63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization

ABFM Family Medicine Certification Study Guide Exam

Track your progress as you read

Finished sections get a check mark.

1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization

Key Takeaways Explain This Topic AI

Post-Traumatic Stress Disorder (PTSD) requires exposure to actual or threatened death, serious injury, or sexual violence (Criterion A) with symptoms persisting >1 month across four diagnostic clusters: intrusion, avoidance, negative alterations in cognitions/mood, and altered arousal/reactivity; symptoms persisting between 3 days and 1 month are classified as Acute Stress Disorder (ASD).

First-line psychotherapy for PTSD consists of trauma-focused modalities (TF-CBT, Prolonged Exposure, EMDR); first-line pharmacotherapy comprises SSRIs (sertraline, paroxetine; FDA-approved) and SNRIs (venlafaxine); prazosin (alpha-1 adrenergic antagonist, 1-15 mg at bedtime) is the evidence-based agent for trauma nightmares and sleep fragmentation.

Benzodiazepines are strictly contraindicated in PTSD because they impede fear extinction, worsen trauma processing, increase long-term PTSD severity, and carry high rates of tolerance and substance misuse without improving core symptoms.

Obsessive-Compulsive Disorder (OCD) is characterized by obsessions (intrusive thoughts/urges) and/or compulsions (repetitive behaviors/mental acts >1 hour/day); gold-standard treatment requires Exposure and Response Prevention (ERP) and high-dose SSRIs (fluoxetine up to 80 mg, sertraline up to 200 mg, paroxetine up to 60 mg, fluvoxamine up to 300 mg) with an extended trial duration of 10-12 weeks before evaluating efficacy.

Somatic Symptom Disorder is managed in primary care with regularly scheduled, predictable, brief clinic visits (every 4-6 weeks) regardless of symptom presence, validating patient suffering while avoiding redundant diagnostic testing, polypharmacy, and invasive procedures; Conversion Disorder displays clinical incompatibility with neurological disease, confirmed by positive exam signs such as the Hoover sign and tremor entrainment test.

Last updated: September 2026

Post-Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) is a debilitating, chronic psychiatric condition triggered by exposure to severe traumatic stressors. In primary care settings, PTSD is frequently underdiagnosed because patients often present with somatic complaints, unexplained pain, sleep disturbances, or comorbid substance use rather than explicitly volunteering traumatic memories.

Neurobiology & Pathophysiology

PTSD is conceptualized as a disorder of fear conditioning, extinction learning, and emotional regulation mediated by disrupted neural circuitry:

Amygdala Hyperactivity : The basolateral amygdala exhibits heightened baseline firing and exaggerated reactivity to trauma-related and neutral threat cues, driving hyperarousal, hypervigilance, and acute autonomic panic.

Prefrontal Cortex (vmPFC & ACC) Hypoactivity : The ventromedial prefrontal cortex (vmPFC) and anterior cingulate cortex (ACC) normally exert top-down inhibitory control over amygdalar hyperresponsiveness. In PTSD, hypoactivity in these structures leads to failed fear extinction learning, permitting conditioned fear memories to persist unchecked.

Hippocampal Volume Reduction : Reduced hippocampal volume and impaired neurogenesis disrupt contextual processing. Patients cannot contextualize memories as belonging to the past; instead, traumatic memories are experienced in the present moment as vivid, intrusive flashbacks.

Neuroendocrine & Autonomic Dysregulation : Unlike major depression (which features sustained hypercortisolemia), PTSD is often characterized by enhanced glucocorticoid receptor sensitivity , resulting in low-to-normal baseline plasma cortisol with blunted cortisol awakening responses alongside chronically elevated central corticotropin-releasing factor (CRF) . Concurrently, hyperactivation of the locus coeruleus noradrenergic system sustains excessive peripheral and central sympathetic tone, manifesting as resting tachycardia, diaphoresis, and sleep-disrupting nightmares. NEUROBIOLOGICAL CIRCUITRY OF PTSD

