eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Posttraumatic Stress Disorder in Children

Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice

Updated: Mar 4, 2008

Introduction

Background

Posttraumatic stress disorder (PTSD) in children and adolescents occurs as a result of a child's exposure to one or more traumatic events that were life-threatening or perceived to be likely to cause serious injury to self or others. In addition, the child or adolescent must have responded with intense fear, helplessness, or horror. Traumatic events can take many forms, including physical or sexual assaults, natural disasters, traumatic death of a loved one, or emotional abuse or neglect. Severe emotional trauma has widespread effects on children's development, in that it clearly obliterates the belief that their parents will protect them. The premature destruction of these beliefs can have profound negative consequences on development.

Traumatized children and adolescents are understandably frequently preoccupied with danger and vulnerability, sometimes leading to misperceptions of danger, even in situations that are not threatening. Multiple researchers (eg, Kardiner, van der Kolk¹ ) note that, once posttraumatic stress symptoms emerge, PTSD leads to neurophysiologic correlates that impact brain function in developing children and adolescents.

In 1980, the term PTSD first came into existence in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III).² Only in 1987 did the DSM series make reference to traumatized children. The first major studies of the effects of large traumas on children were Bloch's 1956 study of the effect of a tornado in Mississippi, Lacey's 1972 study of the effects of an avalanche on a Welsh school, Newman's 1976 work on the Buffalo Creek disaster,³ and Terr's 1979 research on the Chowchilla bus kidnapping.⁴

Pathophysiology

Evidence indicates a genetic predisposition for PTSD, suggesting that it may be linked to the individual's temperament and to reactivity of the hypothalamic pituitary axis.

Frequency

United States

Lifetime prevalence of PTSD is 8%.⁵ The incidence and course of PTSD vary and depend on various factors, including the type of trauma, the proximity to the stressor, and the reaction of the child's parents. After being kidnapped, witnessing the death of a parent, or suffering domestic violence, the rate of PTSD may be 95-100%. Following a sniper attack at school, 40% of children experienced moderate-to-severe PTSD. In one study of children in foster care, 64% who had experienced sexual abuse had PTSD, and 42% who had experienced physical abuse fulfilled the PTSD criteria. Moreover, 18% of the children who were not abused also met PTSD criteria, presumably because they had witnessed violence.

International

The prevalence in a location overwhelmingly depends on the endemicity of violence in the region.

Mortality/Morbidity

Alone, PTSD is not a fatal disorder. Nevertheless, it frequently leads to conduct disorder, substance abuse, depression, and risk-taking that poses considerable danger.

PTSD has a considerable morbidity rate, particularly for children. In addition to the symptoms of numbing, hyperarousal, and recollections of the event that adults experience, children suffer from a decreased ability to participate in the normal academic and social activities of childhood. Therefore, a traumatic event can send a child down a new developmental path, one that is less favorable than the one the child was previously on.  

A host of emotional and behavioral problems frequently arise as a result of PTSD and are not part of the criteria for categorical diagnosis. These include disruptive behavior disorders, eating disorders, sexual acting out, other risk-taking activities, depression, the full range of anxiety disorders, dissociation, mood lability, violence, and difficulty concentrating.

Studies of adults who were sexually or physically abused as children demonstrate significantly higher rates of PTSD (72-100%) than studies of children who were abused (21-55%). This finding indicates that the full impact of abuse may not be experienced until a child reaches adulthood, engages in adult relationships and responsibilities, and develops more sophisticated cognitive capabilities.

Race

No major racial predominance is observed; however, PTSD is more common among individuals in low socioeconomic groups and among those living in areas in which violence is endemic.

Sex

PTSD is more common in women than in men.

Age

PTSD occurs in people of all ages, but younger and elderly persons are the most vulnerable.

