when was ptsd recognized by the american psychiatric association

Diagnosis and Management of Post-traumatic Stress Disorder

Am Fam Medic. 2003 Dec 15;68(12):2401-2409.

Patient Information Handout

Abstract
Backdrop
Diagnosis
Epidemiology
Etiology
Comorbidities
Disease Course and Prognosis
Treatment
References

Article Sections

Abstract
Play down
Diagnosis
Epidemiology
Etiology
Comorbidities
Disease Course and Prognosis
Discourse
References

Although post-traumatic stress disorder (PTSD) is a debilitating anxiety unhinge that may campaign remarkable distress and increased use of health resources, the condition often goes unknown. The lifetime preponderance of PTSD in the US is 8 to 9 percent, and approximately 25 to 30 percentage of victims of significant trauma develop PTSD. The emotional and physical symptoms of PTSD occur in three clusters: re-experiencing the psychic trauma, marked dodging of usual activities, and increased symptoms of arousal. Before a diagnosis of PTSD can be made, the forbearing's symptoms must significantly disrupt normal activities and last for more than peerless month. Approximately 80 percent of patients with PTSD accept leastwise one comorbid psychiatric disorder. The most frequent comorbid disorders include depression, alcohol and drug abuse, and unusual anxiousness disorders. Discussion relies on a multidimensional approach, including supportive patient education, cognitive behavior therapy, and psychopharmacology. Selective serotonin reuptake inhibitors are the mainstay of pharmacologic discussion.

Base-traumatic stress disorder (PTSD) is an anxiety disorder that occurs following exposure to a unhealthiness result. The disorder has non been extensively unnatural in primary feather care; notwithstandin, the events of September 11, 2001, inflated both public and professional awareness of PTSD. Many more cases English hawthorn now be diagnosed in folk apply patients, because they are to a greater extent apt to expose selective information to their physicians and because physicians are more remindful of the diagnosis. One study1 estimated that 11.8 percent of patients presenting to a primary tutelage clinic met the diagnostic criteria for PTSD.

Patients with PTSD use wellness care resources more often than patients without PTSD, including those who have former anxiety disorders.1,2 Because of frustrations in diagnosing and managing their patient's recurrent health chec complaints, some physicians qualify patients with PTSD arsenic "difficult" surgery "heart-sink" patients—that is, patients who evoke "an overwhelming mixed bag of exasperation, defeat, and sometimes plain dislike."3 Prompt acknowledgment and effective discourse of PTSD can greatly benefit these patients, their families, and those who influence with them.

Background

Abstract
Backclot
Diagnosing
Epidemiology
Etiology
Comorbidities
Disease Feed and Prognosis
Handling
References

The psychologic effects of trauma take in been described throughout noncombatant history. Da Costa syndrome ("soldier's heart"), which is characterized by cardiac symptoms associated with irritability and enlarged foreplay, was delineate in veterans of the Solid ground Polite War. During World War I, it was hypothesized that "shell shock" resulted from brain trauma caused by exploding shells. During World War II, terms much as "combat neurosis" and "operational fatigue" were in use to describe battle-related symptoms.

The Vietnam War significantly influenced the current concept of PTSD. In 1980, the Characteristic and Statistical Manual of Mental Disorders, 3d ed. (DSM-III)4 established criteria for the diagnosis of PTSD. Modifications were made in ulterior editions.5,6 This article reviews the current diagnostic criteria for PTSD as contained in the 4th edition, text revision (DSM-IV-TR)7 and focuses on diagnosing and management, including the detection and treatment of comorbidities.

Diagnosis

Purloin
Background
Diagnosis
Epidemiology
Etiology
Comorbidities
Disease Row and Medical prognosis
Treatment
References

A precipitating traumatic result is necessary, but non decent, to puddle the diagnosis of PTSD. The criteria for diagnosis specify factors concerning the victim's perception of the trauma as well as the length and impingement of related symptoms, including persistent re-experiencing of the traumatic event, conspicuous turning away of usual activities, and symptoms of increased arousal (Table 1).7

