Post Traumatic Stress Disorder Treatment, Help and prevention
Management
Prevention and early intervention strategies Modest benefits have been from early access to cognitive behavioral therapy, as well as from some medications such as propranolol. Critical incident stress management has also been suggested as a means of preventing PTSD but subsequent studies suggested iatrogenic effects and later studies both confirmed harm and failed to demonstrate any benefits.
Psychotherapeutic interventions Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support.
The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures. A 2010 review disagrees that these treatments have proven efficacy, and points out methodological flaws in the studies and previous meta-analyses.
EMDR or trauma-focused cognitive behavioral therapy (TFCBT) was recommended as first-line treatments for trauma victims in a 2007 review; however, "the evidence base [for EMDR] was not as strong as that for TFCBT ... Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention."A meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD; however "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.
Behavioral and Cognitive Behavioral therapy
Cognitive Behavioral Therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking and/or behavior responsible for negative emotions. CBT have been proven to be an effective treatment for PTSD, and is currently considered the standard of care for PTSD by the United States Department of Defense In CBT, individuals learn to identify thoughts that make them feel afraid or upset, and replace them with less distressing thoughts. The goal is to understand how certain thoughts about cause PTSD-related stress.
Recent research on contextually based third-generation behavior therapies suggests that they may produce results comparable to some of the better validated therapies.Many of these therapy methods have a significant element of exposure, and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.
Exposure therapy is a type of cognitive behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence. Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure. The US Department of Veterans Affairs has been actively training mental health treatment staff in Prolonged Exposure Therapy and Cognitive Processing Therapyin an effort to better treat US Veterans with PTSD.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association and the United States Department of Veterans Affairs and Department of Defense have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations. However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead that the review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the psychotherapeutically effective components of the procedure.
Interpersonal psychotherapy
Other approaches, particularly involving social supports,may also be important. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure.A current, NIMH-funded trial in New York City is now (and into 2013) comparing interpersonal psychotherapy, prolonged exposure therapy, and relaxation therapy.
Medication
Symptom management: potentially useful medication classes SSRIs (selective serotonin reuptake inhibitors). SSRIs are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram, escitalopram, fluoxetine,fluvoxamine, paroxetine, and sertraline.
Among the anti-depressants described in this section, bupropion and venlafaxine have the lowest patient drop-out rates. Sertraline, fluoxetine, and nefazodone have a modestly higher drop-out rate (~15%), and the heterocyclics and paroxetine have the highest rates (~20%+). Where drop-out is caused or feared because of medication side-effects, it should be remembered that most patients do not experience such side-effects.
Alpha-adrenergic antagonists. Prazosin ("Minipress"), in a small study of combat veterans, has shown substantial benefit in relieving or reducing nightmares. Clonidine ("Catapres") can be helpful with startle, hyperarousal, and general autonomic hyperexcitability.
Anti-convulsants, mood stabilizers, anti-aggression agents. Carbamazepine ("Tegretol") has likely benefit in reducing arousal symptoms involving noxious affect,as well as mood or aggression. Topiramate ("Topamax") has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of effect was seen over time. Zolpidem ("Ambien") has also proven useful in treating sleep disturbances.
Lamotrigine ("Lamictal") may be useful in reducing reexperiencing symptoms, as well as avoidance and emotional numbing. Valproic acid ("Depakene") and has shown reduction of symptoms of irritability, aggression, and impulsiveness, and in reducing flashbacks. Similarly, lithium carbonate has worked to control mood and aggressions (but not anxiety) symptoms. Buspirone ("BuSpar") has an effect similar to that of lithium, with the additional benefit of working to reduce hyperarousal symptoms.
Antipsychotics. Risperidone can be used to help with dissociation, mood issues, and aggression.
Atypical antidepressants.Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with secondary depression, anxiety, and sexual dysfunction symptoms. Trazodone ("Desyrel") can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety.
Beta blockers. Propranolol ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances.
Benzodiazepines. These can be used with caution for short-term anxiety relief, hyperarousal, and sleep disturbance. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or are at all effective in the treatment of posttraumatic stress disorder. Additionally benzodiazepines may reduce the effectiveness of psychotherapeutic interventions and there is some evidence that benzodiazepines may contribute to the development and chronification of PTSD. Other drawbacks include the risk of developing a benzodiazepine dependence and withdrawal syndrome; additionally individuals with PTSD are at an increased risk of abusing benzodiazepines.
Glucocorticoids. Additionally, post-stress high dose corticosterone administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories.The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.
Heterocyclic / Tricyclic anti-depressants anti-depressants. Amitriptyline ("Elavil") has shown benefit for positive distress symptoms, and for avoidance, and Imipramine ("Tofranil") has shown benefit for intrusive symptoms.
Monoamine-oxidase inhibitors (MAOs). Phenelzine ("Nardil") has for some time been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.