• [ Traumatic Trigger / Conditioned Cue ]
• │
• ▼
• ┌────────────────────────────────────────┐
• │ HYPERACTIVE AMYGDALA │ ──> Sympathetic Autonomic Surge
• │ • Unfiltered threat appraisal │ (Tachycardia, Diaphoresis, Panic)
• │ • Exaggerated startle response │ ──> Emotional Reactivity & Fear
• └───────────────────▲────────────────────┘
• │ FAILED INHIBITION
• ┌───────────────────┴────────────────────┐
• │ HYPOACTIVE PREFRONTAL CORTEX (vmPFC) │ ──> Failed fear extinction learning
• │ & ANTERIOR CINGULATE CORTEX (ACC) │ (Inability to suppress panic)
• └────────────────────────────────────────┘
• │ IMPAIRED CONTEXT
• ┌───────────────────┴────────────────────┐
• │ HIPPOCAMPAL VOLUME LOSS & ATROPHY │ ──> Loss of chronological context
• │ • Defective episodic memory retrieval │ (Flashbacks experienced as NOW)
• └────────────────────────────────────────┘
• DSM-5 Diagnostic Criteria for PTSD

A formal diagnosis of PTSD under DSM-5 requires exposure to a traumatic event followed by persistent symptoms spanning four discrete symptom clusters lasting >1 month , causing clinically significant distress or functional impairment: DSM-5 DIAGNOSTIC CRITERIA FOR PTSD

• Diagnostic Category Required Criteria & Clinical Manifestations
• ══════════════════════════════════════════════════════════════════════════════════════════════════════════
• Criterion A Exposure to actual or threatened death, serious injury, or sexual violence
• (Trauma Exposure) through: 1) Direct experience; 2) Witnessing in person; 3) Learning event
• occurred to close family/friend (violent/accidental); or 4) Repeated/extreme

aversive exposure to trauma details (e.g., first responders, forensic workers).

*Note: Media exposure does not qualify unless work-related.

──────────────────────────────────────────────────────────────────────────────────────────────────────

Criterion B ≥1 Intrusion Symptom:

(Intrusion) • Recurrent, involuntary, intrusive distressing memories of the trauma.

• Distressing recurrent trauma-related dreams/nightmares.

• Dissociative reactions (e.g., flashbacks) where trauma feels recurring.

• Intense psychological distress upon exposure to trauma cues.

• Marked physiological reactivity to internal or external trauma cues.

──────────────────────────────────────────────────────────────────────────────────────────────────────

Criterion C ≥1 Avoidance Symptom:

(Avoidance) • Avoidance of internal trauma thoughts, feelings, or memories.

• Avoidance of external reminders (people, places, conversations, activities).

──────────────────────────────────────────────────────────────────────────────────────────────────────

Criterion D ≥2 Negative Alterations in Cognitions and Mood:

(Negative Cognitions • Dissociative amnesia (inability to recall key trauma features; not TBI/drugs).

& Mood) • Persistent, exaggerated negative beliefs about oneself/world ('I am ruined').

• Distorted cognitions leading to persistent self-blame or blaming others.

• Persistent negative emotional state (fear, horror, guilt, anger, shame).

• Markedly diminished interest/participation in significant activities.

• Feelings of detachment or estrangement from others.

• Persistent inability to experience positive emotions (love, joy, satisfaction).

──────────────────────────────────────────────────────────────────────────────────────────────────────

Criterion E ≥2 Alterations in Arousal and Reactivity:

(Arousal & • Irritable behavior and angry outbursts (with little/no provocation).

Reactivity) • Reckless or self-destructive behavior.

• Hypervigilance.

• Exaggerated startle response.

• Concentration difficulties.

• Sleep disturbance (difficulty initiating/maintaining sleep, restless sleep).

──────────────────────────────────────────────────────────────────────────────────────────────────────

Duration & Impact • Criterion F: Duration of symptoms >1 month.

• Criterion G: Clinically significant distress or impairment (social, work).

• Criterion H: Not attributable to substance use or a medical condition.

• ══════════════════════════════════════════════════════════════════════════════════════════════════════════
• Acute Stress Disorder (ASD) vs. PTSD

Acute Stress Disorder : Diagnosed when a patient meets symptom criteria spanning intrusion, negative mood, dissociation, avoidance, and arousal persisting between 3 days and 1 month following trauma exposure.

Diagnostic Transition : If symptoms resolve within 30 days, the diagnosis remains ASD. If symptoms persist beyond 1 month , the diagnosis is formally reclassified as PTSD. Patients with severe ASD carry an 80% risk of progressing to chronic PTSD if left untreated.

