Evidence-Based Reviews

PTSD: A systematic approach to diagnosis and treatment

Current Psychiatry. 2018 April;17(4):35-43

References

1. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association; 1980.
2. North CS, Surís AM, Smith RP, et al. The evolution of PTSD criteria across editions of the DSM. Ann Clin Psychiatry. 2016;28(3):197-208.
3. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013
4. Downs DL, North CS. Trauma-related disorders. Overview of posttraumatic stress disorder. https://www.deckerip.com/products/scientific-american-psychiatry/table-of-contents/. Published July 2017. Accessed February 27, 2018.
5. North CS. Disaster mental health epidemiology: methodological review and interpretation of research findings. Psychiatry. 2016; 79(2):130-146.
6. North CS, Yutzy SH. Goodwin and Guze’s Psychiatric Diagnosis, 6th ed. New York, NY: Oxford University Press; 2010.
7. North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282(8):755-762.
8. North CS, Pfefferbaum B. Mental Health Response to Community Disasters: A Systematic Review. JAMA. 2013;310(5):507-518.
9. North CS, Pollio DE, Smith, RP, et al. Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center. Disaster Med Public Health Prep. 2011;5(suppl 2):S205-S213.
10. North CS, Oliver J, Pandya A. Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters. Am J Public Health. 2012;102(10):e40-e48.
11. Whitman JB, North CS, Downs DL, et al. A prospective study of the onset of PTSD symptoms in the first month after trauma exposure. Ann Clin Psychiatry. 2013;25(3):163-172.
12. North CS, Oliver J. Analysis of the longitudinal course of PTSD in 716 survivors of 10 disasters. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1189-1197.
13. Jeffreys M, Capehart B, Friedman MJ. Pharmacotherapy for posttraumatic stress disorder: review with clinical applications. J Rehabil Res Dev. 2012;49(5):703-715.
14. Lee DJ, Schnitzlein CW, Wolf JP, et al. Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: systemic review and meta-analyses to determine first-line treatments. Depress Anxiety. 2016;33(9):792-806.
15. Foa EB, Keane T, Friedman MJ. Effective treatments for PTSD: practice guidelines from the International Society for traumatic stress studies. New York, NY: The Guilford Press; 2000.
16. Ursano RJ, Bell C, Eth S, et al; Work Group on ASD and PTSD. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association Publishing; 2004.
17. National Collaborating Centre for Mental Health. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London, UK: Gaskell and the British Psychological Society; 2005.
18. Foa EB, Keane TM, Friedman MJ, eds; The Board of Directors of the International Society for Traumatic Stress Studies. Effective treatments for PTSD. 2nd ed. Oakbrook Terrace, IL: The Guilford Press; 2005.
19. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guidelines. Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/. Published June 2017. Accessed February 26, 2018.
20. Phoenix Australia -Centre for Posttraumatic Mental Health. Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne, Australia: Phoenix Australia Centre for Posttraumatic Mental Health; 2013.
21. World Health Organization. Guidelines for the management of conditions specifically related to stress. Geneva, Switzerland: World Health Organization Press; 2013.
22. Benedek DM, Friedman MJ, Zatzick D, et al. Guideline watch (March 2009): practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Focus. 2009;7(2):201-213.
23. Stein DJ, Ipser J, McAnda N. Pharmacotherapy of posttraumatic stress disorder: a review of meta-analyses and treatment guidelines. CNS Spectr. 2009;14(suppl 1):25-31.
24. Forbes D, Creamer M, Bisson JI, et al. A guide to guidelines for the treatment of PTSD and related conditions. J Trauma Stress. 2010;23(5):537-552.
25. Nash WP, Watson PJ. Review of VA/DOD clinical practice guideline on management of acute stress and interventions to prevent posttraumatic stress disorder. J Rehabil Res Dev. 2012;49(5):637-648.
26. Birur B, Moore NC, Davis LL. An evidence-based review of early intervention and prevention of posttraumatic stress disorder. Community Ment Health J. 2017;53(2):183-201.
27. Breslau N, Davis GC. Posttraumatic stress disorder in an urban population of young adults: Risk factors for chronicity. Am J Psychiatry. 1992;149(5):671-675.
28. North CS, Pfefferbaum B, Kawasaki A, et al. Psychosocial adjustment of directly exposed survivors seven years after the Oklahoma City bombing. Compr Psychiatry. 2011;52(1):1-8
29. Rasco SS, North CS. An empirical study of employment and disability over three years among survivors of major disasters. J Am Acad Psychiatry Law. 2010;38(1):80-86.

Symptom groups. DSM-5 symptom criteria for PTSD include 4 symptom groups, Criteria B to E, respectively:

intrusion
avoidance
negative cognitions and mood (numbing)
hyperarousal/reactivity.

A specific number of symptoms must be present in all 4 of the symptom groups to fulfill diagnostic criteria. Importantly, these symptoms must be linked temporally and conceptually to the traumatic exposure to qualify as PTSD symptoms. Specifically, the symptoms must be new or substantially worsened after the event. For example, continuing sleep disturbance in someone who has had lifetime difficulty sleeping would not count as a trauma-related symptom. Most symptom checklists do not properly assess diagnostic criteria for PTSD because they do not anchor the symptoms in an exposure to a traumatic event; diagnosis requires an interview to fully assess all the diagnostic criteria. Finally, the symptoms must have been present for >1 month for the diagnosis, and the symptoms must have resulted in clinically significant distress or functional impairment to qualify.

The Algorithm provides a practical way to systematically assess all DSM-5 criteria for PTSD to arrive at a diagnosis. The clinician begins by determining whether a traumatic event has occurred and whether the individual had a qualifying exposure to it. If not, PTSD cannot be diagnosed. Alternative diagnoses to consider for new disorders that arise in the context of trauma among patients who are not exposed to trauma include major depressive disorder, adjustment disorder, and bereavement, as well as acute stress disorder (which is not validated but has potential utility as a billable diagnosis).

Avoidance and numbing symptoms (present in Criteria C and D) have been shown to represent markers of illness and can be useful in predicting PTSD.^8-10 Unlike symptoms of intrusion and hyperarousal (Criteria B and E, respectively), which are very common and by themselves are nonpathological, avoidance/numbing symptoms occur much less commonly, are associated with functional impairment and other indicators of illness, and are strongly associated with PTSD.⁶ Prominent avoidance/numbing profiles have been demonstrated to predict PTSD in the first 1 to 2 weeks after trauma exposure, before PTSD can be formally diagnosed.¹¹ Posttraumatic stress symptoms are nearly universal after trauma exposure, even in people who do not develop PTSD.⁵ Intrusion and hyperarousal symptoms constitute most of such symptoms,⁷ and these symptoms in the absence of prominent avoidance/numbing can be considered normative distress responses to trauma exposure.¹²

Some PTSD symptoms may seem quite similar to symptoms of depressive disorders and anxiety disorders. PTSD can be differentiated from these other disorders by linking the symptoms temporally and contextually to a qualifying exposure to a traumatic event. More often than not, PTSD presents with comorbid psychiatric disorders, especially depressive disorders, anxiety disorders, and/or substance use disorders.⁵ Epidemiologic research on PTSD has shown consistently that pre-existing psychopathology is a strong predictor of PTSD following trauma exposure, as well as of psychiatric comorbidity. These comorbid conditions may be as important as the PTSD in choosing a treatment, and they should be treated concurrently with PTSD.^6,13

Continue to: Treatment: Medication, psychotherapy, or both

PTSD: A systematic approach to diagnosis and treatment

References

Pages

Recommended Reading