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Lippincott Nursing Pocket Card - May 2024

Posttraumatic Stress Disorder (PTSD)

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Introduction

The American Psychiatric Association (2022) describes posttraumatic stress disorder (PTSD) as a “psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances. An individual may experience this as emotionally or physically harmful or life-threatening and may affect mental, physical, social, and/or spiritual well-being.” PTSD can present as intrusive thoughts, flashbacks and nightmares of past events, avoidance of trauma triggers, hypervigilance, and sleep disturbance and can lead to severe social, occupational, and interpersonal dysfunction (Sareen, 2022).

Causes (Sareen, 2022)

Various types of trauma can result in PTSD such as:
  • Sexual relationship/interpersonal violence (i.e., rape, childhood sexual abuse, intimate partner violence)
  • Interpersonal-network trauma (i.e., unexpected death of a relative, illness of a child)
  • Exposure to organized violence (i.e., refugee, kidnapped, civilian in war zone)
  • Participation in organized violence (i.e., combat exposure, accidentally or purposefully caused death or serious injury)
  • Life-threatening traumatic events (i.e., motor vehicle accident, natural disaster)
  • Medical illness (i.e., myocardial infarction, stroke, intensive care unit hospitalization, obstructive sleep apnea)

Signs and Symptoms (Sareen, 2022)

Patients with PTSD experience significant cognitive, affective, or behavioral symptoms in response to reminders or triggers of a traumatic event. These may include:
  • Intrusion symptoms: “re-experiencing” symptoms such as unwanted thoughts, nightmares or “flashbacks” of the traumatic event typically associated with fear or panic that may occur spontaneously or may be triggered by a similar event
  • Avoidance symptoms: avoidance of things that remind them of the traumatic event such as thoughts, feelings, activities, people, or situations that can result in an impairment in daily life functioning
  • Negative cognition or mood: depression, negative mood changes (may be initial presenting symptoms in PTSD), decreased interest in work or social activities; an inability to connect with others; guilt about the traumatic event
  • Arousal and reactivity changes: irritability or aggressive physical or verbal behaviors; reckless or self-destructive behaviors (i.e., substance abuse), reduced concentration, and insomnia
Dissociative subtype of PTSD is associated with higher levels of impairment, comorbidity, and suicide risk. Dissociative symptoms include:
  • Depersonalization: feeling disconnected from one’s own body, lost, or in a daze
  • Derealization: feeling that the world is not real; experiencing a dreamlike state
  • Amnesia: inability to remember details of the traumatic event or a lack of awareness of situations

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Screening & Assessment

Screening (Sareen, 2022)

PTSD may be an overlooked diagnosis unless proper screening is conducted. A screening form such as the five-item Primary Care PTSD Screen from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is a valid and reliable tool. Perform PTSD screening of the following high-risk individuals:
  • Military personnel and veterans who have been in combat
  • Civilians who have experienced traumatic injury
  • Primary care patients presenting with new anxiety, fear, or insomnia
  • Patients with general anxiety, social isolation, increased substance abuse, or attempts at distraction through excessive work

Assessment (Sareen, 2022)

A comprehensive psychiatric assessment should be performed on all patients with PTSD. Use general assessment questions to investigate PTSD symptoms and use sensitivity during the discussion.
  • How do you feel when you think about the event?
  • Do you have dreams or flashbacks about it?
  • Do you avoid people or activities you associate with the event?
  • Do you forget incidences from that period?
  • Do you look carefully around when you are in a public place?
Patients with PTSD should be assessed for suicidal or parasuicidal thoughts as well as common co-occurring psychiatric conditions, substance use disorders, and medical conditions. Research has found several comorbidities and disorders associated with PTSD.
  • Psychiatric comorbidities: borderline personality disorders, antisocial personality disorder, depression, anxiety, and substance abuse
  • Medical comorbidities: increased risk of obesity, dyslipidemia, tobacco use, hypertension, type II diabetes in women, autoimmune disease, aging, dementia, Alzheimer disease, vascular disease, Parkinson’s disease, traumatic brain injury, and irritable bowel syndrome

