Posttraumatic Stress Disorder

Background

Symptoms of posttraumatic stress disorder (PTSD) can develop after exposure to a traumatic event. A traumatic event may be a single instance, such as a car accident or experience of a natural disaster, or an ongoing pattern of events, such as continuous neglect, physical or sexual abuse, or chronic exposure to war or violent conflict. PTSD causes intrusive memories, hyperarousal, and psychological numbing or avoidance, among other symptoms. It may impair an individual's psychological and physical functioning, decreasing immune system function and increasing susceptibility to illness. Untreated PTSD can increase the risk of HIV transmission or acquisition and worsen the course of HIV treatment.

Individuals with PTSD may experience depression, anxiety, social isolation, impairments in trust and attachments, and feelings of anger, and PTSD often coexists with depression, anxiety, or other psychiatric illnesses. PTSD may be associated with increased risk-taking behavior (e.g., substance abuse, unsafe sex).

The rate of PTSD among individuals with HIV infection (in whom the lifetime prevalence is possibly as high as 42%) is higher than that of the general population (1.3%-7.8%). Women experience PTSD at a higher rate than men. The likelihood of developing PTSD increases in relation to the severity of or proximity to the traumatic event. A history of traumatic experiences may increase an individual's risk of developing PTSD after a new trauma. Although a diagnosis of HIV may trigger PTSD symptoms, a history of trauma or abuse often is present as well. A personal or family psychiatric history may increase the likelihood of developing PTSD.

PTSD is diagnosed, as in HIV-uninfected individuals, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV (see "References," below). It is treatable through diverse therapies and psychopharmacology.

S: Subjective

The following reflect DSM-IV diagnostic criteria; include them in the history.

• The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death, serious injury, or a threat to the physical integrity of self or others.
• The person's response involved intense fear, helplessness, or horror.
• The patient complains of persistently reexperiencing the event in one or more of the following ways:
  • Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions
  • Recurring distressing dreams of the event
  • 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 when awakening or intoxicated)
  • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  • Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Other complaints may include the following:

• Overwhelming emotions caused by memories of the event
• Emotional numbness
• Disruptions in consciousness, memory, or identity
• Depersonalization (i.e., a feeling of watching oneself act, while having no control over a situation)
• Derealization (i.e., alteration in the perception or experience of the external world so that it seems strange or unreal)
• Feelings of estrangement from others
• Episodes of lost time

The patient may experience the following:

• Recurrent distressing recollections of the event
• Recurrent distressing dreams of the event
• Illusions/hallucinations of the event actually occurring
• Psychological distress triggered by cues reminiscent of the event
• Avoidance of thoughts, feelings, or conversation associated with the event
• Avoidance of activities, places, or people associated with the event
• Inability to recall important aspects of the event
• Diminished interest in significant activities
• Detachment
• Restricted range of affect
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance

Also screen for the following:

• Clinical depression
• Anxiety disorders
• Alcohol or other substance-use disorders

O: Objective

• Check vital signs, with particular attention to heart rate (tachycardia) and respiratory rate (shortness of breath, hyperventilation).
• Perform a physical examination, including mental status and neurologic examination (tremor, hyperreflexia, focal abnormalities).
• Look for signs of physical trauma or sexual assault.

A: Assessment

A differential diagnosis may include the following:

• Substance use (e.g., amphetamines, cocaine)
• Substance withdrawal (e.g., alcohol, benzodiazepines)
• Electrolyte imbalances
• Excessive caffeine intake
• Hyperthyroidism
• Medications effects (e.g., efavirenz, isoniazid, steroids, theophylline)
• Allergic reactions
• Head trauma
• Hypoglycemia
• Sleep disturbances or sleep deprivation
• Central nervous system (CNS) or opportunistic infections or malignancies
• Systemic or other infections
• Respiratory disease
• Heart disease, arrhythmias
• Anemia
• Vitamin B12 deficiency

P: Plan

Evaluation

Perform the following tests:

• Complete blood count, electrolytes, creatinine, blood urea nitrogen, glucose
• Thyroid function tests (thyroid stimulating hormone [TSH], T4)
• Vitamin B12 levels
• Other tests as suggested by history and physical examination

Treatment

Once other diagnoses have been ruled out and the diagnosis of PTSD is established, several treatment options are available.

Psychotherapy

Options include individual cognitive-behavioral therapy, dialectical-behavioral therapy, interpersonal therapy, exposure therapy, a stress-management group, relaxation therapy, visualization, guided imagery, supportive psychotherapy, and psychodynamic psychotherapy. Long-term psychotherapy may be indicated if experienced professionals are available and the patient is capable of forming an ongoing relationship. If possible, refer to an HIV-experienced therapist. The specific psychotherapy often depends on the skills and training of the practitioners available in a given health care system or region. In addition, refer the patient to available community-based support.

Pharmacotherapy

Antidepressants

Most antidepressants should be started at low dosages and gradually titrated upward to avoid unpleasant side effects. Therapeutic effects may not be noticed until 2-4 weeks after starting a medication. If there is no improvement in symptoms in 2-4 weeks, and there are no significant adverse effects, the dosage may be increased. Before prescribing a medication, always remember to check for drug-drug interactions, particularly with concurrent antiretrovirals (ARVs). See "Potential ARV Interactions," below, and chapter Major Depression and Other Depressive Disorders for further information about antidepressants, including possible adverse effects and interactions with ARVs.

