Mental Health Book

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Post-Traumatic Stress DisorderAka: PTSD

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  1. Pathophysiology
    1. Normal response to Trauma
      1. Intensity of response varies with event severity
      2. Re-experiencing symptoms: thoughts, dreams, images
      3. Intense emotional reactions
        1. Fear
        2. Bewilderment
        3. Anger
        4. Helplessness
        5. Despair
    2. Post-Traumatic Stress Disorder response to trauma
      1. Abnormal response to environmental triggers
      2. Classical conditioned response to trauma
        1. Traumatic event with serious threat to life
        2. Response to initial event
          1. Intense fear
          2. Helplessness
          3. Horror
      3. Hypothalamic-Pituitary axis involvement
        1. Excessive cortisol release
  2. Common Related Traumas
    1. Natural disaster
      1. Earthquake
      2. Flooding
      3. Hurricane
    2. Structure Fire or explosion
    3. Transportation or Motor Vehicle accident
    4. Other serious accident (home, work, recreational)
    5. Toxic substance exposure
    6. Physical assault or assault with a weapon
    7. Sexual assault or other unwanted sexual experience
    8. War-related trauma (combat or war zone exposure)
    9. Captivity
    10. Life-threatening illness or injury
    11. Severe suffering
    12. Sudden violent death of someone else
    13. Serious injury, or sudden death of someone close
    14. Spontaneous Abortion
  3. Risk Factors
    1. Severity of trauma
    2. Genetic vulnerability (30% association in twins)
    3. History of previous trauma
    4. Preexisting psychiatric disorder
    5. Family History of psychiatric disorder
    6. Limited support systems
    7. Exposure to reactivating environmental events
  4. Symptoms
    1. Intrusive re-experiencing the trauma
      1. Recurrent intrusive thoughts, images, dreams
      2. Intense distress when remembering trauma
    2. Avoidance of reminders of trauma
    3. Increased autonomic arousal
      1. Insomnia
      2. Irritability or angry outbursts
      3. Poor concentration
      4. Hyper-vigilance
      5. Exaggerated startle response
    4. Emotional numbing
    5. Dissociative symptoms
  5. Screening Tools
    1. DREAMS Mnemonic
    2. SPAN Questionnaire
  6. Associated Features
    1. Major Depression
    2. Substance Abuse
    3. Aggressive outbursts
    4. Panic Attacks or Panic Disorder
    5. Profound demoralization and low self esteem
    6. Pervasive guilt, grief or suspiciousness
    7. Suicidal Ideation
    8. Somatic complaints
    9. Interpersonal and work related Impairment
    10. Sexual dysfunction
  7. Management: General Approach
    1. Assess for Chemical Dependency
    2. Reassurance
      1. PTSD is a reaction to the stress of trauma
      2. Predictable course and often resolves with treatment
    3. Anticipatory guidance
      1. Prepare patient for possible symptoms in future
      2. Be careful in somatizing or suggestible patients
    4. Trauma-focused psychotherapy
      1. Cognitive behavioral approaches
      2. Group Therapy
  8. Management: Medications
    1. Dissociative flashbacks or intrusive memories
      1. Propranolol (Inderal) 10-20 mg PO qid prn
    2. Nightmares of trauma
      1. Benzodiazepines prn at bedtime
      2. Cyproheptadine (Periactin) 4 mg PO qhs
    3. Hallucinations of the trauma
      1. Olanzapine (Zyprexa) 2.5 to 5 mg PO qd
    4. Avoidance, numbing sensation or diminished interests
      1. Selective Serotonin Reuptake Inhibitor (SSRI)
      2. Venlafaxine is effective
        1. Davidson (2006) Arch Gen Psychiatry 63:1158
    5. Hyperarousal or Irritability
      1. Propranolol (Inderal) 10-20 mg PO qid prn
      2. Buspirone (Buspar)
      3. Benzodiazepines
    6. Mixed PTSD Symptoms
      1. Divalproex (Depakote) 250-500 mg tid (or 750 mg qhs)
      2. Carbamazepine (Tegretol) 400-800 mg PO qd
  9. References
    1. Butler (1999) Am Fam Physician 60(2):524
    2. Bowles (2000) Am Fam Physician 61(6):1689

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