American Family Physician September 2000
A prudent approach tailors each treatment plan to the needs of the patient. A good first-line treatment plan is thorough education about the disorder and enrollment of the patient into a local PTSD group. If the physician has time constraints or other difficulties providing supportive therapy, referral to a mental health professional should be considered. Any substance abuse issues should be addressed as an adjunct to therapy. Some PTSD symptoms are difficult for patients to tolerate, and rapid pharmacologic treatment may be helpful. More than one class of medications may be needed to control the diverse symptoms.

SSRIs are efficacious against the broadest range of symptoms, and the number of agents available helps to target patients’ symptoms. Although a therapeutic response is usually evident in two to four weeks, any SSRI should be given a minimum of six to eight weeks at therapeutic dosages before it is declared a treatment failure.10

If insomnia continues to be a predominant complaint, trazodone augmentation is a useful and safe alternative to hypnotic agents. Persistent insomnia accompanied by significant hyperarousal and reexperiencing symptoms should be treated with clonidine. The major symptoms of PTSD can be alleviated with the combination of an SSRI, trazodone and clonidine.10 If symptoms persist despite these initial interventions, psychiatric consultation should be obtained before sedative or hypnotic agents are given.

National Center for Posttraumatic Stress Disorder
The aim of all disaster mental-health management should be the humane, competent, and compassionate care of all affected. The goal should be to prevent adverse health outcomes and to enhance the well-being of individuals and communities. In particular, it is vital to use all appropriate endeavors to prevent the development of chronic and disabling problems such as PTSD, depression, alcohol abuse, and relationship difficulties and to help those that do develop these problems to recover quickly.

In addition to targeted, brief early interventions, some trauma survivors may benefit from ongoing counseling or treatment. Candidates for such treatment include survivors with a history of previous traumatization (e.g., survivors of the current trauma who have a history of childhood physical or sexual abuse) or those who have preexisting mental health problems. Below we describe the empirical evidence that currently exists regarding these ongoing behavioral mental health treatments.

The trauma treatment research field is still young, and treatment research can be complicated and difficult to conduct. Because of this, comparisons of different treatments for PTSD are scarce; therefore, a lack of empirical evidence in the literature does not necessarily signify a lack of treatment efficacy. The current process by which trauma experts evaluate treatment options is to study the empirical literature and take into account clinical consensus on treatments that have proven effective in case studies or across clinical settings. The choice of a treatment modality is based on many factors, including unique client life challenges; side effects and potential negative effects; cost; length of treatment; cultural appropriateness; therapist’s resources and skills; client’s resources and stressors; comorbidity of other psychiatric symptoms; the fluctuating course of PTSD; the need to foster resilience; and legal, administrative, and forensic concerns.

While there is limited empirical literature on which to base comparisons of alternative treatment methods, a number of treatment approaches have gained empirical support. Some of these treatments have shown promising results across a number of different settings and with different trauma populations. They are available within VA hospitals and merit attention when considering referral options. Listed below are some treatments that have gained empirical support:

Cognitive-Behavioral Therapy (CBT)

There are more published well-controlled studies on CBT (over 30) than on any other PTSD treatment. CBT treatments for PTSD include:

* Exposure therapy, in which patients are asked to describe their traumatic experiences in detail, on a repetitive basis, in order to reduce the arousal and distress associated with their memories
* Cognitive therapy, which focuses on helping patients identify their trauma-related negative beliefs (e.g., guilt or distrust of others) and change them to reduce distress
* Stress-inoculation training, in which patients are taught skills for managing and reducing anxiety (e.g., breathing, muscular relaxation, self-talk)

CBT treatments usually involve some combination of the above methods combined with education about PTSD and the development of a good therapist-patient relationship. Other CBT treatment methods may be added to address related problems, such as anger (anger management training, assertiveness training) or social isolation (social skills training, communication skills training).

