Post-traumatic stress disorder
Posttraumatic stress disorder follows exposure to actual or threatened death, serious injury, or sexual violence, producing intrusive re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal that persist beyond 1 month with significant distress or impairment. First-line treatment is trauma-focused cognitive behavioral therapy combined with an SSRI or SNRI, with prazosin added for persistent nightmares.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
A trauma-triggered syndrome with four symptom clusters: posttraumatic stress disorder (PTSD) follows exposure to an actual or threatened life-threatening event, such as serious injury, sexual…
- Epidemiology
Prevalence varies with population, gender identity, socioeconomic class, and occupation: rates are higher in first responders, military service members, and marginalized or displaced populations.
- Risk factors
Military service and combat exposure, including mild TBI from blasts, vehicular accidents, or falls during active duty.
- Pathophysiology
Defined by exposure route, not a single mechanism: PTSD arises from direct experience of, witnessing of, or learning about a life-threatening event affecting oneself or a loved one, or from repeated…
- Clinical features
Qualifying trauma exposure: actual or threatened death, serious injury, or sexual violence, experienced directly, witnessed, learned about happening to a close family member or friend, or encountered…
- Differential diagnosis
Acute stress disorder: same trauma exposure and four clusters, but symptoms last 3 days to 1 month rather than persisting beyond 1 month; early trauma-focused therapy in this window can prevent progression to PTSD.
- Diagnosis
The diagnosis is clinical: confirmed once the qualifying trauma exposure, at least 6 symptoms across the four clusters, the more-than-1-month duration threshold, and significant distress or…
- Management
First action is trauma-focused cognitive behavioral therapy (CBT): emotional processing of the trauma, recognizing maladaptive trauma-related thought patterns, and developing adaptive coping…
- Complications
Suicidality and impulsivity: a higher risk of impulsive and self-destructive behavior, including suicide, than the general population.
- Prognosis
Course is variable, from brief to chronic: PTSD can resolve as a time-limited reaction to trauma or persist as a chronic, severely disabling condition.
- Prevention
Intervene during the acute stress disorder window, 3 days to 1 month after the trauma: starting trauma-focused CBT in this window can prevent progression to PTSD, which by definition requires symptoms beyond 1 month.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Acute stress disorder
Acute stress disorder is a trauma-triggered symptom cluster of intrusion, avoidance, negative mood or cognition, and hyperarousal that begins within 1 month of a life-threatening event and lasts 3 days to 1 month; symptoms lasting beyond 1 month become posttraumatic stress disorder. First-line treatment is trauma-focused cognitive behavioral therapy, with pharmacotherapy usually reserved for prominent anxiety or persistent symptoms.
- Major depressive disorder
Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.
- Panic disorder
Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.
- Generalized anxiety disorder
Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.
- Borderline personality disorder
Borderline personality disorder is a cluster B personality disorder defined by 5 or more of 9 DSM-5 criteria spanning instability of relationships, self-image, and affect, marked impulsivity, and recurrent self-injury or suicidality; dialectical behavior therapy is the first-line treatment, with pharmacotherapy reserved as a secondary, symptom-targeted adjunct.
- Traumatic brain injury
Traumatic brain injury is structural or functional brain damage from biomechanical force, graded moderate (Glasgow Coma Scale 9-12) or severe (Glasgow Coma Scale 3-8) when imaging shows contusion, edema, or hemorrhage; management centers on preventing hypotension and hypoxia, controlling intracranial pressure with hyperosmolar therapy and, when refractory, decompressive craniectomy.
- Alcohol use disorder
Alcohol use disorder is a chronic pattern of drinking meeting 2 or more of 11 DSM-5 criteria within a 1-year period, screened with the CAGE or AUDIT-C and confirmed by history. First-line management combines a brief behavioral intervention and cognitive behavioral therapy with naltrexone or acamprosate, reserving disulfiram for highly motivated patients who can maintain abstinence.