Involuntary flashbacks

The correct diagnosis is posttraumatic stress disorder (PTSD). The patient's anxiety, irritability, sleep difficulties, and other symptoms are directly related to the recent traumatic event (car crash), and he has no significant physical injuries or neurologic abnormalities.

Generalized anxiety disorder is incorrect because it involves chronic worry about various life aspects for at least 6 months, unrelated to a specific trauma.

Postconcussion syndrome is not applicable because of the lack of concussion evidence and other symptoms, such as headaches or dizziness.

Acute stress disorder is similar to PTSD but is diagnosed when symptoms occur within 3 days to 1 month after a trauma. Because this patient's symptoms have persisted beyond 1 month, PTSD is the most likely diagnosis.

Patients with PTSD exhibit pronounced cognitive, affective, or behavioral responses to trauma reminders; these responses may include severe anxiety, dissociative episodes, flashbacks, and hyperreactive behaviors. The intensity of these symptoms and the resulting psychosocial impairment are more severe in individuals with PTSD compared with people who experience trauma without developing the disorder. To manage such heightened arousal, individuals with PTSD often engage in avoidance behaviors, leading to emotional numbing; reduced interest in daily activities; and, in severe cases, detachment from others.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) outlines specific criteria for diagnosing PTSD in individuals older than 6 years. These criteria include: (A) exposure to actual or threatened death, serious injury, or sexual violence; (B) the presence of one or more intrusion symptoms related to the traumatic event; (C) persistent avoidance of stimuli associated with the trauma; (D) negative alterations in cognitions and mood related to the trauma; and (E) marked alterations in arousal and reactivity, evidenced by two or more specific symptoms.

Early intervention is key in the treatment of PTSD to prevent the condition from becoming chronic. Although more empirical data are needed, especially regarding pharmacotherapy, early supportive interventions such as psychoeducation and case management have shown promise in acutely traumatized individuals.

Trauma-focused psychotherapy is recommended as the first-line treatment for most adults with PTSD. This approach, which includes exposure-based therapies, is generally preferred over other therapies or pharmacologic treatments, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors. However, in patients with comorbid conditions (eg, depression, psychosis) that impair their ability to engage in trauma-focused therapy, initial pharmacologic management is advised until symptoms stabilize, after which psychotherapy can be introduced.

Clinical trials and meta-analyses have demonstrated the efficacy of various trauma-focused therapies, including trauma-focused cognitive-behavioral therapy, prolonged exposure therapy, and eye movement desensitization and reprocessing. The treatment choice should be collaborative, based on patient presentation, preference, and therapist expertise.

For individuals with PTSD experiencing significant sleep disturbances, particularly nightmares, prazosin is suggested. Clinical studies demonstrate that prazosin effectively reduces overall PTSD symptoms, nightmares, and sleep disturbances in approximately half of the patients treated.

Medication regimens effective for PTSD should be continued for at least 6 months to 1 year to prevent relapse or recurrence. Multiple clinical trials in patients with PTSD who completed acute treatment with SSRIs have demonstrated that those who continued with SSRIs were less likely to have relapse compared with those receiving placebo.

Jasvinder Chawla, MD, Professor of Neurology, Loyola University Medical Center, Maywood; Director, Clinical Neurophysiology Lab, Department of Neurology, Hines VA Hospital, Hines, IL.
Jasvinder Chawla, MD, has disclosed no relevant financial relationships.

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