AJM Theme Issue: Men’s Health
Review
Posttraumatic Stress Disorder: Clinical Features, Pathophysiology, and Treatment

https://doi.org/10.1016/j.amjmed.2005.09.027Get rights and content

Abstract

Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly important because of wars overseas, natural disasters, and domestic violence. After trauma exposes the victim to actual or threatened death or serious injury, 3 dimensions of PTSD unfold: (1) reexperiencing the event with distressing recollections, dreams, flashbacks, and/or psychologic and physical distress; (2) persistent avoidance of stimuli that might invite memories or experiences of the trauma; and (3) increased arousal. Traumatic events sufficient to produce PTSD in susceptible subjects may reach a lifetime prevalence of 50% to 90%. The actual lifetime prevalence of PTSD among US citizens is approximately 8%, with the clinical course driven by pathophysiologic changes in the amygdala and hippocampus. Comorbid depression and other anxiety disorders are common. General principles of treatment include the immediate management of PTSD symptoms and signs; management of any trauma-related comorbid conditions; nonpharmacologic interventions including cognitive behavioral treatment; and psychopharmacologic agents including antidepressants (selective serotonin reuptake inhibitors most commonly), antianxiety medications, mood stabilizing drugs, and antipsychotics. This review of PTSD will provide the reader with a clearer understanding of this condition, an increased capacity to recognize and treat this syndrome, and a greater appreciation for the role of the internist in PTSD.

Section snippets

Clinical features

The term posttraumatic stress disorder was first used in the third edition (1980) of the Diagnostic and Statistical Manual of Mental Disorders, in which it was classified as an anxiety disorder.9 In this third edition, a diagnosis of PTSD required exposure to trauma that would provoke symptoms and signs of PTSD in almost everyone. In the 1987 revision of the Diagnostic and Statistical Manual of Mental Disorders,10 diagnostic criteria were modified to emphasize the avoidance phenomena in which

Pathophysiology

The centerpiece of the central nervous system involved in the fear response is the amygdala. This brain structure governs our ability to experience fear and learn to avoid pain by interceding between emotion and attention in 2 related ways.22 Amygdala signals enhance processing of fear-inducing information by higher cortical structures. That is, they increase the emotional valence assigned to information and memory in the cortex thereby making this information easier to access in future

Treatment

The American Psychiatric Association has recently published guidelines for the treatment of patients with PTSD.23 Included in these guidelines is treatment of patients with acute stress disorder. Acute stress disorder is a common precursor to PTSD. For an in-depth review of treatments for PTSD, the reader is referred to the practice guidelines developed by the International Society for Traumatic Stress Studies edited by Foa et al.24

Conclusions

Interest in PTSD extends beyond the field of mental health to engage the speciality of internal medicine and its various subspecialities. Combat-related trauma is a common cause of PTSD among men, and rape is a common cause of PTSD among women. The initial response to the traumatic stress is largely biologic and driven by the amygdala. Memories managed by the hippocampus and executive decisions managed in the neocortex drive the short-term, mid-range, and long-term outcomes of subjects exposed

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