A 28-year-old man comes to the office at his wife's insistence. He reports severe insomnia but otherwise feels physically healthy. His wife is concerned that the patient is having a difficult time since returning from military duty. She says, "He used to be so upbeat and easygoing. Now his moods fluctuate between really tense and on edge to detached and numb." The patient cannot fall asleep at night because, as soon as he closes his eyes, he sees the horrific scene of his friend being blown up after stepping on a landmine. During the day, he is hypersensitive to loud sounds such as firecrackers or a car backfiring. The patient says, "Sometimes I feel as if I'm back in combat and have to duck and take cover." Vital signs are within normal limits, and physical examination shows no abnormalities. On mental status examination, the patient has an anxious mood and blunted affect. Which of the following is the most appropriate pharmacotherapy?
Posttraumatic stress disorder | |
Clinical |
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Treatment |
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SNRIs = serotonin-norepinephrine reuptake inhibitors; SSRIs = selective serotonin | |
This patient's sleep disturbance, tense moods, feelings of detachment, intrusive images, hypervigilance, and flashbacks are characteristic of post-traumatic stress disorder (PTSD). First-line treatment consists of trauma-focused cognitive behavioral therapy and antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs) have the best evidence for efficacy, and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also commonly used. Although patients with PTSD commonly experience anxiety, hyperarousal, and insomnia, there is little evidence to support the use of benzodiazepines and non-benzodiazepine hypnotics (Choices B and E).
(Choice A) Antipsychotics are not a first-line treatment for PTSD. They may have a limited role as augmentation in patients who have inadequate response to an SSRI/SNRI.
(Choices C and G) The older antidepressants (monoamine oxidase inhibitors and tricyclic antidepressants) are used as second-line treatments for depression, but they have not been shown to be effective in PTSD.
(Choice D) Mood stabilizers (eg, lithium, anticonvulsants with mood-stabilizing properties) have a major role in treating bipolar disorders, but they have not proven effective in treating PTSD.
Educational objective:
First-line treatment for post-traumatic stress disorder includes trauma-focused cognitive-behavioral therapy and antidepressant medication. Selective serotonin reuptake inhibitors have the best evidence for efficacy.