Clinical

History

Diagnostic criteria

• Posttraumatic stress disorder (PTSD) arises subsequent to a serious traumatic event that causes or threatens serious harm, injury, or violation of bodily integrity. The individual experiences intense fear, helplessness, or horror in response. Children may experience disorganized or agitated behavior. The individual does not need to be the actual victim. The individual could have witnessed the traumatic event or have been told about it happening to a close associate. For example, a child who is told about the sexual abuse of another child can develop PTSD.
• The trauma results in the development of 3 types of symptoms. Category A refers to the initial response to the trauma, which involves the experience of horror, helplessness or fear, or disorganized behavior in children. Categories B, C, and D are as follows:
  • Category B - Intrusive recollections
  • Category C - Numbing and withdrawal
  • Category D - Persistent symptoms of increased arousal
• Diagnosis requires reexperiencing of the trauma in one or more of the following ways:
  • Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
  • Recurrent distressing dreams (In children, the dreams are frightening but may not have recognizable content.)
  • Acting or feeling as if the traumatic event is recurring
  • Intense psychological distress upon exposure to cues that symbolize or resemble an aspect of the traumatic event
  • Physiological reactivity upon exposure to cues that symbolize or resemble an aspect of the traumatic event
• Diagnosis requires persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:
  • Efforts to avoid thoughts, feelings, or conversations associated with the trauma
  • Efforts to avoid activities, places, or people that arouse recollections of the trauma
  • Inability to recall an important aspect of the trauma
  • Markedly diminished interest or participation in significant activities (including regression and loss of skills such as toilet training)
  • Feeling of detachment or estrangement from others
  • Restricted range of affect (eg, unable to have loving feelings)
  • Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or normal lifespan)
• Diagnosis requires persistent symptoms of increased arousal (not present before the trauma), as indicated by 3 or more of the following:
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
• Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than one month
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnosing posttraumatic stress disorder in children

• The diagnostic criteria for PTSD are designed for adults, not children. Children have limited verbal skills and different ways of reacting to stress. This means that children may not fulfill the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R) criteria, even though they clearly have a psychiatric disorder analogous to adult PTSD.² In particular, children often do not have 3 of the adult signs of numbing and withdrawal because they lack the verbal skills to express these feelings. Children may also experience an alternation between hyperarousal and numbing/withdrawal.
• Scheeringa et al (1995) recommend altering the criteria for PTSD when assessing very young children, taking into account their ability to report symptoms and the types of symptoms they are likely to have.⁶ The altered criteria do not require that the child be able to report fear, helplessness, or horror in response to the trauma.
  • Diagnosis using the altered criteria requires that the very young child undergo one of the following types of reexperiencing:
    • Posttraumatic play
    • Play reenactment
    • Recurrent recollections
    • Nightmares
    • Episodes with objective features of a flashback or dissociation
    • Distress at exposure to reminders of the event
  • The altered criteria also require only one of the following symptoms of numbing/avoidance (instead of the 3 needed for adults):
    • Constriction of play
    • Relative social withdrawal
    • Restricted range of affect
    • Loss of acquired developmental skills
  • Furthermore, only one of the following symptoms of hyperarousal is required:
    • Night terrors
    • Difficulty going to sleep that is not related to fear of having nightmares or fear of the dark
    • Night waking not related to nightmares or night terrors
    • Decreased concentration
    • Hypervigilance
    • Exaggerated startle response
  • Scheeringa et al endorse an additional class of symptoms to replace the eased category C and category D criteria.⁷ Symptoms of fear and aggression marked by one of the following is required:⁸ :
    • New aggression
    • New separation anxiety
    • Fear of using the restroom alone
    • Fear of the dark
    • New fears of things or situations not obviously related to the trauma
• Posttraumatic play involves joyless repetitive play with traumatic themes. Children also may reenact what occurred or draw pictures related to the event. Posttraumatic dreams in children generally are vaguely formed dreams that the child may not be able to describe.
• In adolescents, the primary symptoms are likely to include invasive images (which they may not talk about), restlessness and aggression, difficulty sleeping, and difficulty concentrating. Other common symptoms include loss of interest in previously enjoyed activities, withdrawal from family and peers, and changes in significant life attitudes. Adolescents with chronic PTSD arising from repeated or prolonged trauma may suffer primarily from dissociative symptoms, numbing, sadness, restricted affect, detachment, self-injury, substance abuse, and aggressive outburst. When interpersonal abuse is the precipitant, the development of dissociative phenomena, somatic complaints, learned helplessness, loss of affect control, hostility, aggression, eating disorders, sexual acting out, personality change, change in belief system, self-destructive and impulsive behavior, substance abuse, social withdrawal, and impaired relationships are a significant possibility.⁸