TABLE 1

Diagnostic Criteria for Post-traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were latter-day:
	1. The person experienced, witnessed, or was confronted with an event or events that involved factual Oregon threatened death or serious injury, or a threat to the physical wholeness of self Beaver State others.
	2. The person's reception involved intense awe, impuissance, or horror. note: In children, this Crataegus laevigata be expressed as an alternative by disorganized or agitated behavior.
B. The traumatic event is persistently re-experienced in nonpareil (or more) of the following ways:
	1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. note: In young children, repetitive trifle may pass off in which themes or aspects of the trauma are hard-core.
	2. Recurrent distressing dreams of the consequence. note: In children, there may be frightening dreams without recognizable smug.
	3. Playacting or feeling as if the painful consequence were continual (includes a sense of reliving the experi ence, illusions, hallucinations, and divisible flashback episodes, including those that occur on awakening or when bibulous). note: In young children, trauma-specific reenactment English hawthorn come.
	4. Intense psychologic distress at pic to interior or extrinsic cues that symbolize operating theatre resemble an facet of the unhealthiness event.
	5. Physiologic reactivity on exposure to internal or extraneous cues that typify or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the harm and numbing of unspecialized responsiveness (not present before the trauma), as indicated aside three (or more) of the following:
	1. Effort to avoid thoughts, feelings, or conversations related with the trauma.
	2. Crusade to void activities, places, operating room people that arouse recollections of the psychic trauma.
	3. Unfitness to recollection an important prospect of the psychic trauma.
	4. Markedly reduced interest or participation in significant activities.
	5. Feeling of detachment or estrangement from others.
	6. Restricted range of affect (e.g., incapable to have loving feelings).
	7. Sense of a foreshortened future (e.g., does non expect to have a life history, marriage, children, or a modal life duo).
D. Persistent symptoms of increased arousal (not acquaint before the trauma), as indicated by two (or more) of the following:
	1. Difficulty falling or staying dead.
	2. Irritability or outbursts of anger.
	3. Difficulty concentrating.
	4. Hypervigilance.
	5. Inflated startle response.
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in friendly, occupational, OR other important areas of function.
	Specify if:
		Acute: If continuance of symptoms is less than three months.
		Prolonged: If duration of symptoms is three months or more.
	Particularise if:
		With delayed onset: If onset of symptoms is at least six months after the stressor.

Before a diagnosing of PTSD can be made, symptoms must last for at least one month and must significantly disrupt normal activities. In persons who have survived a painful event, an anxiousness syndrome that lasts for little than one month is termed "pointed stress disorder"; this condition requires three or more dissociative symptoms in addition to the persistent symptoms associated with PTSD. Symptoms of Posttraumatic stress disorder that concluding less than three months indicate an acute condition. A delayed-action picture occurs in patients who begin experiencing symptoms six months Beaver State more after the traumatic outcome.7

The diagnosis of PTSD whitethorn be difficult to make for many reasons. Patients may not agnize the link between their symptoms and an experienced traumatic event; patients may be unwilling to disclose the event; or the presentation may follow obscured past depression, drug abuse, Beaver State other comorbidities.8 Direct, sympathetic, and nonjudgmental questioning is recommended when physicians takings a patient history. For example, the physician power ask, "Have you always been attacked OR threatened?" or, "Have you ever been in a severe fortuity or natural disaster?"8

Making a connection between a patient role's symptoms and a trauma that occurred in childhood may embody peculiarly difficult to demonstrate. An appropriate question to shew this connecter is, "Many an citizenry are troubled by frightening events that occurred in their childhood. Do you let this problem?"9

A screening questionnaire for PTSD reportedly has a predisposition of 80 per centum and a specificity of 97 percent for the diagnosing of PTSD.10 Examples of the questions include: "Do you get diminished interest in activities"; "Do you have problems quiescency?"; and "Do you find it horny to sense OR appearance affection for others?"10

Epidemiology

Abstract
Background
Diagnosis
Epidemiology
Etiology
Comorbidities
Disease Trend and Medical prognosis
Treatment
References

PREVALENCE

The overall lifetime prevalence of PTSD in the United States is about 8 to 9 percent, and the stipulate is doubly as lowborn in women.7,11,12 Symptoms that fare not meet the full-of-the-moon criteria for Posttraumatic stress disorder appear to be common in the general population and can cost quite common in groups at high risk of PTSD.13 For instance, although the life-time preponderance of PTSD in veterans of the Vietnam War is around 30 percent, about 50 percent of Vietnam veterans had whatsoever clinically significant symptoms of PTSD.14

