History

Fact Explanation
Flashbacks The patient feels as though the traumatic event is repeating itself and that he is reliving the experience. It occurs in the form of a visual experience. [1] It is due to spreading activation in the pathological network of memory. This network is easily triggered and the activation of a component of the trauma memory will in turn activate the entire network including emotional aspects. [2]
Nightmares Nightmares are often related to the traumatic event. [1] It occurs as a result of activation in the pathological network of memory. When the component of the trauma memory is activated, it will in turn activate the entire network, including emotional aspects. [2]
Intrusive thoughts Recurrent distressing thoughts of the traumatic experience occur in the mind of the person despite his attempts to stop them. [1] This phenomenon occurs due to the spreading activation in the pathological network of memory. [2]
Avoidance Patients try to push memories of the event out of their minds and avoid thinking about it. Thus it will maintain the conditioned fear response to the reminder of the traumatic event. [2]
Hyper arousal symptoms: Irritability, Difficulty in sleeping, Anxiety It's due to enhanced secretion of adrenaline and noradrenaline to stress. As a result the sympathetic nervous system of the patient is activated, giving rise to the mentioned symptoms. [3]
Traumatic life events This condition results as a direct consequence of exposure to a traumatic event. However not all individuals develop it. Those with risk factors are at a greater risk of developing it. The risk factors can be categorized into environmental, demographic , prior psychiatric disorders and cognitive. Environmental- Previous exposure to chronic stress, Poor social support Demographic- Being a female Previous psychiatric disorders- Anxiety, Substance abuse, Personality disorders Cognitive- Low IQ . [4]
References
  1. GRINAGE. B.D., Diagnosis and management of post-traumatic stress disorder. American family physician. [Viewed on 11 March 2014]. Available from: http://www.aafp.org/afp/2003/1215/p2401.html
  2. EHLERS, A., Post traumatic stress disorders. In: GELDER, M.G., ANDREASEN, N.C., LOPEZ-IBOR, J.J., GEDDES, J.R. New oxford textbook of psychiatry. 2nd ed. vol 2. New York : Oxford University Press, 2009, pp.704-705.
  3. EHLERS, A., Post traumatic stress disorders. In: GELDER, M.G., ANDREASEN, N.C., LOPEZ-IBOR, J.J., GEDDES, J.R. New oxford textbook of psychiatry. 2nd ed. vol 2. New York : Oxford University Press, 2009, pp.705-706.
  4. HALLIGAN. S.L., YEHUDA. R., Risk factors for PTSD. PTSD Research quarterly.[online] . The National Center for PTSD. 2000. vol 11 (3). 1-7 [ viewed 07 March 2014] . Available from: http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V11N3.pdf

Examination

Fact Explanation
Appearance and behavior - Exaggerated startled response, Agitation, Hypervigilance This is due to the enhanced secretion of adrenaline and noradrenaline to stress. The sympathetic nervous system is activated as a result of this. [1]
Mood - Depressed Depressed mood is common among PTSD patients due to repeated re-experiencing of the traumatic event in everyday life. [2]
Speech - Unaffected. Speech is not usually affected unless the patient is suffering from a concomitant affective disorder. [2]
Perception - Illusions, Hallucinations Illusions and hallucinations with relation to the traumatic event may occur as a form of re-experiencing. [3]
Cognition - Lack of concentration and attention This is due to the enhanced secretion of adrenaline and noradrenaline to stress. [1]
References
  1. EHLERS, A., Post traumatic stress disorders. In: GELDER, M.G., ANDREASEN, N.C., LOPEZ-IBOR, J.J., GEDDES, J.R. New oxford textbook of psychiatry. 2nd ed. 2. New York : Oxford University Press, 2009, pp.705-706.
  2. GRINAGE, D.G., Diagnosis and management of post-traumatic stress disorder [online]. American family physician. [Viewed 11 March 2014]. Available from: http://www.aafp.org/afp/2003/1215/p2401.html
  3. Post traumatic stress disorder. Psych central. [Viewed March 7, 2014]. Available from: http://psychcentral.com/disorders/sx32.htm

Differential Diagnoses

Fact Explanation
Acute stress disorder Acute stress disorder requires three or more dissociative symptoms with persistent symptoms associated with PTSD. And also it does not last beyond 4 weeks from the time of the traumatic incident. In contrast, PTSD has it's onset between 4 weeks and 6 months from the traumatic incident. [1]
Depression In depression there is predominant low mood, lack of energy and lack of interest.[2] Depression may also occur following trauma but core features of PTSD such as re-experiencing and avoidance are not present. [3]
Specific phobias In phobias fear and avoidance is restricted to certain situations. [2] However re-experiencing is not a symptom of phobia. [3]
Panic disorders In panic disorders there are recurrent and unexpected panic attacks that are not caused by stimuli that recall a specific event. [3]
Dissociative disorders In this condition there are persistent and recurrent feelings of detachment from oneself. Also there are gaps in recall, often related to traumatic events. Notably, symptoms of re-experiencing and hyper-arousal are absent. [3]
Adjustment disorders Adjustment disorders have many different presentations with symptoms of low mood, anxiety, traumatic stress symptoms and feelings of inability to cope or carry on. However the intensity of symptoms is less. And the stresses may or may not meet with the DSM-IV-TR diagnostic criteria for PTSD. [3]
Obsessive compulsive disorder Obsessive compulsive disorder has recurrent intrusive thoughts , images or ideas along with compulsive behavior. PTSD is different from this condition as it has no compulsive component and the recurrent intrusive thoughts are only related to the traumatic event. [4]
References
  1. GRINAGE, D.G., Diagnosis and management of post-traumatic stress disorder [Online]. American family physician. [Viewed 07 March 2014]. Available from: http://www.aafp.org/afp/2003/1215/p2401.html
  2. Gaskell and the British Psychological Society. The management of PTSD in adults and children in primary and secondary care. Great Britain: Cromwell Press Limited. 2005. Available from: http://www.nice.org.uk/nicemedia/pdf/CG026fullguideline.pdf
  3. Post traumatic stress disorder. BMJ best practice. [Viewed 07 March 2014]. Available from: file:///H:/Post-traumatic%20stress%20disorder%20-%20Diagnosis%20-%20Differential%20-%20Best%20Practice%20-%20English.htm
  4. Post traumatic stress disorder. Psych central. [Viewed 11 March 2014]. Available from: http://psychcentral.com/disorders/sx32.htm