Physical

• Numerous physical findings have been noted; however, whether these findings are a result of PTSD, predisposing factors, or the result of comorbid problems (eg, substance abuse) is unclear. Findings include the following:
  • Hippocampal volume is smaller in individuals with PTSD.⁹
  • Areas of the brain that are involved in threat perception (eg, amygdala) have altered metabolism in adult trauma survivors with PTSD.
  • Activity of the anterior cingulate (an area of the brain that inhibits the amygdala and other brain regions involved in the fear response) is decreased in people with PTSD.
  • Basal cortisol levels are low.
  • Cortisol response to dexamethasone is increased.
  • Concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus are increased.
• Some studies have shown that children who have been abused have elevated cortisol levels compared with control subjects. Studies also indicate that adults with PTSD who were abused as children have higher cortisol levels than those who were abused and did not develop PTSD. Research evidence also indicates that girls who have been sexually abused have increased catecholamine activity. Trauma survivors have pituitary adrenocortical hyperresponsivity to stress. PTSD leads to increased pulse, blood pressure, muscle tension, and skin resistance.
• One problem with the research is that studies tend to show that changes in physiological measures, such as heart rate and skin conductance, appear to be the same in individuals with current and prior PTSD. This indicates that the changes may represent either a predisposition or a permanent change resulting from PTSD (eg, trait rather than state).

Causes

• PTSD may be caused by exposure to a severe traumatic stress that threatens death or serious injury or threat to personal integrity, as follows:
  • Rape
  • Sexual and physical abuse
  • Car accidents
  • Fires
  • Experiencing war
  • Receiving a serious medical diagnosis
  • Being subjected to invasive painful treatment of medical problems
• Numerous factors increase the likelihood that a child will develop PTSD in response to a given stress, including the following:
  • Lack of social and parental support
  • Prior exposure to traumatic incidents
  • A preexisting psychiatric disorder
  • Repeated trauma
  • Trauma caused by a person (especially if by a trusted caregiver) rather than resulting from an accident
• Parental reaction is a critical factor affecting the child's reaction. Parents' anxiety and difficulty coping with life as the result of the trauma may overwhelm a child, whereas parental ability to cope and to provide a safe haven for a child may markedly affect the child's ability to deal with the stressor or the propensity to develop protracted PTSD.
• PTSD is particularly likely to develop if a child experiences dissociation at the time of the trauma.

Differential Diagnoses

Other Problems to Be Considered

• Acute stress reaction
• Adjustment disorder
• Malingering
• Psychotic disorders
• Substance-induced disorders
• Postconcussive syndrome

Many problems are comorbid with posttraumatic stress disorder (PTSD) and need to be considered when PTSD is found. These comorbid disorders include depression, childhood disruptive disorders, the full range of anxiety disorders, substance abuse, and sexual acting out. Furthermore, in the presence of these other disorders, the possibility of PTSD should be considered.

Workup

Other Tests

Numerous psychological tests may be helpful in assessing posttraumatic stress disorder (PTSD); some are directly designed to evaluate for PTSD symptoms, and others are designed to examine symptoms of related disorders. The following tests may be helpful:

• Children's Posttraumatic Stress Disorder Inventory (CPTSDI)
• Beck Depression Inventory
• Mississippi Scale for Combat-Related PTSD
• Trauma Symptom Checklist for Children

