A 34-year-old woman comes to the office with her husband due to behavioral changes over the past 6 weeks. The husband says, "She's not an angry person, but ever since she was in a car accident, little things seem to set her off. She yells and honks at people for not using their turn signals and gets upset when we have to wait for a table at restaurants." The patient describes difficulty sleeping due to thoughts "swirling" in her head and feeling panicked every time she wakes up. She does not use illicit substances or take any medications. The patient sustained a wrist fracture in a motor vehicle collision 2 months ago; medical history is otherwise unremarkable. Family history is significant for a brother diagnosed with bipolar disorder. Vital signs and physical examination, including neurological examination, are within normal limits. On mental status examination, the patient appears restless and tired. Which of the following is the best next step in management of this patient?
Posttraumatic stress disorder | |
Clinical |
|
Treatment |
|
SNRIs = serotonin-norepinephrine reuptake inhibitors; SSRIs = selective serotonin | |
This patient's recent onset of behavioral changes following a traumatic event (motor vehicle collision) is suggestive of posttraumatic stress disorder (PTSD). Extreme irritability, sleep disturbance, anxiety/panic, and intense psychological distress in response to reminders of the event are characteristic. Angry outbursts with little or no provocation may also occur, as seen in this patient. Other common symptoms of PTSD include nightmares, flashbacks, emotional detachment, and avoidance.
Treatment of PTSD consists of psychotherapy and/or pharmacotherapy with a serotonergic antidepressant. Trauma-focused cognitive-behavioral psychotherapy (CBT) is commonly first-line treatment, although other forms of psychotherapy (eg, eye movement desensitization and reprocessing, interpersonal therapy, mindfulness-based stress reduction) may also be used. CBT helps the patient emotionally process the trauma and recognize and correct maladaptive thought patterns while also targeting avoidance behaviors with exposure techniques (eg, in vivo or imaginal exposure).
(Choices A and B) Serotonergic antidepressants (eg, sertraline, venlafaxine) are first-line pharmacotherapy for PTSD. Buspirone is an antianxiety medication that is used in generalized anxiety disorder, not PTSD. Antipsychotics (eg, quetiapine) may be used as augmentation to an antidepressant in treatment-resistant cases.
(Choice C) Although this patient has new-onset behavioral changes, there is no indication to obtain a brain MRI because she does not appear to be delirious or psychotic and has no findings suggestive of underlying neuropathology (eg, normal neurological examination).
(Choice D) Reassurance and short-term alprazolam would not adequately treat PTSD. Benzodiazepines (eg, lorazepam) have not shown efficacy in PTSD and carry the risk of abuse and dependence. Without targeted treatment (ie, psychotherapy and/or pharmacotherapy), PTSD can result in prolonged disability due to social and occupational impairment.
(Choice F) Group therapy can provide support to the patient but would not adequately target her PTSD symptoms. Trauma-focused cognitive-behavioral therapy is the most effective form of psychotherapy and should be offered as first-line treatment.
(Choice G) Lithium is a mood stabilizer used to treat bipolar disorder. Although hypomanic/manic episodes may present with irritability and anger rather than euphoria, this patient lacks other manic symptoms (eg, increased energy, decreased need for sleep, grandiosity, pressured speech). Her behavioral changes following a traumatic event are more likely due to PTSD.
Educational objective:
Trauma-focused cognitive-behavioral therapy is the first-line treatment of posttraumatic stress disorder. It combines cognitive therapy and exposure techniques to help the patient process the trauma and decrease avoidance behaviors.