RISK FACTORS

The epidemiology of PTSD is directly linked to the epidemiology of trauma.11 The likelihood of developing PTSD varies with severity, duration, and proximity of the old trauma.4 Approximately 25 to 30 percent of victims of traumatic events develop symptoms of PTSD; withal, response to trauma varies with the severity and the personal experience associated with the trauma.12,15,16 In work force, exposure to military combat and witnessing someone being badly injured or killed are the types of trauma most commonly associated with a diagnosing of PTSD. The near common traumatic events associated with PTSD in women are despoil and unisexual molestation.11

Persons who have been victimized previously are at greater risk of exposure of being victimized again. A chronicle of childhood abuse increases the risk for victimization and Posttraumatic stress disorder in adults.17 Because there is a strong relationship between mental disorders and victimization by assault, patients with mental health problems have a high risk of PTSD. One study18 noted that 72.2 percent of patients in profession mental health centers had been exposed to physical or unisexual assault operating room were family members of homicide victims.18 Similarly, persons WHO abuse alcoholic beverage or drugs are approximately 1.5 times more likely to experience traumatic events than nondrug users and give birth, therefore, an increased risk of underdeveloped PTSD. A story of behaviour problems before the age of 15 years, A occurs in patients with antisocial personality disorder, also increases the risk of PTSD.18

Although PTSD is the least studied anxiety disorder, data suggest that genetic factors may step-up vulnerability to PTSD if the person is exposed to an adequate threat.13 Age and ethnicity do not appear to affect morbidity.12,19

Etiology

Nobble
Background
Diagnosis
Epidemiology
Aetiology
Comorbidities
Disease Course and Prognosis
Treatment
References

Although the etiology of PTSD is unknown, nearly investigators consider that a personal predisposition is necessary for symptoms to prepare after a health problem event. Clinically significant symptoms following a traumatic event hap in a nonage of persons. Those likely to develop PTSD tend to have a preexistent depression or anxiety disorder, operating theatre a family history of anxiety and neuroticism.20

From a biological perspective, the body's nonstarter to return to its pretraumatic body politic differentiates PTSD from a uncomplicated fear response. In a normal fear response, the immediate good-hearted discharge activates the "fight-or-flight of stairs" chemical reaction. Increases in both catecholamines and cortisol occur relative to the severity of the stressor. Cortisol loose stirred away ACTH-releasing divisor via the hypothalamic-pituitary-excretory organ (HPA) axis acts in a negative feedback loop to suppress sympathetic activating and cause further release of cortisol.

In patients with PTSD, ambient cortisol levels are lower than normal; this state has been attributed to degenerative "adrenal exhaustion" from suppression of the HPA axis by unforgettable severe anxiety. However, Recent data21 note that Cortef levels in the immediate aftermath of a motor vehicle shipwreck were significantly lower in persons who went on to develop PTSD. In a allied study,22 cortisol levels immediately after rape were lower in women with a previous history of rape. Several investigators have hypothesized that the HPA axis and the sympathetic systema nervosum are disassociated in persons WHO develop PTSD, which may allow for an torrential catecholamine sack that affects formation of memories during the trauma and perhaps exacerbates symptoms when that person is exposed to cues after the trauma.15

Comorbidities

Abstract
Scop
Diagnosis
Epidemiology
Etiology
Comorbidities
Disease Course and Prognosis
Treatment
References

PTSD is associated with increased rates of affective disorders, anxiety disorders, and meat maltreatment. Information from the National Comorbidity Survey12 point that at least unity additive psychiatric cark is present in 88.3 percent of men and 79.0 percent of women who induce a story of PTSD. In increase, 59 percent of men and 44 percent of women who have PTSD meet the criteria for three or much psychiatrical diagnoses. Women who birth PTSD are 4.1 times as potential to develop a major depression and 4.5 times A likely to rise mania as women who do non have PTSD. Men who birth PTSD are 6.9 times as likely to develop depression and 10.4 multiplication as likely to develop mania Eastern Samoa hands who dress not give PTSD.23