Treatment

Medical Care

• The first step in the psychotherapy for posttraumatic stress disorder (PTSD) in children is helping the child gain a sense of mastery over the trauma and helping the child to feel safe again. In older children, gaining a sense of mastery includes the ability to recall, relate, narrate, and reconsider the trauma without feeling overwhelmed and without dissociating. Relaxation training and medication may be helpful in enabling the child to do this. In younger children, play provides an opportunity to work through the trauma. However, play often breaks down in PTSD, and repetitive reenactment that is not enjoyable may be observed. If this occurs, intervention may be necessary; comment to the child about the need for time before the child feels safe again and about the fear of scary thoughts returning.
• Helping the child and the parents destigmatize the child's symptoms is crucial. Helping help them understand that the repeated recollections, numbing, and hyperarousal are natural responses to the experience of a traumatic event and not signs of serious mental illness or weakness is important.
• Attention must be given to the multiple emotional and behavioral problems that can arise (eg, depression, anxiety, impulsive behavior, substance abuse, aggression, eating disorders, sexual acting out, labile mood, rage, panic attacks, dissociation). Treatment of these problems may involve medication, psychotherapy, or both.
• A major problem associated with PTSD in children is that the anxiety and other problems that develop interfere with a child's ability to participate in the normal developmental experiences of childhood. The child often finds schoolwork and socializing difficult. As a result, serious secondary problems arise. Supportive therapy is needed to help keep a child on track or to get a child back on track.
• The ability of the parents to remain as calm and as connected to the child as possible is crucial to the child's ability to resolve PTSD. In particular, the parents should avoid contaminating the child with their own painful feelings and verbalizing the fear that the child is permanently damaged.

Medication

Selective serotonin reuptake inhibitors (SSRIs) are the medications of choice in managing anxiety, depression, avoidance behavior, and intrusive recollections. Beta-blockers and alpha-adrenergic agonists (eg, guanfacine, clonidine) are helpful in reducing arousal, decreasing forced reexperiencing of the trauma, and avoiding the neurophysiologic kindling that can contribute to chronic illness. These medications are most helpful if used very soon after the onset of symptoms.

Mood stabilizers can be helpful in dealing with increased arousal, impulsivity, and already established kindling once the illness has become chronic. The mood stabilizers are not interchangeable. Carbamazepine may ameliorate persistent reexperiencing of the event, whereas valproic acid may ameliorate symptoms of avoidance.

Atypical antipsychotics are infrequently used compared with the medications listed above. They should only be used for patients unresponsive to other medications or when marked agitation or psychosis is present.

Selective serotonin reuptake inhibitors (SSRIs)

These agents are the first-line medications for managing anxiety, depression, avoidance behavior, and intrusive recollections. Antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT) and may also have a weak effect on norepinephrine and dopamine neuronal reuptake.

SSRIs are greatly preferred to the other classes of antidepressants because the adverse effect profile of SSRIs is less prominent and improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.⁷ This is the largest study to date to address this issue.

Currently, evidence does not associate obsessive compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Sertraline (Zoloft)

FDA approved for OCD in children >6 y. FDA approved for PTSD in adults. PO liquid concentrate available.

Dosing

Adult

50 mg/d PO; may increase after 1 wk; usual effective dose is 50-200 mg/d; not to exceed 200 mg/d

Pediatric

<6 years: Not established
6-12 years: 25 mg/d PO, not to exceed 200 mg/d
>12 years: 12.5 mg PO qd, may increase gradually qwk; not to exceed adult dose

Interactions

Inhibits CYP2C9, CYP2C19, CYP3A4, and, to a lesser extent, CYP2D6 and CYP1A2
Increases toxicity of MAOIs, diazepam, tolbutamide, tryptophan, and warfarin; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk before beginning SSRIs

Contraindications

Documented hypersensitivity; do not use within 14 d of MAOIs

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in preexisting seizure disorders, recent MI, unstable heart disease, and hepatic and renal impairment
Common adverse effects in children include insomnia, agitation, somnolence, upset stomach, and headache; sexual dysfunction may occur; causes more GI upset and diarrhea than other SSRIs; may cause rash, which requires discontinuing medication; may cause restlessness, anorexia, weight change, and nightmares; libido dampening and sexual dysfunction in adolescents can occur

Fluoxetine (Prozac)

FDA approved for depression and OCD in children and adolescents. Half-life is 7-9 d. Most activating of SSRIs. Some believe most effective for depression. Many people require adjuvant medication to help sleep (eg, trazodone 100 mg). Liquid formulation available.