In general, cognitive-behavioral methods have proven very effective in producing significant reductions in PTSD symptoms (generally 60-80%) in several civilian populations, especially rape survivors. However, the degree of symptom reduction is likely to be somewhat less in veterans with chronic combat-related PTSD. Nevertheless, the magnitude and permanence of treatment effects appears greater with CBT than with any other treatment.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR involves having the patient bring to mind images of the trauma while engaging in back-and-forth eye movements (or while alternating oneâs attention back and forth using taps or sounds). It also addresses trauma-related negative beliefs. It has been shown to be more effective than psychodynamic, relaxation, supportive, or placebo wait list therapies (where patients are put on a waiting list to receive treatment but don’t actually receive it by the time they are tested). Research comparing EMDR to the more generally accepted cognitive-behavioral techniques shows significantly better results with CBT than with EMDR, particularly at three-month follow-up. CBT results also show greater sustainability. Research looking at the different components of EMDR shows that the eye movement component adds no additional treatment effect to the imagery exposure and the process of dealing with negative beliefs.

Psychodynamic Therapy

Research on the use of psychodynamic therapy is difficult to conduct because psychodynamic techniques do not focus on symptom reduction. Instead, they focus on more fluid intra- and interpersonal processes. To date, there has been only one randomized clinical trial on the efficacy of psychodynamic treatment in reducing PTSD symptoms. In this trial, 18 sessions of Brief Psychodynamic Psychotherapy were shown to effectively reduce PTSD intrusion and avoidance symptoms by approximately 40%, and improvement was sustained for 3 months. While clinicians often support the utilization of psychodynamic techniques in the treatment of trauma, particularly in the treatment of more complex trauma, much more research is needed to demonstrate the techniques effectiveness with PTSD.

Group Therapy

While various studies have shown most group treatments to have beneficial effects with respect to psychological distress, depression, anxiety, and social adjustment, there have been few rigorous tests of group treatments relating to PTSD symptoms. Three studies of CBT group treatments (including Cognitive Processing Therapy, Assertion Training, and Stress Inoculation Therapy) have been conducted with women traumatized by childhood or adult sexual abuse. All PTSD symptom clusters were reduced 30-60%, and improvement was sustained for six months. One CBT group treatment for combat veterans showed a 20% reduction in PTSD symptom severity. One study of psychodynamic group treatment found an 18% reduction in PTSD symptoms among women with PTSD due to childhood sexual abuse. One controlled trial of supportive group treatment for female sexual assault survivors showed a 19-30% reduction in intrusion and avoidance symptoms, which was maintained for six months.

Inpatient Treatment

There have been no satisfactory studies on inpatient treatment for PTSD and trauma-related conditions. However, clinical consensus agrees that inpatient therapy is appropriate for crisis intervention, management of complex diagnostic cases, delivery of emotionally intense therapeutic procedures, and relapse prevention.

Marital and Family Therapy

There have been no research studies done on the effectiveness of marital/family therapy in treating PTSD. However, because of trauma’s unique effects on interpersonal relatedness, clinical wisdom indicates that spouses and families ought to be included in the treatment of those with PTSD. Of note, marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been successfully (individually) rehabilitated.
Social Rehabilitative Therapies

While social rehabilitative therapies (i.e., teaching social, coping, and life function skills) have been proven effective for chronic schizophrenics and other groups of persistently impaired psychiatric individuals, they have yet to be formally tested with PTSD clients.

Since these therapies appear to generalize well from clients with one mental disorder to clients with another, it is reasonable to expect that they will also work with PTSD clients. There is clinical consensus that appropriate outcomes would be improvement in self-care, family functioning, independent living, social skills, and maintenance of employment.

Hypnosis

While research on the use of hypnosis with trauma survivors indicates very little improvement in trauma symptoms, clinical consensus indicates that it can be helpful as an adjunctive rather than primary treatment, especially with dissociation and nightmares.

Creative Therapies

There is currently no controlled evidence on creative therapies (art, drama, music, body-oriented therapies). Some clinicians believe that such therapies are uniquely fitted to address specific somatic manifestations of trauma (i.e., sensory defensiveness, somatic memories, etc.). Caution is recommended in the use of somatic treatments, especially regarding the need to maintain physical safety and appropriate professional boundaries; therefore, it is important that therapists are well trained in this modality.

PTSD Resources for serving military and veterans:

• The National Center for PTSD
• National Institute of Mental Health
• PTSDSupport.net
• Iraq Veterans Against the War PTSD page
• New York State Office of Mental Health
• Military blogger - Jimbo at Blackfive
• Military blogger - Kat at John of Argghhh
• Military blogger - Grim at Blackfive

152 views Tags:

Subscribe

This entry was posted by Chuck Simmins on Thursday, December 6th, 2007 at and is filed under Medicine, Military. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.