More cardinal half of men with PTSD also have a comorbid alcohol problem, and a pregnant portion of men and women who have Posttraumatic stress disorder have a comorbid illicit-substance use job.12 In patients who have got PTSD, phobias tend to be more prevalent than generalized anxiety disorder or terror disorder; the danger of nigh entirely anxiousness disorders is increased markedly in these patients23 (Mesa 2).12 The rate of attempted suicide in patients World Health Organization deliver PTSD is estimated at 20 per centum.24

TABLE 2

Comorbidities in Patients with Post-traumatic Stress Disorderliness*

Comorbidity	Men (%)	Women (%)
Major depressive disorder	47.9	48.5
Inebriant misuse or dependence	51.9	27.9
Drug abuse or addiction	34.5	26.9
Simple phobias	31.4	29.0
Social phobic disorder	27.6	28.4
Dysthymia	21.4	23.3

Disease Course and Prognosis

Abstract
Background
Diagnosis
Epidemiology
Etiology
Comorbidities
Disease Course and Prognosis
Treatment
References

PTSD English hawthorn happen at any age, even in puerility. Symptom continuance is variable and is affected past the proximity, duration, and intensity of the trauma, besides as comorbidity with different psychiatric disorders.7,20 The patient's subjective interpretation of the injury also influences symptoms.18 In patients who are receiving treatment, the average duration of symptoms is approximately 36 months. In patients who are not receiving treatment, the average duration of symptoms rises to 64 months. More than one third of patients who have PTSD never fully recover.12

Factors associated with a good prognosis include rapid interlocking of treatment, early and current social support, avoidance of retraumatization, positive premorbid function, and an petit mal epilepsy of otherwise psychiatric disorders operating room substance abuse.19,25

Treatment

Abstract
Background
Diagnosis
Epidemiology
Aetiology
Comorbidities
Disease Course and Medical prognosis
Discussion
References

The treatment of patients with PTSD relies on a multidimensional approach.26 Treatment options include patient didactics, social support, and anxiety direction through psychotherapy and psychopharmacologic interference. Patient Education Department and social support are important first interventions to charter the patient and mitigate the impact of the traumatic event. Local and national support groups may help to destigmatize the mental health diagnosing and reaffirm that symptoms of PTSD involve more than just a reaction to accentuat and require handling. Support from family and friends encourages understanding and acceptance that may alleviate survivor guilt. However, the mainstay of discussion is psychopharmacologic and psychological medicine intervention (Figure 1).

Diagnosis and Treatment of Post-traumatic Stress Disorder

FIGURE 1.

Algorithmic rule for the diagnosing and treatment of post-unhealthiness stress disorder. (DSM-Intravenous feeding = Identification and Statistical Manual of Mental Disorders, 4th ed.; PTSD = position-unhealthiness stress disorder; SSRI = exclusive 5-hydroxytryptamine reuptake inhibitor)

PSYCHOTHERAPY

Studies prove that cognitive-demeanor treatment is stiff in meliorative the symptoms of PTSD. In a study27 of patients receiving various forms of psychological feature-behavior treatment in cardinal sessions over a six-week period, the percentage of patients who attained positive closing-state function (outlined as a 50 percent reduction in severity of PTSD symptoms) ranged from 21 to 46 percent. A similar hit the books showed that 32 to 53 percent of patients receiving 10 Sessions of psychological feature-deportment treatment over a 16-week period achieved positive end-state function.27

Specific types of cognitive-demeanor treatment admit cognition therapy, exposure therapy, and stress inoculation training. These therapies focus on ways for patients to confront fear and develop anxiety-management tools. The different forms of psychological feature-behavior treatment tend to be equally efficacious when used individually and in combination. Other therapies, much as group therapy, eye movement desensitization, and reprocessing therapy, may have some role in the treatment of PTSD; however, because their efficacy has non been considerably demonstrated, psychological feature-behavior treatment remains the primary mode of therapy.26–28

Approximately 14 percent of patients with PTSD discontinue psychotherapy. The highest shake off-out rates (busy 50 percent) occur with exposure therapy, indicating that many patients have got difficultness with re-experiencing the injury.26,27 The in attendance physician can offer solid therapeutic intervention with good listening skills and empathic support. If solution of PTSD symptoms does not occur with initial support and medication, referring the uncomplaining to a therapist may atomic number 4 guaranteed.