Dosing

Adult

10-20 mg/d PO initially, with a dose of 20 mg after 1 wk; may increase up to 80 mg/d prn; typical dose is 20 mg/d

Pediatric

<8 years: Not established
>8 years: 10 mg/d PO initially, may increase to 20 mg/d PO after 1 wk; although higher doses have been used for children with OCD, they have not been shown beneficial in PTSD

Interactions

Potent inhibitor of CYP3A4; also inhibits CYP2C9, CYP2C19, and CYP2D6 to a lesser degree
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs, thioridazine, and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk before beginning SSRIs

Contraindications

Documented hypersensitivity; do not use within 14 d of stopping MAOIs or initiate MAOIs within 6 wk of stopping fluoxetine; do not initiate thioridazine within 6 wk of fluoxetine

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment and history of seizures; common adverse effects include insomnia, headaches, upset stomach, nausea, vomiting, tremor, and sexual dysfunction; social disinhibition, agitation, and mania may occur

Paroxetine (Paxil)

Not approved by FDA for use in children. PO susp available.

Dosing

Adult

10 mg/d PO initially; increase to 20 mg/d after 1 wk; not to exceed 80 mg/d

Pediatric

Limited data suggest 5-10 mg/d PO initially; may increase gradually prn; not to exceed 20 mg/d

Interactions

Inhibits CYP450 2D6, thus may increase toxicity of 2D6 substrates (eg, phenothiazines, propafenone, flecainide and encainide, other SSRIs, tricyclic antidepressants); phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to using other SSRIs

Contraindications

Documented hypersensitivity; concurrent administration with MAOIs or administering within 14 d of discontinuing MAOIs; coadministration with thioridazine or pimozide

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Newborn infants exposed to SSRIs during the third trimester of pregnancy have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; preliminary analysis of a retrospective study shows increased congential malformations as a whole, particularly for cardiovascular malformations, with paroxetine compared to other antidepressants with exposure during the first trimester
Caution in history of seizures, mania, renal disease, and cardiac disease; commonly causes weight gain and sexual dysfunction; bupropion can restore libido, and sildenafil can restore potency
Headache and abdominal discomfort are generally mild and transient (approximately 1 wk), although they can require cessation of therapy

Citalopram (Celexa)

Newest SSRI. Appears to have the most benign side effect profile, with fewer sexual adverse effects than other SSRIs. Not FDA approved for children. PO solution available.

Dosing

Adult

10-20 mg/d PO initially; 30 mg usually is needed for full effect

Pediatric

Not established; limited data suggest 5-10 mg/d PO for younger children

Interactions

Coadministration with cimetidine increases levels; do not use within 14 d of MAOIs; caution with coadministration of other serotonergic drugs

Contraindications

Documented hypersensitivity; MAOIs within 14 d

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in history of seizures, mania, renal disease, and cardiac disease is prudent given what is known of SSRIs; adverse effect profile shows it is the least likely SSRI to cause sexual adverse effects

Beta-adrenergic–blocking agents

These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

Propranolol (Inderal)

May be useful for treatment of hyperarousal.

Dosing

Adult

10-120 mg PO tid

Pediatric

Up to 2.5 mg/kg/d PO divided tid

Interactions

Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, or rifampin may decrease propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol
Increases levels of neuroleptics (eg, chlorpromazine, thioridazine); may increase effects of hydralazine, haloperidol, and benzodiazepines

Contraindications

Documented hypersensitivity; uncompensated CHF; bradycardia; cardiogenic shock; AV conduction abnormalities; asthma

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in diabetes mellitus (may cause hypoglycemia or hyperglycemia and mask signs of hypoglycemia) and hyperthyroidism; beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; adverse effects include depression, decreased energy, and, possibly, decreased mental acuity

Alpha-adrenergic agonists

The centrally acting antihypertensives clonidine and guanfacine have been used to treat children with attention deficit hyperactivity disorder. An inhibition of norepinephrine release in the brain may be the mechanism of action.

Clonidine (Catapres)

Not approved by FDA for any psychiatric uses in children. Available in tab or transdermal skin patches. Frequently given to children. Affects alpha1-, alpha2-, and alpha3-adrenergic receptors.

