POSTTRAUMATIC STRESS DISORDER – PART TWO

This article is from Cigna

PTSD is a complex neurobiological condition, with some evidence suggesting a dysregulation of multiple neuro-chemical systems that include adrenaline, noradrenaline, vasopressin, oxytocin, serotonin, stress-responsive hormones like cortisol, the endogenous opiod system, and possibly others

When considering a treatment plan and management of PTSD one must consider numerous factors before starting a treatment(s). In addition to looking at evidence-based psychotherapy and/or medication treatments, other factors include available therapies in the geo-access area, the clinician’s skill level with such therapies, the tolerability of the treatment, co-occurring disorders, potential side effects and interactions if medications are chosen, supports available and the level of care needed to treat the individual at the time of assessment.

Psychotherapy, in most cases, is a first-line treatment in the management of PTSD. Many types of psychotherapy and psychosocial treatments have been used, with some psychotherapy treatments having stronger evidence-based support over others. As for pharmacotherapy, antidepressants are also an important treatment option for PTSD. Although is it is not uncommon to see combinations of psychotherapy and pharmacotherapy being used for PTSD, especially with co-occurring disorders such as depression, other anxiety disorders and substance abuse, we still need additional studies to understand how effective such combinations are when treating PTSD alone. Of course, it is also important to treat any co-occurring disorders as well.

Psychotherapy treatments that have been used with PTSD include various cognitive behavioral treatments, in particular cognitive behavioral therapy (CBT), cognitive exposure-based treatment, cognitive processing therapy (CPT), and eye-movement desensitization and reprocessing (EMDR). Others include psychodynamic therapy, group therapy, marital and family therapy, social rehabilitative therapies and hypnosis. However, the cognitive behavioral therapies, like prolonged exposure and cognitive therapy (with psycho-education, anxiety management and cognitive restructuring), along with EMDR, have the strongest evidence-based support. There is still insufficient data to determine the effectiveness of hypnosis for PTSD. As for group therapy, although commonly used for the treatment of PTSD, there is still not sufficient data to determine if groups are as or more effective than individual therapy. Part of the problem in doing such studies is that often different programs use different types of group therapies for PTSD including supportive and educational, psychodynamic and CBT models, making it harder to do adequate randomized control studies. However, one must remember that not having any evidence-based support for a treatment due to a lack of studies being done does not always mean that a specific treatment is not effective. In other cases some treatments have been clearly shown through randomized clinical trials to be non-effective.

As for pharmacotherapy, in general antidepressants are currently the preferred medication for PTSD, with the greatest amount of literature supporting the selective serotonin reuptake inhibitors. There is also evidence to support the use of tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), but due to side effects and interactions, in most cases SSRIs are considered first-line choices. There is also increasing evidence to support use of some of the newer antidepressants such as venlafaxine and mirtazapine. So far there has been conflicting evidence to support bupropion in the treatment of PTSD, at least as a first-line treatment. In those individuals who tend to be resistant to medication and/or psychotherapy or with other symptoms such as high anxiety, psychosis or irritability, other options can be considered. There are ongoing studies to look at atypical antipsychotic medications as well as some of the anticonvulsants for augmentation or to treat co-occurring disorders.

Since an estimated 70-85% of those with PTSD experience nightmares and sleep disturbances, it is important to make sure that this is addressed during treatment. Sleep disruption, like difficulties falling asleep due to increased arousal and anxiety, frequent awakenings due to distressing dreams or nightmares or fear of falling back to sleep, are common. Although antidepressants can be helpful, at times they may have limited benefits with sleep and nightmares. Anti-adrenergics (alpha blockers) such as prazosin have been shown to be very helpful in many who experience recurrent nightmares and sleep disturbances. There are some theories that alpha blockers may help with sleep in PTSD not so much by causing sedation, but through decreasing the hyperactivity of the adrenergic system as well as by possibly normalizing rapid eye movement sleep and improving sleep maintenance. However, further research still needs to be done regarding the actual mechanism of action. One additional therapy to consider for sleep disruption and nightmares is a cognitive behavioral treatment called imagery rehearsal therapy (IRT), which has been used specifically for decreasing chronic nightmares and improving sleep in those with PTSD. This therapy works by educating the individual about nightmares and sleep, keeping daily sleep logs and using pleasant imagery exercises to replace the disturbing elements of a targeted nightmare with more pleasant or more neutral content. With IRT, then, one is consciously altering nightmares by repeated rehearsals. Light therapy is another treatment option being considered. However, although some studies propose bright light therapy as an alternative treatment to help with sleep and PTSD symptoms, there is still limited supportive data at this time.

In summary, multiple factors must be considered when choosing psychotherapy or pharmacotherapy options for treating PTSD, as with any other mental health condition. Some factors include choosing an evidence-based treatment(s), the availability of the selected treatment, the training and skill level of the clinician with respect to the treatment chosen, co-occurring disorders, medical conditions, the availability of supports and the potential side effects and interactions with other medications when a pharmacotherapy is chosen. Current first-line treatments include cognitive behavioral treatments and EMDR for psychotherapy and SSRI’s for pharmacotherapy. There is a high occurrence rate of sleep disturbances with PTSD and, therefore, this should be an important targeted symptom to focus on throughout the treatment

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