A 79-year-old widow was referred by her primary care physician (PCP) for isolating herself from others and episodic outbursts. She has a history of severe physical abuse during childhood and throughout her married life. While generally avoiding discussion about her deceased husband, she says, “I don’t remember much, but maybe he wouldn’t have hit me so much if I wasn’t such a negative person!” She wakes up multiple times during the night although she denies any nightmares. She attributes her symptoms to changes that happen as “one normally ages. Taking into account the patient's long-term trauma and episodic nature of her outburses, as well as other variables including the fact that she has sequestered herself from others, the initial assessment suggests a diagnosis of PTSD. Scroll down for the quiz >>
The correct answer is C. Suggest initiating sertraline
Sertraline and paroxetine have FDA approval for the treatment of PTSD; the VA/DoD guidelines also recommend either fluoxetine or venlafaxine as first-line monotherapy options. Of these 4 agents, paroxetine and venlafaxine have noticeable anticholinergic adverse effects and fluoxetine has a long half-life and significant drug-drug interactions, which suggests the need for monitoring if any of the medications besides sertraline are used in older adults.
It is important to note that research has demonstrated that older adults with DSM-IV-defined PTSD at the time of initial assessment might have partial PTSD after a period of 3 to 6 months, so follow-up is indicated.1 PTSD might be the rare DSM disorder that requires the presence of an external event(s) for diagnosis, but once manifest, it is no different from other psychiatric conditions (eg, mood or substance-use disorders) in having a relapsing and recurring course.
For more on this topic, see PTSD in Late Life: Special Issues, on which this quiz is based.
1. Chopra MP, Zhang HM, Pless Kaiser A, et al. PTSD is a chronic, fluctuating disorder affecting mental quality of life in older adults. Am J Geriatr Psychiatry. 2014;22:86-97.