Screening in Primary Care: The PC-PTSD-5

The Primary Care PTSD Screen for DSM-5 ( PC-PTSD-5 ) is a validated 5-item screening tool designed for outpatient clinical practice. It begins with an initial trauma exposure inquiry; if affirmed, the patient answers 5 yes/no questions reflecting re-experiencing, avoidance, hyperarousal, emotional numbness, and guilt. A score of ≥3 or ≥4 points constitutes a positive screen and mandates a comprehensive clinical diagnostic interview.

• Evidence-Based Treatment of PTSD
• 1. First-Line Psychotherapy (Gold Standard)

Psychotherapy is the primary, most effective treatment for PTSD, displaying superior long-term remission rates compared to pharmacotherapy alone:

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) : Combines psychoeducation, cognitive restructuring of distorted trauma-related beliefs (e.g., survivor guilt, overgeneralized mistrust), and graded exposure.

Prolonged Exposure (PE) : Utilizes systematic, repeated imaginal exposure (revisiting the trauma memory in detail) and in vivo exposure (gradually approaching safe, real-world situations avoided due to trauma triggers) to achieve fear habituation and extinction.

Eye Movement Desensitization and Reprocessing (EMDR) : Combines patient recall of distressing trauma memories with bilateral sensory stimulation (saccadic eye movements, alternating auditory tones, or tactile taps) to facilitate adaptive neurocognitive memory reprocessing.

2. First-Line Pharmacotherapy

When psychotherapy is inaccessible, declined, or only partially effective, pharmacotherapy is indicated:

Selective Serotonin Reuptake Inhibitors (SSRIs) : Sertraline (start 25-50 mg daily, titrate to 100-200 mg daily) and Paroxetine (start 20 mg daily, titrate to 40-50 mg daily) are the two medications carrying FDA approval for PTSD. Fluoxetine (20-60 mg daily) also exhibits robust evidence.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) : Venlafaxine ER (start 37.5-75 mg daily, titrate to 150-225 mg daily) possesses strong randomized trial evidence and is widely recognized as a first-line alternative.

Dosing Strategy : Start at low doses to minimize initial noradrenergic agitation or jitteriness, and titrate over 8-12 weeks. Pharmacotherapy should continue for at least 6-12 months following symptom remission before considering a slow taper.

3. Management of Trauma Nightmares & Sleep Disruption: Prazosin

Trauma nightmares and nocturnal awakenings are driven by excessive noradrenergic outflow from the locus coeruleus during rapid eye movement (REM) sleep:

Agent & Mechanism : Prazosin is a lipid-soluble, centrally active alpha-1 adrenergic receptor antagonist . By crossing the blood-brain barrier and competitively blocking post-synaptic alpha-1 receptors, prazosin dampens central sympathetic overdrive, normalizes REM sleep architecture, and reduces or eliminates trauma nightmares.

Titration Protocol : Initiate at 1 mg orally at bedtime to prevent first-dose syncope. Titrate upward by 1-2 mg every 3-7 days based on nightmare suppression and tolerability. Typical effective doses range from 2-6 mg at bedtime in women and 6-15 mg at bedtime in men (divided doses can be used in refractory combat veterans).

Adverse Effects & Monitoring : Orthostatic hypotension, dizziness, reflex tachycardia, and dry mouth. Baseline and standing blood pressure must be monitored during dose titration.

4. Strict Contraindication: Benzodiazepines in PTSD

Caution

Benzodiazepines (e.g., alprazolam, clonazepam, lorazepam, diazepam) are STRICTLY NOT RECOMMENDED for PTSD.

Impaired Fear Extinction : Benzodiazepines potentiate GABA-A signaling in the amygdala and prefrontal cortex, actively inhibiting the neuroplasticity required for fear extinction and emotional processing during psychotherapy.

Worse Clinical Outcomes : Meta-analyses demonstrate that patients prescribed benzodiazepines exhibit higher long-term PTSD severity, higher rates of depression, and greater treatment dropout.

Substance Misuse & Disinhibition : Because PTSD frequently co-occurs with alcohol and substance use disorders, benzodiazepine therapy carries high addiction potential, tolerance, physical dependence, and risk of paradoxical disinhibition or accidental fatal overdose.

Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder (OCD) is a chronic, severely distressing psychiatric condition affecting 2-3% of the population, characterized by intrusive thoughts and repetitive behavioral or mental rituals.

Neurobiology & Pathophysiology

OCD arises from dysregulation within the Cortico-Striato-Thalamo-Cortical (CSTC) loops , particularly involving hyperactive parallel circuits connecting the orbitofrontal cortex (OFC) , anterior cingulate cortex (ACC) , and caudate nucleus of the striatum :

In healthy individuals, the caudate nucleus acts as an inhibitory filter ('gatekeeper'), screening out irrelevant intrusive thoughts generated by the orbitofrontal cortex.

In OCD, striatal gating fails, leading to unchecked orbitofrontal hyperactivation. The patient experiences an unrelenting subjective feeling that 'something is wrong' or catastrophic danger is imminent (obsession), compelling repetitive motor or mental actions (compulsions) to temporarily neutralize anxiety. CSTC LOOP HYPERACTIVITY IN OCD

• ┌────────────────────────────────────────┐
• │ Orbitofrontal Cortex (OFC) & │ <──── Sustained Error Signal
• │ Anterior Cingulate Cortex (ACC) │ ('Something is terribly wrong!')
• └───────────────────┬────────────────────┘
• │ Direct Excitatory Pathway
• ▼
• ┌────────────────────────────────────────┐
• │ Ventral Striatum / Caudate │ <──── Defective Gating / Filtering
• │ (Failure of normal inhibition) │
• └───────────────────┬────────────────────┘
• │
• ▼
• ┌────────────────────────────────────────┐
• │ Thalamus Activation │ ───> Drives Compulsive Rituals
• │ (Disinhibited cortical drive) │ (Temporary anxiety reduction)
• └────────────────────────────────────────┘
• DSM-5 Diagnostic Criteria for OCD

Diagnosis requires the presence of obsessions, compulsions, or both , meeting the following operational thresholds:

Obsessions : Defined by both:

Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, causing marked anxiety or distress.

The individual attempts to ignore, suppress, or neutralize them with another thought or action (i.e., by performing a compulsion).

Common themes : Contamination (dirt, germs), pathological doubt and harm (leaving stoves on, fear of hitting pedestrians), symmetry and ordering, taboo sexual, religious, or aggressive thoughts.

Compulsions : Defined by both:

Repetitive behaviors (e.g., handwashing, ordering, checking locks) or mental acts (e.g., praying, counting, silently repeating words) that the individual feels driven to perform in response to an obsession or according to rigidly applied rules.

Behaviors or mental acts are aimed at preventing or reducing anxiety or preventing a dreaded event; however, these acts are either clearly excessive or not realistically connected to what they are designed to neutralize.

Time-Consuming or Impairing : The obsessions or compulsions are time-consuming (taking >1 hour per day) or cause clinically significant distress or functional impairment.

Insight Specifier :

Good/fair insight : Recognizes beliefs are definitely or probably not true.

Poor insight : Believes beliefs are probably true.

Absent insight / delusional beliefs : Completely convinced that OCD beliefs are true (e.g., convinced the house will burn down if the switch is not touched 20 times).

• Evidence-Based Management of OCD
• 1. First-Line Psychotherapy: Exposure and Response Prevention (ERP)

Exposure and Response Prevention (ERP) , a specialized form of CBT, represents the non-pharmacologic gold standard for OCD.

Mechanism : Patients are systematically, hierarchically exposed to stimuli that trigger obsessional distress (e.g., touching a public restroom doorknob) while strictly refraining from engaging in compulsive rituals (e.g., washing hands).

Outcome : Over sustained exposure sessions, the patient learns that anticipated catastrophes do not materialize and that anxiety naturally habituates without ritualistic neutralization.

