Living Art Enterprises / Science Source
The most likely diagnosis for this patient is veteran posttraumatic stress disorder (PTSD), given his history of combat exposure and symptoms, such as severe headaches, difficulty concentrating, mood swings, nightmares, flashbacks, increased startle response, and hypervigilance. MRI findings showing significant changes in the limbic system and hippocampal regions support this diagnosis. Other potential diagnoses, like traumatic brain injury, chronic migraine, and major depressive disorder, are less likely because of their inability to account for the full range of his symptoms and specific MRI abnormalities.
PTSD, experienced by a subset of individuals after exposure to life-threatening events, has a lifetime prevalence of 4%-7% and a current prevalence of 1%-3%, with higher rates in older women, those with more trauma, and combat veterans. Nearly half of US veterans are aged 65 or older, many being Vietnam-era veterans at elevated risk for PTSD. Prevalence rates in older veterans range between 1% and 22%.
PTSD is characterized by intrusive thoughts, flashbacks, nightmares, avoidance of reminders, hypervigilance, and sleep difficulties, significantly disrupting interpersonal and occupational functioning. Screening tools like the primary care (PC) PTSD-5 and PCL-5, used in primary care settings, are effective for early detection, provisional diagnosis, and monitoring of symptom changes. The clinician-administered PTSD scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DSM-5 (CAPS-5) is the gold standard for diagnosis, particularly among veterans, with multimethod assessments combining self-report measures and semi-structured interviews recommended for accuracy. The DSM-5 criteria for PTSD diagnosis describe exposure to traumatic events, intrusion symptoms, avoidance behaviors, negative mood, and altered arousal, with symptoms persisting for over a month and causing significant distress or functional impairment.
Research has identified consistent anatomical and functional changes in PTSD patients, such as smaller hippocampi, decreased corpus callosum and prefrontal cortex, increased amygdala reactivity, and decreased prefrontal cortex activity. PTSD, linked to alterations in brain regions involved in fear learning and memory, shows diminished structural integrity in executive function areas, reduced cortical volumes in the cingulate brain cortex and frontal regions, and reduced white matter integrity in key brain pathways. Neuroimaging findings, however, are primarily used for research currently and have yet to be widely implemented in clinical guidelines.
International PTSD treatment guidelines consistently recognize trauma-focused cognitive-behavioral therapies (CBTs), such as cognitive processing therapy (CPT), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) as the gold standard. Recent guidelines have expanded the list of recommended treatments: The 2023 Department of Veterans Affairs and Department of Defense guidelines in the United States also endorse therapies like written narrative exposure and brief eclectic therapy. Internationally, guidelines do not perfectly coincide, as the 2018 update from the United Kingdom's National Institute for Health and Care Excellence (NICE) gives the highest recommendations to PE and CPT but rates EMDR slightly lower for military veterans because of limited evidence. Overall, guidelines consistently advocate for trauma-focused psychological interventions as the primary treatment for PTSD.
Guidelines from NICE and the World Health Organization do not recommend medications as the primary treatment; the American Psychiatric Association and the US Department of Veterans Affairs support selective serotonin reuptake inhibitors and prazosin but advise against benzodiazepines. Inpatient care may be necessary for individuals who pose a danger to themselves or others, or for those with severe PTSD from childhood abuse, to aid in emotional regulation and treatment.
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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