Dosing

Adult

0.05 mg/d PO initially; may increase by 0.05 mg q3-4d until dose reaches 0.1-0.3 mg/d PO divided tid

Pediatric

Limited data suggest 0.15-0.3 mg/d PO divided tid

Interactions

Concurrent CNS depressants may increase effects; TCAs may decrease levels; sudden death reported in coadministration with methylphenidate hs

Contraindications

Documented hypersensitivity; cardiovascular disease; depressive symptoms

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cerebrovascular disease, coronary insufficiency, sinus node dysfunction, and renal impairment; check ECG before use and after dosage increases; common adverse effects include drowsiness, depression, dry mouth, dysphoria, and photophobia; less common adverse effects are headache, abdominal pain, nosebleeds, irritability, decreased glucose tolerance, and exacerbation of existing arrhythmias; discontinue slowly to avoid cardiac rhythm problems

Guanfacine (Tenex)

Action similar to clonidine, but has a longer half-life and less sedation. More selective alpha-agonist. Not recommended for children <12 y. Effects alpha2-adrenergic receptors only.

Dosing

Adult

0.5 mg/d PO initially; may increase by 0.5 mg q3d until desired effect reached; typical dose is 1-3 mg/d PO divided bid/tid

Pediatric

Not established

Interactions

Increases effect of other hypotensive agents; TCAs may decrease hypotensive effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic impairment, severe coronary insufficiency, and recent MI; check ECG before use and after dosage increases; drowsiness may occur but less problematic than with clonidine; may cause depression, dysphoria, photophobia, and dry mouth; less common adverse effects are headache, abdominal pain, nosebleeds, irritability, decreased glucose tolerance, and exacerbation of existing arrhythmias; discontinue slowly to avoid cardiac rhythm problems

Mood stabilizers

These agents are helpful in dealing with increased arousal, impulsivity, and already established kindling when posttraumatic stress disorder (PTSD) becomes chronic.

Carbamazepine (Tegretol)

Initially used as an antiseizure medication and mood stabilizer. Also used for explosive outbursts.

Dosing

Adult

200 mg/d PO divided doses initially; may increase by increments of 100 mg/d twice per wk; if adverse effects occur, decrease dose by 200 mg
Dose range is 300-1600 mg/d PO; monitor plasma levels (ie, 4-12 mcg/mL) to maintain dose within therapeutic range

Pediatric

6-12 years: 100 mg/d PO divided bid initially; may increase by 100 mg/d qwk
Maintenance: 20-30 mg/kg/d PO divided bid/qid; not to exceed 1000 mg/d
>12 years: Administer as in adults to achieve plasma level of 8-12 mcg/mL

Interactions

Halothane coadministration may cause hepatocellular damage; grapefruit juice, influenza vaccine, isoniazid, cimetidine, erythromycin, and phenelzine increase plasma levels; phenytoin, alprazolam, clonazepam, primidone, and phenobarbital decrease CBZ level and levels of interacting agents; fluoxetine increases level
Decreases levels of imipramine, phenothiazines, haloperidol, theophylline, thyroid hormones, ritonavir, saquinavir, contraceptives, risperidone, thiothixene, cyclosporine, corticosteroids, doxycycline, trazodone, doxepin, and amitriptyline
Increases plasma levels of diltiazem and verapamil; can reduce its own level by autoinduction; coadministration with lithium or loxapine increases toxicity of CBZ and the interacting agents; coadministration with clozapine further increases bone marrow toxicity and resulting agranulocytosis

Contraindications

Documented hypersensitivity; MAOIs within 14 d; history of liver disease, cardiovascular disease, or blood dyscrasias

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Slight but significant risk of causing agranulocytosis or aplastic anemia during drug initiation; avoid using hazardous equipment or driving; other depressants and alcohol may lead to increased dizziness and sleepiness; keep in a dry place; drinking grapefruit juice while taking CBZ elevates blood levels; report any indications of blood dyscrasias (eg, easy bruising, sore throats, fever, rash)
May cause sedation, blood dyscrasias including aplastic anemia, exfoliative dermatitis, nausea, vomiting, dizziness, ataxia, diplopia, nystagmus, tics, muscle cramps, decreased thyroid function, hepatitis, renal impairment, urinary incontinence, hair loss, motor and vocal tics, rash, interstitial pneumonitis, cardiac conduction delay, SIADH, and lenticular opacities
Adverse behavioral reactions may occur during the first mo, including mania, extreme irritability, agitation, insomnia, obsessive thinking, hallucinations, delirium, psychosis, paranoia, hyperactivity and aggression, and memory problems

Valproic acid (Depakene, Depakote)

Useful in certain types of epilepsy, bipolar disorder, migraine headaches, impulsivity, dissociation, and PTSD. Extended-release (ie, qd administration) form is available. Requires higher dosing because 80% absorbed.