2. First-Line Pharmacotherapy: High-Dose SSRIs

Pharmacotherapy for OCD differs fundamentally from the treatment of major depressive disorder (MDD) in two critical ways: higher dosing and longer latency to response . SSRI DOSING COMPARISON: OCD VS. MAJOR DEPRESSION

• Medication Standard MDD Dosing Range Target OCD Dosing Range Max Daily Dose in OCD
• ═══════════════════════════════════════════════════════════════════════════════════════════════════
• Fluoxetine 20 - 40 mg daily 60 - 80 mg daily 80 mg daily
• ───────────────────────────────────────────────────────────────────────────────────────────────────
• Sertraline 50 - 100 mg daily 150 - 200 mg daily 200 mg daily (up to 250-400 mg off-label)
• ───────────────────────────────────────────────────────────────────────────────────────────────────
• Paroxetine 20 - 40 mg daily 40 - 60 mg daily 60 mg daily
• ───────────────────────────────────────────────────────────────────────────────────────────────────
• Fluvoxamine 100 - 200 mg daily 150 - 300 mg daily 300 mg daily (FDA-approved for OCD)
• ═══════════════════════════════════════════════════════════════════════════════════════════════════

Extended Trial Duration : While depression often responds within 4-6 weeks, OCD requires 10 to 12 weeks at the maximum tolerated dose before determining treatment efficacy. Premature discontinuation or dose reduction is a frequent clinical pitfall.

3. Second-Line & Augmentation Strategies

Atypical Antipsychotic Augmentation : In patients with partial response to maximum-dose SSRI therapy after 12 weeks, augmenting with low-dose Aripiprazole (2.5-10 mg daily) or Risperidone (0.5-2 mg daily) produces meaningful symptom reduction in 30-50% of treatment-refractory patients.

Clomipramine : A tricyclic antidepressant (TCA) with potent, non-selective serotonin reuptake inhibition. Highly efficacious for OCD, but relegated to second-line status due to anticholinergic adverse effects (dry mouth, urinary retention, severe constipation), alpha-1 antagonism (orthostatic hypotension), lowered seizure threshold, and fatal cardiotoxicity in overdose (QTc prolongation, fatal arrhythmias).

Somatic Symptom and Related Disorders

Somatic symptom disorders are common in primary care, representing up to 10-20% of adult outpatient visits. Patients experience prominent, distressing physical symptoms accompanied by disproportionate psychological distress, healthcare utilization, and functional impairment. SPECTRUM OF SOMATIC SYMPTOM & RELATED DISORDERS

Condition Core Diagnostic Feature Physical Symptoms Present?

• ════════════════════════════════════════════════════════════════════════════════════════════════════════
• Somatic Symptom Disorder ≥1 distressing somatic symptom + excessive, YES (Prominent pain, fatigue,
• (SSD) disproportionate thoughts/anxiety/behaviors GI complaints >6 months)
• ────────────────────────────────────────────────────────────────────────────────────────────────────
• Illness Anxiety Disorder Preoccupation with having/acquiring a serious MINIMAL OR NONE (Preoccupation
• (formerly Hypochondriasis) illness; excessive checking or avoidance with disease concept itself)
• ────────────────────────────────────────────────────────────────────────────────────────────────────
• Conversion Disorder ≥1 symptom of altered voluntary motor or YES (Neurological deficits
• (Functional Neurological) sensory function with clinical INCOMPATIBILITY incompatible with anatomy)
• ────────────────────────────────────────────────────────────────────────────────────────────────────
• Factitious Disorder Falsification of physical/psychological signs YES (Deceptive production;
• WITHOUT external secondary gain internal sick role reward)
• ────────────────────────────────────────────────────────────────────────────────────────────────────
• Malingering Intentional production/feigning of symptoms VARIABLE (External secondary
• (Not a mental disorder) motivated by EXTERNAL INCENTIVES (money, drugs) gain: disability, evasion)
• ════════════════════════════════════════════════════════════════════════════════════════════════════
• 1. Somatic Symptom Disorder (SSD)

DSM-5 Criteria :

One or more somatic symptoms that are distressing or result in significant disruption of daily life.

Excessive thoughts, feelings, or behaviors related to the somatic symptoms, manifested by at least one of:

Disproportionate and persistent thoughts about the seriousness of one's symptoms.

Persistently high level of anxiety about health or symptoms.

Excessive time and energy devoted to these symptoms or health concerns.

State of being symptomatic is persistent (typically >6 months ).