Because PTSD can have devastating effects along family members and those about the patient, family and other group therapies may be indicated as adjuncts to individual treatment of the patient with PTSD.29

PHARMACOLOGY

Recent interest in the treatment of PTSD has stimulated large, prospective, double-blind, placebo-priest-ridden clinical trials of the efficacy of exclusive serotonin re-uptake inhibitors (SSRIs) in the discussion of the symptoms of PTSD. Currently, paroxetine (Paxil) and sertraline (Zoloft) are the only medications that give been approved by the U.S. Food and Dose Administration for the discussion of PTSD. In two separate 12-week, double-blind, placebo-controlled trials,30,31 both paroxetine and sertraline were found to be effective in the acute discourse of symptoms of PTSD. Of the patients who received 20 mg or 40 mg of paroxetine, 62 percent and 54 percent, respectively, responded positively compared with 37 percent of patients WHO received placebo.30 [Evidence level A, randomised regimented visitation] Patients who received a mean daily dosage of 146 mg of Zoloft had a 60 percent affirmative reception rate compared with a 38 percent positive response charge per unit in patients receiving placebo.31

Another study32 showed that sertraline was effective in preventing relapse of symptoms of PTSD during a 28-hebdomad sustentation stage pursual 24 weeks of intense therapy. This learn besides showed that continuing treatment with sertraline at a mean daily dose of 137 mg yielded a 5 percent relapse rate compared with a 26 percent relapse rate in those receiving placebo.32 Other trials33 have been conducted, including four open trials and two limited trials of fluoxetine, and five open trials of fluvoxamine. These studies paint a picture that several SSRIs are helpful in the amelioration of acute symptoms of PTSD.33

Search into the employ of antipsychotic agent medications in patients who have PTSD is limited for the most part to case studies. Approximately 10 percent of patients with PTSD are treated with an antipsychotic medication; these patients tend to have symptoms of PTSD that are more intrusive and severe.34 Case reports notation a step-dow in flashbacks and nightmares with the use of risperidone. Clozaril was reported to be actual in a diligent with co-occurrence psychosis World Health Organization was a experienced of the Vietnam. Results of an open-label trial of olanzapine in 46 patients with combat-induced PTSD suggest possible efficaciousness in the treatment of PTSD.34

Preceding studies33 indicate that the use of tricyclic antidepressant drug antidepressants and monoamine oxidase inhibitors are reasonably effective in the treatment of PTSD and are superior to placebo; however, because of their fallout profiles, these medications are currently well thought out second- or third-argumentation agents. Open-label investigations33 of the use of the mood stabilizers lamotrigine, valproate, and carbamazepine exhibit promise in reduction the symptoms of PTSD. Furthermore, buspirone and clonazepam undergo shown some benefit in reducing anxiousness in patients with PTSD.33 A recent pilot study suggests that propranolol, administered after an acute traumatic event, may have a hindrance core on the subsequent development of PTSD.35

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The Author

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BRADLEY D. GRINAGE, M.D., is director of forensic psychiatry and help professor at the University of Kansas Educate of Medicate–Wichita. He received his medical exam stage from the University of Kansas School of Medicine, Kansas City. Dr. Grinage completed a residency in common big psychiatry in the United States Air Pressure and a fellowship in forensic psychiatry at the University of Missouri School of Medicine, Kansas City....

Address map to Bradley D. Grinage, M.D., University of Kansas School of Medicine–Wichita, Department of Psychological medicine and Behavioral Sciences, 1010 N. Kansas, Wichita, KS 67214-3199 (electronic mail:bgrinage@kumc.edu) Reprints are non easy from the author.

The author thanks Anne D. Walling, M.D., of the University of Kansas School of Medicine–Wichita, and Angela Dudley for assist in the prep of the manuscript.

The author indicates that he does non have any conflicts of interest group. Sources of financial backin for this article: no reported. He serves as a lecturer for Pfizer, Bristol-Myers Squibb, and Eli Lilly.

REFERENCES

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