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SOURCE

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Source: Melton ST, Kirkwood CK, Wells BG. Posttraumatic Stress Disorder and Obsessive-Compulsive Disorder. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146065465.

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DEFINITION

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  • Anxiety disorder occurring as result of seeing or living through dangerous event.

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ETIOLOGY

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  • Abnormalities in brain function.

  • Genetic and environmental factors likely involved.

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PATHOPHYSIOLOGY

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  • Chronic noradrenergic overactivity downregulates α2-adrenoreceptors in patients with posttraumatic stress disorder (PTSD).

  • Abnormalities of GABA inhibition may lead to increased response to stress in patients with PTSD.

  • 5-HT may increase anxiety in patients with PTSD.

  • Hypersecretion of corticotropin-releasing factor but subnormal levels of cortisol at the time of trauma and chronically.

  • Lower hippocampal volumes may be precursor for subsequent development of PTSD.

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EPIDEMIOLOGY

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  • Estimated lifetime prevalence: 8.7% in the United States.

  • 8.2% of men and 20% of women exposed to life-threatening traumatic event will develop PTSD.

  • Genetic factors may influence vulnerability after traumatic event.

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RISK FACTORS

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  • Living through dangerous or traumatic event, for example:

    • Accident.

    • Disaster.

    • Sexual abuse.

  • Witnessing others get injured or killed.

  • History of emotional disorder or depression.

  • History of physical or sexual abuse.

  • Having little social support after traumatic event.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Exposure to traumatic event causes intense fear, helplessness, or horror.

  • Intrusion/Re-experiencing symptoms.

    • Recurrent intrusive, distressing memories of trauma.

    • Recurrent disturbing dreams of event.

    • Feeling that event is recurring (eg, dissociative flashbacks)

    • Physiologic reaction to or psychological distress from reminders of trauma.

  • Avoidance symptoms.

    • Avoidance of conversations, thoughts, or feelings about trauma.

    • Avoidance of people, places, or activities that are reminders of event.

  • Persistent Negative Alterations in Thinking and Mood.

    • Inability to recall important aspect of trauma.

    • Anhedonia.

    • Estrangement from others.

    • Restricted affect.

    • Negative beliefs about oneself.

    • Distorted beliefs causing one to blame others or themselves for the trauma.

    • Negative mood state.

  • Hyperarousal symptoms.

    • Decreased concentration.

    • Easily startled.

    • Self-destructive behavior.

    • Hypervigilance.

    • Insomnia.

    • Irritability or anger outbursts.

  • Specifiers.

    • Dissociative symptoms: depersonalization or derealization.

    • With delayed expression: full criteria are not met until at least 6 months posttrauma.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Must have at least one intrusion symptom, at least one symptom of avoidance of stimuli associated with the trauma, at least two symptoms of negative alterations in cognition and mood, and at least two symptoms of increased arousal.

  • Symptoms from each category must be present >1 month and cause significant distress or impairment.

  • PTSD can occur at any age; course variable.

  • Subtypes.

    • Acute: Duration of symptoms <3 months.

    • Chronic: Symptoms last for >3 months.

    • Delayed onset: Symptoms begin at least 6 months post-event.

  • Most persons with PTSD meet criteria ...

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