PTSD is an anxiety disorder characterized by the persistent reexperience of a trauma, efforts to avoid recollecting the trauma, and hyperarousal (Table 3-3).

Epidemiology

The prevalence of PTSD is estimated at 0.5% among men and 1.2% among women. PTSD may occur at any age from childhood through aJulthood and may begin hours, days, or even years after the initial trauma.

Etiology

The central etiologic factor in PTSD is the trauma.
There may be some necessary predisposition to PTSD because not all people who experience similar traumas develop the syndrome. Magnetic resonance imaging studies support a finding of altered hippocampal volume in PTSD.

Clinical Manifestations

History and Mental Status Examination
People with PTSD have endured a traumatic event (e.g., combat, physical assault, rape, explosion) in which they experienced, witnessed, or were confronted with actual or potential death, serious physical injury, or a threat to physical integrity. The traumatic event is subsequently reexperienced through repetitive intrusive images or dreams or through recurrent illusions, hallucinations, or flashbacks of the event. In an adaptive attempt, these patients make efforts to avoid recollections of the event, often through psychological mechanisms (e.g., dissociation, numbing) or actual avoidance of circumstances that will evoke recall. They also experience feelings of detachment from others and exhibit evidence of autonomic hyperarousal (e.g., difficulty sleeping, exaggerated startle response).

Differential Diagnosis
Symptoms that resemble PTSD may be seen in depression, GAD, panic disorder, OCD, and dissociative disorder. When symptoms resemble PTSD, verify that there also are symptoms from all three categories; if not, consider one of the above diagnoses.

Management

Treatment is with a combination of symptom-directed psychopharmacologic agents and psychotherapy (individual or group). TCAs and MAOls are the most commonly used medications in PTSD, especially when there is a comorbid major depression. SSRls have also been used. Psychotherapy is typically tailored to the nature of the trauma, degree of coping skills, and the support systems available to the patient.