Management - General Measures

Fact Explanation
Psychological - Stress management Helps in coping with stresses.[1]
Psychological - Psychodynamic therapy Improves patients' understanding of the influence on their past on present behavior.[1]
Pharmacological - Benzodiazepines: Clonazepam These agents are effective against anxiety, insomnia and irritability, but they should be used with great caution owing to the high frequency of co-morbid substance dependence in patients with PTSD. [2]
Patient education Nearly every patient can benefit from education, which is started at the time of diagnosis. It helps in better coping with their current stresses. [2]
Social management Social support is an important initial intervention to engage the patient and reduce the impact of the traumatic event. Local support groups may help to destigmatize the mental health diagnosis and make him realize that the symptoms of PTSD involve more than simply a reaction to stress and that the patient requires treatment. Support from family and friends encourages understanding and acceptance that may reduce survivor guilt. [3]
References
  1. EHLERS, A., Post traumatic stress disorders. In: GELDER, M.G., ANDREASEN, N.C., LOPEZ-IBOR, J.J., GEDDES, J.R. New oxford textbook of psychiatry. 2nd ed. 2. New York : Oxford University Press, 2009, pp.709.
  2. LANGE, J.T., LANGE, C., CABALTICA. R.B.G., Primary care treatment of post-traumatic stress disorder [online]. American family physician. [Viewed 07 March 2014]. Available from: http://www.aafp.org/afp/2000/0901/p1035.html
  3. GRINAGE, D.G., Diagnosis and management of post-traumatic stress disorder [Online]. American family physician. [Viewed 07 March 2014]. Available from: http://www.aafp.org/afp/2003/1215/p2401.html

Management - Specific Treatments

Fact Explanation
Psychotherapy - Trauma focused cognitive behavioral therapy It addresses the lack of control and the unpredictability inherent in traumatic situations. Thus patients improve their symptoms and behavior as they begin to think and act more realistically with regard to their situational and psychological difficulties. [1]
Psychotherapy - Eye movement desensitization and reprocessing It helps to activate a cognitive network that helps patients differentiate real threats from imagined threats.[2]
Pharmacotherapy - Selective serotonin reuptake inhibitor (SSRI) : Paroxetine, Sertralin It reduces the symptoms of the condition, reduces comorbid symptoms and improves the quality of life. SSRI is the 1st line agent used.[3] Paroxetin and Sertralin are the preferred agents. [4] It takes 6 to 8 weeks for these antidepressants to act and patients should be prescribed for at least 1 year to prevent relapses. Also if non responding to a particular group, may have to combine with other groups of antidepressants. [5]
Pharmacotherapy - Mono amine oxidase inhibitor: Phenelzine It reduces the symptoms of the condition. [3] Phenelzine is the preferred agent. [4] It takes 6 to 8 weeks for these antidepressants to act and patients should be prescribed for at least 1 year to prevent relapses. [5]
Pharmacotherapy - Tricyclic antidepressants: Amitriptyline It reduces the symptoms of the condition. [3] Amitriptyline is the preferred agent. [4] It takes 6 to 8 weeks for these antidepressants to act and patients should be prescribed for at least 1 year to prevent relapses. [5]
References
  1. NILAMADHAB, K., Cognitive behaviour therapy for treatment of post traumatic stress disorder :a review. Neuropsychiatric disease and treatment [online]. Dove medical press. April 2011. vol 7. 167-181 [viewed 06 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083990/?report=classic
  2. LEVIN, P., LAZROVE, S., VAN DER KOLK, B., What psychological testing and neuroimaging tell us about the treatment of Posttraumatic Stress Disorder by Eye Movement Desensitization and Reprocessing. Journal of anxiety disorders [online]. Elsiveir. January-April 1999. vol 13(1-2). 159-172[viewed 06 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10225506
  3. STEIN, D.J., IPSER, J.C., SEEDAT. S., Pharmacotherapy for post traumatic stress disorder. Cochrane Database System Review [online]. John Wiley & Sons. 25 JAN 2006 [viewed 06 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16437445
  4. EHLERS, A., Post traumatic stress disorders. In: GELDER, M.G., ANDREASEN, N.C., LOPEZ-IBOR, J.J., GEDDES, J.R. New oxford textbook of psychiatry. 2nd ed. 2. New York : Oxford University Press, 2009, pp.710.
  5. COHEN, H., Treatment of PTSD. Psych central. [Viewed March 7, 2014]. Available from: http://psychcentral.com/lib/an-overview-of-treatment-of-ptsd/000161