Primary Care Management Framework (The 'C-Care' Strategy) :

Regularly Scheduled, Predictable Visits : Schedule brief, fixed-interval visits (e.g., every 4 to 6 weeks ) regardless of whether symptoms are currently flared. This decouples clinical access from acute symptom severity, removing subconscious reinforcement of the sick role.

Validate the Suffering : Acknowledge that the patient's symptoms and suffering are genuine ('I believe that your pain is real and distressing, even though tests have not shown tissue damage'). Never dismiss symptoms as 'all in your head.'

Perform a Brief, Focused Physical Exam : Examine the symptomatic area at each encounter. This builds therapeutic trust and provides physical reassurance without incurring laboratory costs.

Avoid Low-Yield Diagnostics & Polypharmacy : Resist ordering redundant imaging, laboratory panels, or invasive procedures to appease health anxiety. Avoid habit-forming medications (sedatives, opioids).

Focus on Function over Cure : Transition therapeutic goals from symptom eradication to functional rehabilitation, pain coping, and activities of daily living.

Engage in Psychotherapy : Recommend Cognitive Behavioral Therapy (CBT) framed as an active tool to manage symptom-related stress and restore functional independence.

2. Illness Anxiety Disorder

Preoccupation with having or acquiring a serious, undiagnosed illness.

Somatic symptoms are absent or only mild in intensity.

High health anxiety with excessive illness-related behaviors (repeatedly checking skin, monitoring pulse, compulsive web searching) or maladaptive avoidance (avoiding doctor appointments or hospitals).

Illness preoccupation persists for ≥6 months .

Distinguishing factor from SSD: In SSD, the patient is incapacitated by distressing physical symptoms ; in Illness Anxiety Disorder, the distress arises from the fear of having a disease despite minimal or absent bodily symptoms.

3. Conversion Disorder (Functional Neurological Symptom Disorder)

Conversion disorder involves one or more symptoms of altered voluntary motor or sensory function that demonstrate clear clinical incompatibility between the symptom and recognized neurological disease .

Diagnostic 'Positive' Signs on Physical Examination

Diagnosis does not rely solely on excluding disease; it requires positive clinical signs demonstrating internal inconsistency and preservation of underlying physiological pathways:

The Hoover Sign (Functional Lower-Extremity Weakness) :

Procedure : With the patient supine, the examiner places a hand under each heel. The patient is asked to perform voluntary hip extension of the paretic leg (which displays weakness). Next, the patient is asked to flex the contralateral, normal hip against resistance.

Positive Hoover Sign : During contralateral hip flexion, the examiner feels strong, involuntary downward pressure from the paretic heel due to the normal synergistic extension reflex. This confirms that pyramidal corticospinal motor pathways are anatomically intact.

Tremor Entrainment Test (Functional Tremor) :

A functional limb tremor changes frequency or rhythm to match the voluntary rhythmic tapping of the unaffected limb, or the tremor stops completely when the patient concentrates on tapping.

Give-Way (Collapsing) Weakness :

Sudden, jerky cessation of muscle resistance during manual muscle testing, rather than the smooth, sustained weakness of organic upper or lower motor neuron lesions.

Tubular (Tunnel) Visual Fields :

Constricted visual fields that maintain an identical visual field diameter when tested at 1 meter and 2 meters, violating the geometric laws of optical dispersion.

Psychogenic Non-Epileptic Seizures (PNES) :

Clinical features distinguishing PNES from epileptic seizures include: closed eyes with active resistance to manual eyelid opening, preserved pupillary light reflexes, prolonged ictal duration (>15-30 minutes), asynchronous thrashing, side-to-side head shaking, pelvic thrusting, absence of post-ictal stertorous breathing, and normal ictal EEG without epileptiform activity.

Management of Conversion Disorder

Delivering the Diagnosis : Present the diagnosis transparently and empathetically. Explain that the neurological 'hardware' (brain, spinal cord, nerves) is structurally intact, but the 'software' (functional brain signaling) is experiencing temporary disruption.

Physical & Occupational Therapy : Early referral for physical therapy focusing on functional movement retraining, redirection of attention, and progressive mobility without reinforcing abnormal gait patterns.

Psychotherapy : CBT to explore comorbid stressors, alexithymia, and anxiety.

Loading diagram... Clinical Decision Algorithm for PTSD, OCD, and Somatic Symptom Disorder