Dr. Zanni is a psychologist and health systems consultant based in Alexandria, Virginia.
Originally called shell shock or battle fatigue, most people associate posttraumatic stress disorder (PTSD) with military service for good reason: up to 29% of combat veterans and 78% of prisoners of war develop PTSD.1 Regardless, psychologically and functionally impairing PTSD can arise from any traumatic situation.
After trauma, extreme fear, helplessness, or anxiety are normal short-term reactions that generally dissipate over time, as individuals cope and adjust. Approximately 33% of acute trauma sufferers, however, develop symptoms lasting longer than 30 days. Symptom duration distinguishes PTSD from normal acute stress reactions.
PTSD's hallmark symptoms include re-experiencing the trauma, avoidance and/or emotional numbness, and hyperarousal.2 Table 13 lists PTSD's diagnostic criteria. PTSD's categories include acute (duration <3 months), chronic (duration ≥3 months), and delayed onset where symptoms emerge more than 6 months after trauma is experienced. Most adult victims develop symptoms within 3 months of the event.4
PTSD's prevalence ranges from 8% to 10%, with 3.6% of adult Americans suffering from PTSD within any given year.4,5 Longer, more severe trauma increases PTSD risk. Among the general population, PTSD is most commonly associated with automobile accidents (56%), followed by personal assault (35%).1 PTSD is more common among women, but men present with more irritability and are more likely to increase alcohol consumption.1 Up to 30% of PTSD patients develop a chronic, lifelong form.6
Along with military combat service, workers who see trauma daily, such as rescue and emergency personnel, are at risk. Other situations associated with PTSD risk include:
In most cases, PTSD sufferers are the victims; however, people who cause catastrophic events also are at risk. Families of PTSD victims may likewise be affected.
Early intervention can hasten the generally gradual recovery process. Treatment reduces the average duration of symptoms from 64 to 36 months.4 Treatment generally lasts 3 to 6 months, but those with comorbid mental health problems may require longer treatment.7 Interventions generally include medication management and psychotherapy. Treatment planning is complicated, partly because symptoms of PTSD wax and wane.
The FDA-approved selective serotonin reuptake inhibitors sertraline (Zoloft) and paroxetine (Paxil) are first-line treatments. Sertraline is especially useful for women who experienced physical or sexual trauma. Paroxetine targets all symptom clusters (re-experiencing the event, avoidance behaviors, and hyperarousal). Agents used to target specific symptoms include benzodiazepines for anxiety; anticonvulsants for impulsivity and emotional lability; beta-blockers for hyperarousal; and clonidine for nightmares. Monoamine oxidase inhibitors effectively reduce re-experiences, but have minimal impact on avoidance symptoms.4 Table 2 includes pharmacotherapy options for PTSD.
Cognitive behavior therapy helps patients recognize and change thought patterns associated with troublesome emotions and memories; it is particularly effective.5,9
Avoidance symptoms of PTSD create counseling challenges; consequently, pharmacists must pace counseling to the patient's comfort level. Along with medication counseling, the following guidelines help pharmacists address core issues:
Nearly 50% of PTSD sufferers refuse to seek treatment, fearing what others might think and/or are concerned that their condition might negatively affect their employment.4,7 Pharmacists, like all health care professionals, must work toward eradicating the stigma associated with PTSD?all the more reason for thorough counseling.
One study linked multiple pregnancies to an increased risk of developing atrial fibrillation later in life, and another investigated the association between premature delivery and cardiovascular disease.
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