Post-traumatic stress disorder Study Guide

📖 Core Concepts Post‑Traumatic Stress Disorder (PTSD) – mental disorder that develops after exposure to a traumatic event (e.g., sexual assault, combat, natural disaster). Diagnostic requirement – symptoms must persist > 1 month (DSM‑5) and cause functional impairment. Four DSM‑5 symptom clusters Re‑experiencing (intrusive memories, nightmares, flashbacks) Avoidance (efforts to evade trauma cues) Negative alterations in cognition/mood (persistent negative beliefs, anhedonia) Arousal & reactivity (hyper‑vigilance, irritability, sleep disturbance) Epidemiology – 3–5 % global lifetime prevalence; 9 % U.S. lifetime prevalence, higher in women. Risk factors – interpersonal violence, combat, childhood abuse, female gender, low social support, genetics (30 % heritability). Core neurobiology – hyper‑active amygdala, hypo‑active medial prefrontal cortex, reduced hippocampal volume, HPA‑axis dysregulation (low basal cortisol, over‑reactive adrenaline). 📌 Must Remember Duration: > 1 month (DSM‑5) or > 3 months (some sources) after trauma. Screening tools: PCL‑5, PC‑PTSD‑5, Primary Care PTSD Screen (5‑item). Gold‑standard interview: CAPS‑5 (Clinician‑Administered PTSD Scale). First‑line psychotherapy: trauma‑focused CBT (including prolonged exposure, cognitive processing therapy, EMDR). First‑line meds: SSRIs (sertraline, fluoxetine, paroxetine) and SNRI (venlafaxine). FDA‑approved: sertraline & paroxetine. Benzodiazepines: contraindicated – may worsen PTSD, increase chronicity, and interfere with therapy. Prazosin: α1‑adrenergic antagonist for nightmares (variable efficacy). MDMA‑assisted psychotherapy: emerging evidence of superior efficacy vs psychotherapy alone. Psychological debriefing: ineffective or possibly harmful; not recommended. 🔄 Key Processes Diagnostic workflow Screen (PCL‑5/PC‑PTSD‑5) → Positive → Full clinical interview (CAPS‑5) → Confirm 4 symptom clusters + duration + functional impairment. Trauma‑focused CBT (exposure‑based) sequence Psychoeducation → In‑vivo exposure → Imaginal exposure → Cognitive restructuring → Skills training → Relapse prevention. EMDR protocol History & preparation → Identify target memory → Dual attention bilateral stimulation (rapid eye movements) while recalling → Install positive cognition → Body scan → Closure. Pharmacotherapy initiation Start SSRI (e.g., sertraline 25 mg daily, titrate up) → Monitor side‑effects & response (4–6 weeks) → If nightmares persist, add prazosin (starting 1 mg at bedtime). 🔍 Key Comparisons PTSD vs. Acute Stress Disorder – ASD symptoms < 1 month; PTSD > 1 month, may have delayed onset. SSRIs vs. SNRIs – Both first‑line; SNRIs (venlafaxine) add norepinephrine reuptake inhibition, useful when hyper‑arousal dominates. Benzodiazepines vs. Antidepressants – BZDs offer rapid anxiolysis but increase PTSD risk & hinder therapy; antidepressants provide modest symptom reduction with better long‑term outcomes. Psychological Debriefing vs. Early CBT – Debriefing: single‑session, no benefit; Early CBT: multi‑session, modest prevention of chronic PTSD. ⚠️ Common Misunderstandings “Any stress reaction is PTSD.” → PTSD requires specific symptom clusters, duration > 1 month, and functional impairment. “Benzodiazepines are safe for anxiety in PTSD.” → They may worsen PTSD and impede psychotherapy. “All trauma leads to PTSD.” → Only a minority develop PTSD; risk is moderated by type of trauma, genetics, and support. “Complex PTSD = regular PTSD.” → ICD‑11 separates Complex PTSD (additional disturbances in self‑organization) from classic PTSD. 🧠 Mental Models / Intuition “Fear‑learning circuit” – Trauma creates a strong amygdala‑driven fear memory; CBT/EMDR aim to re‑train the prefrontal cortex to inhibit that response. “Genetic load + stress → lower cortisol → hyper‑reactivity.” Think of genetics as a “volume knob” that amplifies the stress response. “Screen → Interview → Treat” – A three‑step funnel ensures only true cases receive intensive therapy. 🚩 Exceptions & Edge Cases Delayed onset PTSD – symptoms may appear months–years after trauma; still meet criteria if > 1 month once they appear. Combat‑related delayed PTSD – 25 % of combat‑exposed cases have delayed onset. Moral injury – characterized by shame/guilt, not primary fear; treat with different psychotherapies (e.g., meaning‑focused). Complex PTSD (ICD‑11) – requires additional disturbances in self‑identity and relational functioning. 📍 When to Use Which First‑line psychotherapy: any patient with confirmed PTSD, unless severe medical instability. Add medication: when moderate‑to‑severe symptoms, comorbid depression/anxiety, or sleep/nightmare problems. EMDR vs. Prolonged Exposure: EMDR preferred if patient resists imaginal exposure; both have comparable efficacy. Prazosin: specifically for persistent nightmares or hyper‑arousal not controlled by SSRI. MDMA‑assisted therapy: consider in research/clinical trial settings for treatment‑resistant PTSD. 👀 Patterns to Recognize Interpersonal violence → higher PTSD risk than accidents/natural disasters. Early hyper‑arousal + dissociation predicts poorer outcome; flag for intensive intervention. Comorbid substance use → higher dropout; plan integrated treatment. Female gender + prior mental illness → higher prevalence; prioritize screening. 🗂️ Exam Traps Distractor: “Benzodiazepines are first‑line for PTSD.” – Wrong; they are contraindicated. Distractor: “PTSD requires 12 symptom clusters in DSM‑5.” – Misreading; DSM‑5 has four clusters (12 individual symptoms across them). Distractor: “Psychological debriefing prevents PTSD.” – Evidence shows no preventive benefit, may increase risk. Distractor: “All SSRIs are FDA‑approved for PTSD.” – Only sertraline and paroxetine have FDA approval. Distractor: “Complex PTSD is diagnosed under DSM‑5.” – It is an ICD‑11 construct, not a DSM‑5 category. --- Use this guide for a rapid, confidence‑building review before your exam. Good luck!