Miscellaneous other medications. Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerlandand Israel.
Prevention and early intervention strategies Modest benefits have been from early access to cognitive behavioral therapy, as well as from some medications such as propranolol. Critical incident stress management has also been suggested as a means of preventing PTSD but subsequent studies suggested iatrogenic effects and later studies both confirmed harm and failed to demonstrate any benefits.
Psychotherapeutic interventions Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support.
The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures. A 2010 review disagrees that these treatments have proven efficacy, and points out methodological flaws in the studies and previous meta-analyses.
EMDR or trauma-focused cognitive behavioral therapy (TFCBT) was recommended as first-line treatments for trauma victims in a 2007 review; however, "the evidence base [for EMDR] was not as strong as that for TFCBT ... Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention."A meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD; however "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.
Behavioral and Cognitive Behavioral therapy
Cognitive Behavioral Therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking and/or behavior responsible for negative emotions. CBT have been proven to be an effective treatment for PTSD, and is currently considered the standard of care for PTSD by the United States Department of Defense In CBT, individuals learn to identify thoughts that make them feel afraid or upset, and replace them with less distressing thoughts. The goal is to understand how certain thoughts about cause PTSD-related stress.
Recent research on contextually based third-generation behavior therapies suggests that they may produce results comparable to some of the better validated therapies.Many of these therapy methods have a significant element of exposure, and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.
Exposure therapy is a type of cognitive behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence. Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure. The US Department of Veterans Affairs has been actively training mental health treatment staff in Prolonged Exposure Therapy and Cognitive Processing Therapyin an effort to better treat US Veterans with PTSD.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association and the United States Department of Veterans Affairs and Department of Defense have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations. However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead that the review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the psychotherapeutically effective components of the procedure.
Interpersonal psychotherapy
Other approaches, particularly involving social supports,may also be important. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure.A current, NIMH-funded trial in New York City is now (and into 2013) comparing interpersonal psychotherapy, prolonged exposure therapy, and relaxation therapy.
Medication
Symptom management: potentially useful medication classes SSRIs (selective serotonin reuptake inhibitors). SSRIs are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram, escitalopram, fluoxetine,fluvoxamine, paroxetine, and sertraline.
Among the anti-depressants described in this section, bupropion and venlafaxine have the lowest patient drop-out rates. Sertraline, fluoxetine, and nefazodone have a modestly higher drop-out rate (~15%), and the heterocyclics and paroxetine have the highest rates (~20%+). Where drop-out is caused or feared because of medication side-effects, it should be remembered that most patients do not experience such side-effects.
Alpha-adrenergic antagonists. Prazosin ("Minipress"), in a small study of combat veterans, has shown substantial benefit in relieving or reducing nightmares. Clonidine ("Catapres") can be helpful with startle, hyperarousal, and general autonomic hyperexcitability.
Anti-convulsants, mood stabilizers, anti-aggression agents. Carbamazepine ("Tegretol") has likely benefit in reducing arousal symptoms involving noxious affect,as well as mood or aggression. Topiramate ("Topamax") has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of effect was seen over time. Zolpidem ("Ambien") has also proven useful in treating sleep disturbances.
Lamotrigine ("Lamictal") may be useful in reducing reexperiencing symptoms, as well as avoidance and emotional numbing. Valproic acid ("Depakene") and has shown reduction of symptoms of irritability, aggression, and impulsiveness, and in reducing flashbacks. Similarly, lithium carbonate has worked to control mood and aggressions (but not anxiety) symptoms. Buspirone ("BuSpar") has an effect similar to that of lithium, with the additional benefit of working to reduce hyperarousal symptoms.
Antipsychotics. Risperidone can be used to help with dissociation, mood issues, and aggression.
Atypical antidepressants.Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with secondary depression, anxiety, and sexual dysfunction symptoms. Trazodone ("Desyrel") can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety.
Beta blockers. Propranolol ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances.
Benzodiazepines. These can be used with caution for short-term anxiety relief, hyperarousal, and sleep disturbance. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or are at all effective in the treatment of posttraumatic stress disorder. Additionally benzodiazepines may reduce the effectiveness of psychotherapeutic interventions and there is some evidence that benzodiazepines may contribute to the development and chronification of PTSD. Other drawbacks include the risk of developing a benzodiazepine dependence and withdrawal syndrome; additionally individuals with PTSD are at an increased risk of abusing benzodiazepines.
Glucocorticoids. Additionally, post-stress high dose corticosterone administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories.The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.
Heterocyclic / Tricyclic anti-depressants anti-depressants. Amitriptyline ("Elavil") has shown benefit for positive distress symptoms, and for avoidance, and Imipramine ("Tofranil") has shown benefit for intrusive symptoms.
Monoamine-oxidase inhibitors (MAOs). Phenelzine ("Nardil") has for some time been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.
Miscellaneous other medications. Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerlandand Israel.