Checklist
DSM-IV-TR diagnostic criteria for posttraumatic stress disorder
| Criterion A. The person has been exposed to a traumatic event in which both of the following have been present: | |
| □ | 1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others |
| □ | 2. The person’s response involved intense fear, helplessness, or horror |
| Criterion B. The traumatic event is persistently re-experienced in at least 1 of the following ways: | |
| □ | 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions |
| □ | 2. Recurrent distressing dreams of the event |
| □ | 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated) |
| □ | 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event |
| □ | 5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event |
| Criterion C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least 3 of the following: | |
| □ | 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma |
| □ | 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma |
| □ | 3. Inability to recall an important aspect of the trauma |
| □ | 4. Markedly diminished interest or participation in significant activities |
| □ | 5. Feeling of detachment or estrangement from others |
| □ | 6. Restricted range of affect |
| □ | 7. Sense of foreshortened future |
| Criterion D. Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least 2 of the following: | |
| □ | 1. Difficulty falling or staying asleep |
| □ | 2. Irritability or outbursts of anger |
| □ | 3. Difficulty concentrating |
| □ | 4. Hypervigilance |
| □ | 5. Exaggerated startle response |
| □ | Criterion E. Duration of disturbance (symptoms in B, C, and D) is >1 month |
| □ | Criterion F. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning |
| Source: Adapted from Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 | |
Treating PTSD in depression
Pharmacotherapy and psychotherapeutic interventions are important to PTSD patients’ recovery. Limited resources often prevent these patients from receiving expert psychotherapeutic intervention, however, leaving pharmacotherapy as the mainstay of treatment. This is unfortunate, because psychological interventions may be sufficient and preferred in some instances (Box).17–20
Pharmacotherapy for comorbid MDD. Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine are first-line interventions for PTSD in depressed patients who do not meet criteria for a bipolar spectrum disorder. Placebo-controlled studies suggest that sertraline,21,22 fluoxetine,23 and paroxetine,24 are effective; doses higher than those used to treat depression may be required. Extended-release venlafaxine25 in dosages similar to those needed for depressive disorders also can be effective. Bupropion does not appear to be beneficial in treating PTSD.
The monoamine oxidase inhibitor phenelzine was long used successfully in treating PTSD but for the most part has been replaced by SSRIs. Because of its associated dietary restrictions, risk of hypertensive crises, and other side effects, phenelzine probably is best reserved for patients who do not respond to treatment with SSRIs or venlafaxine.
Pharmacotherapy for comorbid bipolar spectrum. If one accepts that most patients meeting criteria for MDE have a bipolar spectrum disorder, then most affectively ill patients with PTSD would need to be treated as if they have bipolar disorder. Oddly enough, this creates difficulties for the use of not only antidepressants and benzodiazepines, but also mood stabilizers:
- Patients with BPD and comorbid anxiety disorders, including PTSD, may be resistant to mood stabilizers.26,27
- Antidepressants can precipitate hypomanic or manic switches or onset of mixed hypomania, a mixed state, or rapid cycling in patients with a bipolar spectrum disorder.28–30
- Benzodiazepines do not appear to relieve acute or chronic PTSD-related distress, and discontinuation could cause rebound symptoms.31
Because no outcome studies have addressed PTSD management in patients with bipolar spectrum disorders, clinicians must rely on their judgment when formulating treatment plans. One strategy is to treat patients with mood stabilizers, then leave well enough alone if both the mood and anxiety symptoms remit (which is possible but unlikely in my experience). I often start treatment for the bipolar spectrum disorder and co-existing PTSD using mood stabilizers (including atypical antipsychotics) and prazosin, an α-1antagonist originally used for treating hypertension.