Dosing

Adult

250 mg PO tid initially; may increase dose gradually until level of 50-125 mcg/mL achieved
Maintenance: 750-3000 mg/d PO in divided doses
Panic episode: 20 mg/kg PO q12h for 2 doses initially; then 10 mg/kg bid
Maintenance: 500-3500 mg/d PO to achieve plasma level of 50-125 mcg/mL

Pediatric

10-15 mg/kg/d PO divided bid/tid initially; increase by 5-10 mg/kg/d PO qwk until therapeutic plasma level achieved
Maintenance: 30-60 mg/kg/d PO divided bid/tid

Interactions

Inhibits CYP2C19, 2C9, and 2D6Coadministration with cimetidine, salicylates, felbamate, erythromycin, and SSRIs may increase toxicity; rifampin may reduce valproate levels significantly; in pediatric patients, protein binding and metabolism of valproate decrease when taken concomitantly with salicylates
Coadministration with carbamazepine may cause variable changes of carbamazepine concentrations, with possible loss of seizure control; may increase diazepam and ethosuximide toxicity (monitor closely); may increase phenobarbital and phenytoin levels, while either one may decrease valproate levels; may displace warfarin from protein binding sites (monitor coagulation tests); may increase zidovudine levels

Contraindications

Documented hypersensitivity; hepatic disease or dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Monitor for hepatic toxicity (obtain liver function tests before initiating therapy and 3-6 mo thereafter); increase LFTs (3 times that of baseline is common and not a problem); most dangerous if used in very young children; serum ammonia levels may increase independently of other liver functions and may cause altered mental status; check platelet count and bleeding times before therapy and during treatment; may cause pancreatitis (monitor accordingly)
Advise patient to immediately report any abdominal pain; may cause erythema multiforme
Adverse effects include sedation, GI upset (treat with H2 blocker), weight gain, liver toxicity, blood dyscrasias, alopecia, tremor, ataxia, platelet problems, impaired cognitive function, and hyperammonemia

Follow-up

Further Outpatient Care

• Besides treatment of the presenting categorical diagnostic symptoms (eg, reexperiencing, numbing, hyperarousal), children with posttraumatic stress disorder (PTSD) require treatment of all associated problems (eg, depression, anxiety, destructive acting out) and ongoing support of participation in the normal developmental experiences of childhood.
• Long-term support and social skills training may be needed to help a child remedially gain the skills that were not developed during a period of months or years of withdrawal, especially if PTSD is not treated shortly after the incident.
• Monitoring and educating the child and parents is important because symptoms may reoccur, even after resolution.

Prognosis

• The prognosis of PTSD widely varies. Although one half of individuals with PTSD recover within 3 months, some proceed to develop a long-term problem with a posttraumatic personality, including impulsive behavior, substance abuse, aggression, eating disorders, sexual acting out, labile mood, rage, panic attacks, and dissociation.
• Terr (1991) describes type 1 and type 2 traumas.¹⁰ Type 1 trauma involves individual incidents, whereas type II trauma involves long-term exposure. Long-term exposure has a far more serious prognosis.
• Symptoms may reoccur months or years later in response to subsequent stressful or life-changing events.

Patient Education

• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education articles Post-traumatic Stress Disorder (PTSD) and Stress.

Miscellaneous

Special Concerns

• Posttraumatic stress disorder (PTSD) has become a dominating issue in forensic psychiatry. Large numbers of lawsuits involve accusations of PTSD. The forensic evaluation of PTSD is a complex matter that requires expertise well beyond that of the clinician who treats PTSD.
• For information about the forensic evaluation, see "Forensic Evaluation of PTSD."⁸

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Keywords

PTSD, post traumatic stress disorder, posttraumatic stress syndrome, trauma, traumatic event, emotional trauma, disorders of extreme stress, conduct disorder, substance abuse, depression, eating disorders, behavioral disorders, sexual acting out, depression, anxiety disorders, posttraumatic play, nightmares, night terrors, dissociative phenomena, personality change, social withdrawal, impaired relationships, rape, sexual abuse, childhood disruptive disorders

Contributor Information and Disclosures

Author

Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

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