Diagnostic Criteria (Sareen, 2022)

A diagnosis of PTSD is made for patients over the age of six years who meet all of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) criteria.
  • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
    • Directly experiencing the traumatic event(s)
    • Witnessing the event(s) as it occurred to others
    • Learning a traumatic event(s) occurred to a close family member or friend
    • Experiencing repeated or extreme exposure to details of traumatic event(s)
  • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s) after the traumatic event(s) occurred:
    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)
    • Dissociative reactions (i.e., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
    • Marked physiologic reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the event(s) occurred, evidenced by one or both of the following:
    • Avoidance of distressing memories, thoughts, or feelings about the traumatic event(s)
    • Avoidance of external reminders (people, places, conversations, activities, objects, situations) that cause distressing memories, thoughts, or feelings about the traumatic event(s)
  • Negative changes in cognitions and mood associated with the traumatic event(s), beginning or worsening after the event(s) occurred, as evidenced by two (or more) of the following:
    • Inability to remember an important aspect of the traumatic event (often due to dissociative amnesia)
    • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
    • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame oneself or others
    • Persistent negative emotional state (i.e., fear, horror, anger, guilt, or shame)
    • Significantly reduced interest or participation in important activities
    • Feelings of detachment or estrangement from others
    • Persistent inability to experience positive emotions
  • Significant changes in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
    • Irritable behavior and angry outbursts (with minimal or no provocation) often expressed as verbal or physical aggression toward people or objects
    • Reckless or self-destructive behavior
    • Hypervigilance
    • Exaggerated startle response
    • Difficulties with concentration
    • Sleep disturbance (i.e., difficulty falling or staying asleep, or restless sleep)
  • Duration of the disturbance is more than one month.
  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The disturbance is not caused by the physiologic effects of a substance (i.e., medication, alcohol) or another medical condition.

Treatment

Treatment Goals (Stein, 2024) 

Treatment should begin as soon as possible after diagnosis is made. Early initiation may prevent chronicity. Treatment goals should be individualized for each patient.

  • Maintain the safety of the patient and others through assessments of suicidal and homicidal tendencies at scheduled visits.
  • Reduce distressing symptoms related to unwanted intrusive memories.
  • Limit avoidant behaviors of the stimuli associated with the traumatic event.
  • Lessen the risk of relapse symptoms and reduce anxiety related to fear of recurrence.
  • Manage related comorbidities such as substance use disorder (SUD) or mood dysregulation.
  • Improve adaptive and psychosocial functioning through psychotherapy in combination with pharmacologic management. 

Treatment (Stein, 2024)

  • Trauma-focused psychotherapy is the preferred first-line treatment.
  • Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRI) are the alternative first line treatments in patients with depression or psychosis, particularly if their symptoms interfere with psychotherapy.
  • Alternative treatment options include cognitive-behavioral therapy, exposure-based therapy, eye movement desensitization and reprocessing therapy.
  • Modified psychotherapy that incorporates treatment for PTSD is used for individuals with substance use disorder, personality disorders, and moderate-to-severe traumatic brain injury.
  • Prazosin may be used for individuals with PTSD who experience significant sleep disturbance (i.e., nightmares).
  • For patients with significant psychotic symptoms, a combination of SSRI and a second-generation antipsychotic medication may be used.
  • Treatment duration lasts for at least six months to one year to prevent relapse.
References

American Psychiatric Association (2022, November). What is Posttraumatic Stress Disorder (PTSD). https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

Sareen, J. (2022, September 15). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis

Stein, M. B. (2024, April 16). Management of posttraumatic stress disorder in adults.. https://www.uptodate.com/contents/management-of-posttraumatic-stress-disorder-in-adults
 

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