• Selective serotonin reuptake inhibitors (SSRIs) have the strongest evidence for efficacy and tolerability for PTSD and are first-line medication treatment. Two SSRI antidepressants have a specific indication for PTSD approved by the U.S. Food and Drug Administration (FDA): sertraline (Zoloft) at recommended dosages of 50-200 mg per day (usual starting dosage: 25 mg daily) and paroxetine (Paxil) at recommended dosages of 20-50 mg per day (usual starting dosage: 25 mg daily). Other SSRIs include fluoxetine (Prozac), citalopram (Celexa), and escitalopram (Lexapro).
• The serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants such as venlafaxine (Effexor) and duloxetine (Cymbalta), as well as the antidepressant mirtazapine (Remeron), are second-line treatments if SSRIs prove ineffective or are not well tolerated.
• Tricyclic antidepressants (TCAs) may be employed if the individual has had a good response to them in the past and they do not cause severe side effects, or if the individual has failed to respond to or cannot tolerate SSRIs or SNRIs. TCAs in low dosages also may be used for sleep; see chapter Insomnia.

Anxiolytics

Antianxiety medications have not been shown to be effective treatments for PTSD when used alone but may be effective, as adjunctive therapy, in reducing anxiety symptoms. Treatment may include intermediate half-life benzodiazepines such as oxazepam (Serax)10 mg PO Q6H or lorazepam (Ativan) 0.5 mg PO Q8H. Longer-acting benzodiazepines such as clonazepam (Klonopin) may be useful at dosages of 0.25-0.5 mg PO BID. Levels of many benzodiazepines may be increased by certain protease inhibitors and nonnucleoside reverse transcriptase inhibitors; see "Potential ARV Interactions," below.

Benzodiazepines can reduce anxiety rapidly, often within hours, but may have counterbalancing side effects early in the course of their use that include sedation and incoordination. In addition, physical dependency may develop in patients who use them for more than a few weeks. Benzodiazepines are not recommended for people who have a history of alcohol abuse or dependence. Benzodiazepines ideally would be used only briefly and intermittently to quell acute and severe anxiety symptoms.

Buspirone (BuSpar) is a nonaddictive anxiolytic. It usually must be taken for at least 1-2 weeks before anxiety symptoms begin to lessen. Starting dosage is 5 mg PO TID. If symptoms persist, the dosage can be increased by 5 mg per dose each week to a maximum of 10-15 mg PO TID (for a total daily dosage of 30-45 mg). Low-dose benzodiazepines may be used during the initial weeks of buspirone therapy, until the effects of buspirone are felt. The major potential adverse effects of buspirone are dizziness and lightheadedness.

Anticonvulsants

Mood stabilizers such as valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), and topiramate (Topamax) may be added for patients with a partial response to an antidepressant. They may be particularly helpful for those who have considerable irritability, anger, or hostility, as well as those with reexperiencing symptoms (e.g., flashbacks, intrusive memories). Gabapentin (Neurontin) 200-400 mg BID or QID sometimes helps to diminish anxiety. Treatment with these agents usually should be done by or in consultation with a psychiatrist.

Antipsychotics

Older and newer antipsychotics (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone) may be suitable for individuals with psychotic features of PTSD or those who have a comorbid psychotic illness. These medications also may be helpful for some individuals who have not benefited from medications indicated for PTSD. Adverse effects may include dyslipidemia, hyperglycemia, weight gain, and sudden cardiac death. Consultation with a psychiatrist is recommended.

Other medications

A variety of other medications have been used as adjunctive treatment when insomnia and nightmares persist despite adequate use of psychotropic medications. Research is still quite limited, but suggests that the antihypertensive drugs clonidine (Catapres) and prazosin (Minipress) may help with the insomnia and nightmares of PTSD.

Patients with advanced HIV disease, as with geriatric patients, may be particularly vulnerable to the CNS effects of certain medications. Medications that affect the CNS should be started at low dosage and titrated slowly. Similar precautions should apply to patients with liver dysfunction.

Patient Education

• Explain to patients that illness (physical or emotional) is not a character flaw or a moral or spiritual weakness.
• Inform patients that both behavioral interventions and medication can be very helpful in treating PTSD. If one strategy is not successful, many others are available.
• Advise patients that psychiatric medications are often given for a long time, usually for a year or longer.
• Advise patients that, when they start taking an antidepressant medication for PTSD, they should expect that it will take 2-4 weeks for them to notice any improvement. Their symptoms should continue to decrease over the following weeks. If they do not have much improvement in symptoms, providers may choose to adjust the dosage of the medication or to change medications. Patients must continue taking their medications so that symptoms do not return.
• Advise patients that they may develop problems with sexual function because of psychiatric medications. They should report any problems to their prescribers.

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington: American Psychiatric Association; 1994.
• Cohen M, Hoffman RG, Cromwell C, et al. The prevalence of distress in persons with human immunodeficiency virus infection. Psychosomatics. 2002 Jan-Feb;43(1):10-5.
• Essock SM, Dowden S, Constantine NT, et al.; Five-Site Health and Risk Study Research Committee. Risk factors for HIV, hepatitis B, hepatitis C among persons with severe mental illness. Psychiatr Serv. 2003 Jun;54(6):836-41.
• McNicholl I. HIV InSite Database of Antiretroviral Drug Interactions. San Francisco: UCSF Center for HIV Information. Accessed June 21, 2012.
• New York State Department of Health AIDS Institute. Mental Health Care for People with HIV Infection: Clinical Guidelines for the Primary Care Practitioner. Accessed June 21, 2012.
• New York State Department of Health AIDS Institute. Trauma and Post-Traumatic Stress Disorder in Patients with HIV/AIDS; 2007.
• van Liempt S, Vermetten E, Geuze E, et al. Pharmacotherapeutic treatment of nightmares and insomnia in posttraumatic stress disorder: an overview of the literature. Ann N Y Acad Sci. 2006 Jul;1071:502-7.