1. Post Traumatic Stress Disorder Identification and Management Am Fam Physician 2013 88(12):827-834

2. Diagnostic Criteria A. Exposure to actual or threatened death 1. Direct Experience 2. Witnessing, in person, the event 3. Learning that the event happened to close family or friend 4. Repeated or extreme exposure of event or events One or more

3. Diagnostic Criteria B. Presence of one or more intrusion syndrome 1. Recurrent distressing memories 2. Recurrent distressing dreams 3. Dissociative re-experiencing 4. Intense distress at exposure to cues 5. Marked physiological reaction to cues One or more

4. Diagnostic Criteria C. Persistent avoidance of reminders 1. Distressing memories 2. External reminders One or more

5. Diagnostic Criteria D. Decline in mood/cognition after the event 1. Inability to remember the event 2. Exaggerated negative beliefs about self, others or the world 3. Self Blame 4. Persistent negative mood state (fear, anger, horror, guilt, shame) 5. Diminished interest in significant activities 6. Feelings of detachment 7. Difficulty experiencing positive emotions Two or more

6. Diagnostic Criteria E. Marked alteration in arousal and reactivity 1. Irritability/angry outbursts 2. Reckless behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep Disturbance Two or more

7. Epidemiology  High lifetime risk of trauma (60% of men, 50% of women)  Of those exposed, 8% of men and 20% of women develop PTSD  Prevalence much higher in populations exposed to natural disaster and war  History of trauma increases likelihood of PTSD

8. In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you... 1. Have had nightmares about it or thought about it when you did not want to? YESNO 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YESNO 3. Were constantly on guard, watchful, or easily startled? YESNO 4. Felt numb or detached from others, activities, or your surroundings? YESNO Primary Care PTSD Screen Current research suggests that the results of the PC-PTSD screen should be considered positive if the patient answers yes to 3 or more of these items. For screen positive, thorough interview and/or administer PCL-5.

9. Psychiatric Comorbidities  Substance Abuse  Depression  Anxiety Disorders  Suicidal ideation(1 in 5 attempt suicide)  Generalized Physical Symptoms (Physical injury is a risk factor for PTSD)

10. Suicide- Questions to ask  Have you thought about how you would harm yourself?  What is your plan?  Do you have access to the method (e.g., gun and bullets, poison, pills)?  What has kept you from acting on these thoughts?  Do you have any intention of following through with the thoughts of self- harm?  What are your plans for the future?  Have you or a family member ever attempted suicide in the past?  Have you or a family member ever been diagnosed with or treated for anxiety, depression, or other mental health problems?  Are you currently using alcohol or drugs (illicit or prescription)?  Have there been any changes in your employment, social life, or family?  Do you have friends or family with whom you are close? Have you told them about these thoughts?  Do you tend to be impulsive with your decisions or behavior?  Is there a gun in the house?

11. Management  Trauma focused therapies  Chronic pain  Sleep disturbance  Screening for substance use  Low threshold for involving behavioral health specialists

12. Pharmacotherapy  Antidepressants – First line therapy  SSRI & SNRI help with the most PTSD Symptoms  Important counseling about discontinuation syndrome, which may be mistaken for worsening PTSD  Other antidepressants can be used

13. Pharmacotherapy  Augmenting agents – Prazosin alleviates nightmares (but the effects of other alpha adrenergic blockers, alpha 2 agonists and beta agonists are unknown)  Benzodiazepines are contraindicated  Antihistamines and hypnotics may be used for short term sleep disturbance  Trazadone is safe for longer term use

14. Psychotherapy  Narrative exposure  In vivo exposure  Cognitive restructuring  Relaxation techniques  EMDR (eye movement desensitization and reprocessing)  Psychoeducation and support important in the office  Referral for family and marital therapy as needed  Supportive care

15. PTSD Clinical Recommendations  New patients with a history of trauma should be screened for symptoms C  Trauma focused therapy including psychotherapy and pharmacotherapy are first line treatments for PTSD A  Monotherapy for should be optimized before prescribing additional agents C  Adjunctive treatment with prazosin (Minipress) is recommended for patients with sleep disturbance, nightmares B  Benzodiazepines should be avoidedB  Atypical antipsychotics should generally be avoided.C