guard, anxious or depressed as a result of the experience?
- Are you having more difficulty doing your job or getting along with coworkers?
- Have you had any trouble with the law?
- Do you feel more uncomfortable interacting with family or friends, or are you having more difficulty getting along with them?
- this set of questions not formally studied, author recommends mental health consultation if positive response to 1 question in each set
- Reference - J Fam Pract 1999 Mar;48(3):222
- experience of at least 6 re-experiencing or arousal symptoms validated as brief screening instrument for PTSD, performed as well as full clinical interviews in study of 157 crime victims and study of 41 rail crash survivors (Br J Psychiatry 2002 Aug;181(2):158)
- STEPP screening after pediatric traffic accident can predict persistent subsyndromal stress; 269 children aged 8-17 years admitted for traffic-related injuries and one parent each completed risk factor survey, 171 families (63%) completed follow-up for at least subsyndromal PTSD with continuing impairment; 3 or more risk factors among parents (witnessing accident, present with child in transit to hospital, feeling helpless as initial response, child history of behavior or attention problems, suspected extremity fracture, child age > 12 years) had 96% sensitivity, 53% specificity, 27% positive predictive value and 99% negative predictive value for persistent traumatic stress in parents; 4 or more risk factors among children (history of behavior or attention problems, awareness that others were hurt or killed in accident, time unaware of location of parents, immediate response of fear, immediate thought of possible death, suspected extremity fracture, pulse rate at triage > 104/minute if < 12 years old or > 97/minute if > 12, female) had 88% sensitivity, 48% specificity, 25% positive predictive value and 95% negative predictive value for persistent traumatic stress in children (JAMA 2003 Aug 6;290(5):643)
- brief screening approach reported in outpatient gynecology; 292 women who attended gynecology clinic for routine annual examination were offered 4-li screening if they reported a traumatic event; four lis called SPAN (Startle, Physiological arousal, Anger, and emotional Numbness), SPAN questionnaire compared with full psychiatric assessment; 88 women (30%) reported significant traumatic events but only 32 of these women agreed to full psychiatric assessment (potentially introducing substantial selection bias); 31 of 32 women had one or more psychiatric diagnoses including 25 (78%) meeting criteria for PTSD; SPAN instrument had 72% sensitivity and 71% specificity for PTSD (Obstet Gynecol 2004 Oct;104(4):770 in Am Fam Physician 2005 Aug 1;72(3):518)
- self-report scale potentially useful for screening adolescents in South Africa, based on comparison with interviews in 58 adolescents, of whom 38% reported symptoms severe enough to be classified as PTSD (Annals of General Psychiatry 2005 Jan 31;4:2)
- self-administered 7-li screen potentially useful
- 134 patients attending Veterans Affairs general medical and women's health clinics completed self-administered Breslau short screening scale and were then interviewed by trained psychologists (blind to screen results) using Clinician-Administered PTSD Scale as reference standard
- 7-li Breslau screen used 7 questions following "In your life, have you ever had any experience that was so frightening, horrible, or upsetting, that in the past month . . ."
- did you avoid being reminde dof this experience by staying away from certain places, people or activities? did you find it hard to have love or affection for other people?
- did you lose interest in activities that were once important or enjoyable?
- did you begin to feel more isolated or distant from other people?
- did you begin to feel that there was no point in planning for the future?
- after this experience were you having more trouble than usual falling asleep or staying asleep?
- did you become jumpy or get easily startled by ordinary noises or movements?
- 25% of subjects had PTSD
- 3 or more positive answers had 97% sensitivity and 78% specificity
- 5 or more positive answers had 76% sensitivity and 91% specificity
- 80 patients had screen score 0-2, of whom only 1 had PTSD
- 27 patients had screen score 3-5, of whom 10 (37%) had PTSD
- 27 patients had screen score 6-7, of whom 22 (81%) had PTSD
- Reference - J Gen Intern Med 2006 Jan;21(1):65
- screening for mental disorders before deployment would not have predicted PTSD or reduced subsequent morbidity in United Kingdom armed forces deployed to Iraq war
- Point-of-Care Guide on screening instruments for PTSD can be found in Am Fam Physician 2007 Dec 15;76(12):1848 full-text
General references used :
- Clinical Evidence 2001 Dec;6:769, search date 2001 May
Reviews :
Guidelines :
Patient information :
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