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Source: Kirkwood CK, Melton ST, Well 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. https://accesspharmacy.mhmedical.com/content.aspx?bookid=1861§ionid=146065465
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Short-term goal for posttraumatic stress disorder (PTSD)—reduction in core symptoms
Long-term goal for PTSD—remission
Cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing—most effective nonpharmacologic methods to reduce PTSD symptoms
First line for PTSD → selective serotonin reuptake inhibitors (SSRIs) or venlafaxine
First line for obsessive-compulsive disorder (OCD) → SSRI
Augmentation with low doses of antipsychotics may be helpful
If inadequate response to SSRI after 4–6 weeks at maximum dose—switch to another SSRI
Medication taper can be considered after 1–2 years of treatment
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POSTTRAUMATIC STRESS DISORDER
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Can develop from traumatic or stressful events (wars, terrorist attacks, torture, robbery, natural disasters, etc.)
Significant psychiatric illness in civilian and deployed service personnel
Co-occurrence with anxiety, depression, substance abuse, and traumatic brain injury make it hard to diagnose
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Neuroendocrine theories
Abnormalities occurring pretrauma, during trauma, and posttrauma contribute to PTSD
Normally corticotropin releasing factor (CRF) stimulates release of cortisol from adrenal glands. Catecholamines and cortisol levels rise in tandem, which reduces stress response by tempering the sympathetic reaction through negative feedback on pituitary and hypothalamus.
Hypersecretion of CRF but subnormal levels of cortisol leads to greater severity of PTSD symptoms, particularly in nonmilitary patients.
Neurochemical theories
Neurotransmitters potentially involved: 5-HT (serotonin), NE (norepinephrine), glutamate
Dysregulation of processing of sensory input and memories may contribute to dissociative and hypervigilant symptoms.
Abnormalities of GABA inhibition may lead to increased awareness or response to stress.
Neuroimaging studies
Studies suggest certain areas of brain are altered by psychological trauma: amygdala, ventromedial prefrontal cortex, dorsal anterior cingulate cortex, and hippocampus.
Decreased amygdala activation correlated with resilience to PTSD and response to cognitive behavioral therapy (CBT)
Most consistent findings are decreased hippocampus volumes and N-acetylaspartate levels.
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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
Exposure to traumatic event
Must have at least one intrusion symptom, at least one symptom of avoidance of stimuli associated with trauma, and at least two symptoms of increased arousal—symptoms must be present for >1 month ...