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Post-traumatic stress disorder, a psychiatric disorder, arises following exposure to perceived life-threatening trauma. Its symptoms can mimic those of anxiety or depressive disorders, but with appropriate screening, the diagnosis is easily made. Current treatment strategies combine patient education; pharmacologic interventions, such as selective serotonin reuptake inhibitors, trazodone and clonidine; and psychotherapy. As soon after the trauma as possible, techniques to prevent the development of post-traumatic stress disorder, such as structured stress debriefings, should be administered. A high index of suspicion for post-traumatic stress disorder is needed in patients with a history of significant trauma. (Am Fam Physician 2000;62:1035-40,1046.)

Post-traumatic stress disorder (PTSD) can affect a wide range of patients in family practice, regardless of culture, age, sex or socioeconomic class. Busy clinicians need to be aware of its possible diagnosis to provide compassionate and effective care to affected patients or to initiate preventive interventions to those at risk.

The overall prevalence of this disease in the U.S. population is estimated to be between 1 and 12 percent.(1) In populations at risk, it ranges from 0.2 percent in postpartum women to 18 percent in professional firefighters, 34 percent in adolescent survivors of motor vehicle crashes, 48 percent in female rape victims and 67 percent in prisoners of war.(2-5)

The clinical course is variable. Symptoms may emerge immediately and disappear after several months, or they may take longer than six months to appear and last indefinitely. In prevalence studies, one half of those suffering from PTSD have been estimated to still meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), after one year, and up to one third still have weekly symptoms 10 years after the trauma.(1,6) This article provides strategies for primary care physicians to diagnose, treat and refer patients with PTSD.

Diagnostic Criteria

Four categories of criteria are needed to accurately diagnose PTSD (Table 1). First, a traumatic event occurred in which the person witnessed or experienced actual or threatened death or serious injury and responded with intense fear, horror or helplessness. Second, on exposure to memory cues, the person has reexperiencing symptoms, such as intrusive recollections, nightmares, flashbacks or psychologic distress. Third, the patient avoids trauma-related stimuli and feels emotionally numb. Fourth, the person has increased arousal, manifested by hypervigilance, irritability or difficulty sleeping. The symptoms persist for at least one month and significantly disturb the patient's social or occupational functioning (or both).(6)

Acute stress disorder (ASD), an anxiety disorder, is similar to PTSD in that it occurs after exposure to a traumatic event. Symptoms of ASD appear within four weeks of the trauma and last from two days to four weeks. As with PTSD, they include reexperiencing, avoidance and increased arousal. However, fewer symptoms are required in each category to make a diagnosis. ASD is distinguished from PTSD by having more dissociative symptoms; that is, patients describe feeling "as if in a daze" or have temporary amnesia about the trauma. ASD may progress to PTSD but is more responsive to treatment, emphasizing the need for early recognition and intervention.

Comorbidity

Up to 80 percent of patients with PTSD have a comorbid psychologic disorder.(7) Having had a psychiatric diagnosis before a trauma increases a person's risk for developing PTSD. Also, having PTSD increases the risk of later developing psychiatric problems.(8) The most common diseases that occur with PTSD are major depression, dysthymia, generalized anxiety disorder, substance abuse, somatization, panic disorder, bipolar disorder, phobias and dissociative disorders.(7) Any coexisting psychiatric conditions should be treated simultaneously with PTSD because the particular psychologic issues cannot be separated.

Screening Techniques

Diagnosing PTSD in an office visit can be challenging. The diagnosis is frequently missed because patients do not typically volunteer information about the traumatic event or the stereotypic PTSD symptoms. Although direct questioning is necessary, making the diagnosis requires more than checking off a list of symptoms. It often requires a nonjudgmental approach and expressions of empathy and interest. Patients differ in their perception of trauma. Gently probing for symptoms facilitates the rapport patients need to be more forthcoming about their distress.

To ensure that the diagnosis is not missed, a brief trauma history should be included in all evaluations for anxiety or depression. Traumatic events of adulthood can be asked about directly: for example, "Have you ever been physically attacked or assaulted? Have you ever been in a severe accident? Have you ever been in a war or disaster?" A positive response should alert the examiner to inquire further about the relationship between the event and the current symptoms. Traumatic childhood experiences require reassuring statements of normality to put the patient at ease: "Many people continue to think about frightening aspects of their childhood. Do you?"(9)

The mnemonic DREAMS can help elicit pertinent details after the trauma history has been obtained (Table 2). With each event, the examiner should determine if the patient appears emotionally Detached (called alexithymia), either from the event or in relationships with others. It may also manifest as a general numbing of emotional responsiveness. The patient Reexperiences the event in the form of nightmares, recollections or flashbacks. The Event involved substantial emotional distress, with threatened death or loss of physical integrity, and feelings of helplessness or disabling fear. The patient Avoids places, activities or people that remind the patient of the event. The symptoms have been present longer than one Month, and the patient experiences Sympathetic hyperactivity or hypervigilance, which may include insomnia, irritability and difficulty concentrating. As with all psychiatric interviews, assessing imminent danger of the patient to self or others is essential.

Treatment

The diagnosis and treatment of PTSD are complicated. The wide range of symptoms and intricate psychobiologic features make therapy difficult. The three arms of treatment are patient education, pharmacotherapy and psychotherapy. Nearly every patient can benefit from education, which is started at the time of diagnosis. Families may also welcome education about PTSD. The National Alliance for the Mentally Ill (NAMI) has excellent resources and lists of local support groups for patients with PTSD (as well as other mental illness). They can be contacted by calling 800-950-NAMI or on the Internet at http://www. NAMI.org. State affiliates of NAMI list local support groups at http://www.apollonian. com/namilocals/default.asp.

If symptoms are severe enough to prevent effective trauma-focused therapy, pharmacotherapy is warranted as a next step. Pharmacotherapy and psychotherapy have been shown to alleviate the three clusters of PTSD symptoms: reexperiencing, avoidance and hypervigilance.(10)

SEROTONERGIC AGENTS

Studies have consistently shown that serotonergic dysregulation can create avoidance, hypervigilance and other associated symptoms.(11) Selective serotinin reuptake inhibitors (SSRIs) have the broadest range of efficacy--being able to reduce all three clusters of PTSD symptoms.(11) In addition, these agents are used to treat many diseases that often coexist with PTSD. Patients taking sertraline (Zoloft) have reduced alcohol consumption, and those taking fluvoxamine (Luvox) have had a reduction in obsessional thoughts and the elimination of insomnia.(11,12)

Trazodone (Desyrel) at doses of 50 to 200 mg has SSRI properties and serotonin blockade action. It reverses the SSRI-induced insomnia; augments the antidepressant effects of SSRIs; promotes sleep through its sedative properties; and suppresses rapid eye movement sleep, thus reducing the nightmares associated with PTSD.(10)

TRICYCLIC ANTIDEPRESSANTS

The effectiveness of tricyclic antidepressants in relieving symptoms of PTSD has been mixed. In several studies, their use resulted in modest lessening of the symptoms of reexperiencing and minimal or no effect on avoidance or arousal symptoms. Patients treated with tricyclic antidepressants have not shown greater improvement than those treated with SSRIs, so the newer agents have replaced the antidepressants in pharmacotherapy for PTSD.(13)

MONOAMINE OXIDASE INHIBITORS