Monday, May 29, 2006

stress management : Diagnosis and management of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder that occurs following exposure to a traumatic event. The disorder has not been extensively studied in primary care; however, the events of September 11, 2001, raised both public and professional awareness of PTSD. Many more cases may now be diagnosed in family practice patients, because they are more apt to disclose information to their physicians and because physicians are more aware of the diagnosis. One study (1) estimated that 11.8 percent of patients presenting to a primary care clinic met the diagnostic criteria for PTSD.

Patients with PTSD use health care resources more often than patients without PTSD, including those who have other anxiety disorders. (1,2) Because of frustrations in diagnosing and managing their patient's recurrent medical complaints, some physicians characterize patients with PTSD as "difficult" or "heart-sink" patients--that is, patients who evoke "an overwhelming mixture of exasperation, defeat, and sometimes plain dislike." (3) Prompt recognition and effective treatment of PTSD can greatly benefit these patients, their families, and those who work with them.


The psychologic effects of trauma have been described throughout military history. Da Costa syndrome ("soldier's heart"), which is characterized by cardiac symptoms associated with irritability and increased arousal, was described in veterans of the American Civil War. During World War I, it was hypothesized that "shell shock" resulted from brain trauma caused by exploding shells. During World War II, terms such as "combat neurosis" and "operational fatigue" were used to describe combat-related symptoms.

The Vietnam War significantly influenced the current concept of PTSD. In 1980, the Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (DSM-III) (4) established criteria for the diagnosis of PTSD. Modifications were made in subsequent editions. (5,6) This article reviews the current diagnostic criteria for PTSD as contained in the 4th edition, text revision (DSM-IV-TR) (7) and focuses on diagnosis and management, including the detection and treatment of comorbidities.

A precipitating traumatic event is necessary, but not sufficient, to make the diagnosis of PTSD. The criteria for diagnosis specify factors concerning the victim's perception of the trauma as well as the duration and impact of associated symptoms, including persistent re-experiencing of the traumatic event, marked avoidance of usual activities, and symptoms of increased arousal (Table 1). (7)

Before a diagnosis of PTSD can be made, symptoms must last for at least one month and must significantly disrupt normal activities. In persons who have survived a traumatic event, an anxiety syndrome that lasts for less than one month is termed "acute stress disorder"; this condition requires three or more dissociative symptoms in addition to the persistent symptoms associated with PTSD. Symptoms of PTSD that last less than three months indicate an acute condition. A delayed picture occurs in patients who begin experiencing symptoms six months or more after the traumatic event. (7)

The diagnosis of PTSD may be difficult to make for many reasons. Patients may not recognize the link between their symptoms and an experienced traumatic event; patients may be unwilling to disclose the event; or the presentation may be obscured by depression, substance abuse, or other comorbidities. (8) Direct, empathic, and nonjudgmental questioning is recommended when physicians take a patient history. For example, the physician might ask, "Have you ever been attacked or threatened?" or, "Have you ever been in a severe accident or natural disaster?" (8)

Making a connection between a patient's symptoms and a trauma that occurred in childhood may be particularly difficult to establish. An appropriate question to establish this connection is, "Many people are troubled by frightening events that occurred in their childhood. Do you have this problem?" (9)

A screening questionnaire for PTSD reportedly has a sensitivity of 80 percent and a specificity of 97 percent for the diagnosis of PTSD. (10) Examples of the questions include: "Do you have diminished interest in activities"; "Do you have problems sleeping?"; and "Do you find it hard to feel or show affection for others?" (10)
American Family Physician, Dec 15, 2003 by Bradley D. Grinage

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