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Source: Melton ST, Kirkwood CK. Anxiety Disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7990166. Accessed May 26, 2012.

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

  • Abnormalities in brain function
  • Genetic and environmental factors likely involved.

  • 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 time of trauma and chronically.
  • Lower hippocampal volumes may be precursor for subsequent development of PTSD.

  • Estimated lifetime prevalence: 6.8% in 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.

  • 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

Signs and Symptoms

  • Exposure to traumatic event causes intense fear, helplessness, or horror.
  • Reexperiencing symptoms
    • Recurrent intrusive, distressing memories of trauma
    • Recurrent disturbing dreams of event
    • Feeling that event is recurring (e.g., dissociative flashbacks)
    • Physiologic reaction to reminders of trauma
  • Avoidance symptoms
    • Avoidance of conversations about trauma
    • Avoidance of thoughts or feelings about trauma
    • Avoidance of activities that are reminders of event
    • Avoidance of people or places that arouse recollections of trauma
    • Inability to recall important aspect of trauma
    • Anhedonia
    • Estrangement from others
    • Restricted affect
    • Sense of foreshortened future (e.g., does not expect to have career, marriage)
  • Hyperarousal symptoms
    • Decreased concentration
    • Easy to startle
    • Hypervigilance
    • Insomnia
    • Irritability or anger outbursts

Means of Confirmation and Diagnosis

  • Must have at least 1 reexperiencing symptom, 3 signs or symptoms of persistent avoidance of stimuli, and at least 2 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 for another mental disorder; 80% have concurrent depression, anxiety disorder, or substance abuse or dependence.

  • Decrease core symptoms, disability, and comorbidity.
  • Improve quality of life and resilience to stress.

  • Persons experiencing traumatic event should receive pharmacotherapy, psychotherapy, or both if symptoms persist for 3–4 weeks with social or occupational impairment.

  • Psychotherapies include:
    • Anxiety management
    • Cognitive behavioral therapy (CBT)
    • Group therapy
    • Hypnosis
    • Psychodynamic therapies
    • Psychoeducation
  • Psychotherapy may be used in patients with mild symptoms, those who prefer not to use medications, or in conjunction with drugs in patients with severe symptoms.

  • Figure 1: Algorithm for pharmacotherapy of PTSD
  • Antidepressants (Table 1)
    • First-line: Selective serotonin reuptake inhibitors ...

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