Posttraumatic Stress Disorder Treatment & Management

  • Author: T Allen Gore, MD, MBA, CMCM, DFAPA; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Apr 25, 2012
 

Approach Considerations

Many of the complications and disabilities associated with prolonged PTSD may be prevented by initiating assessment and treatment quickly after the traumatic event, well before a diagnosis of PTSD can be made.

Treatment is often best accomplished with a combination of pharmacologic and nonpharmacologic therapies. Medications may be required to control the physiological symptoms, which can enable the patient to tolerate and work through the highly emotional material in psychotherapy. (For adolescents and children, treatment is primarily psychotherapeutic in nature.)

Treatment is often complicated by comorbid disorders. If present, alcohol or substance abuse problems should be the initial focus of treatment. In the presence of coexisting depression, treatment should focus on the PTSD, because its course, biology, and treatment response are unlike those associated with major depression.

Treatment consists of group therapy, individual and family therapy, cognitive behavioral therapy, play therapy, art therapy, anxiety management, eye movement desensitization and reprocessing (EMDR), hypnosis, and relaxation techniques.

EMDR has been successful in helping the survivors of various traumas, such as domestic violence, sexual abuse, crime, and combat. The method involves psychotherapy that combines various therapeutic approaches with eye movements (or other types of rhythmic stimulation) to stimulate the brain's information-processing mechanisms.

A meta-analysis of studies in adults with PTSD indicated that trauma-focused cognitive-behavior treatment (CBT) and EMDR should be first-line nonpharmacologic therapies for PTSD.[27, 28, 29] A randomized controlled trial comparing the trauma-focused CBT modality of brief eclectic psychotherapy and EMDR found that both are effective psychotherapeutic treatments, but EMDR may be a more time-efficient method for treating PTSD.[30]

In a study of service members with PTSD caused by the traumatic events of September 11, 2001, or by Operation Iraqi Freedom, self-managed, Internet-based CBT led to a greater reduction in PTSD symptoms than did Internet-based supportive counseling.[31]

Studies have suggested that even a single CBT for sleep abnormalities can significantly improve daytime PTSD symptoms, as can pharmacologic treatments for sleep abnormalities.[32, 33]

Some patients may benefit from psychodynamically oriented psychotherapy, especially if PTSD was caused by early sexual or physical abuse. Flooding, a technique involving prolonged exposure to the adverse stimuli, has been used with some success on veterans.

Inpatient care

Inpatient care is necessary only if the patient becomes suicidal or homicidal or if complicating comorbid conditions requiring inpatient treatment (eg, depression, substance abuse) are present.

Although limited to 5 case management studies, the inpatient treatment of patients who had PTSD symptoms after returning from Global War on Terror (GWOT) missions was examined at a center. Treatment cocktails included aripiprazole and either cognitive-behavioral psychotherapy or sertraline. The therapeutic cocktail was observed to reduce the recurrence of hyperarousal episodes, which was the predominant symptom. However, in one patient, a paradoxical hyperarousal was observed.[34]

Remission criteria for PTSD

Remission criteria for patients with PTSD involve subjective goals and objective goals.[35] Objective goals include test results. Tests include the Treatment Outcome PTSD Scale, or TOPS-8[36] ; the Hamilton Rating Scale for Anxiety, or HAM-A[37] ; the Hamilton Rating Scale for Depression, or HAM-D[38] ; and the Sheehan Disability Scale.[39] Criteria are as follows:

  • Subjective goal - No or minimal PTSD symptoms
  • Objective goal - TOPS-8 score less than or equal to 5 or 6
  • Subjective goal - No or minimal anxiety
  • Objective goal - HAM-A score less than or equal to 7-10
  • Subjective goal - No functional impairment
  • Objective goal - Sheehan Disability Scale score less than or equal to 1 on each item (mildly disabled)
  • Subjective goal - No or minimal symptoms of depression
  • Objective goal - HAM-D score less than or equal to 7

Go to Anxiety Disorders for more complete information on this topic.

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Long-Term Monitoring

Having experienced trauma, some patients with PTSD may be socially uncomfortable. Encouragement over time may be helpful to keep them therapeutically engaged, which yields optimal medical and psychiatric benefits.

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Consultations

Patients with posttraumatic stress disorder (PTSD) and related conditions can be encountered in several treatment settings. Physicians practicing the following specialties are likely to encounter patients with PTSD and should request assistance from their colleagues in psychiatry.

Family practice and internal medicine

As previously mentioned, patients with PTSD are more likely to use the healthcare system, but less likely to seek mental health treatment; therefore, primary care physicians are likely to be the first encounter for a patient with untreated PTSD. Additionally, patients with chronic untreated PTSD are likely to have other chronic conditions that require treatment and/or hospitalization, further enhancing the likelihood they will encounter a primary care physician. It is important to remember that a patient with untreated PTSD is unlikely to be aware of his or her condition and PTSD can be obscured by comorbid conditions and/or somatization. When a primary care physician suspects a patient may have PTSD, referral to a psychiatrist is warranted for a definitive diagnosis.

Pediatrics

Children can develop PTSD, but their symptoms are likely to be different from those expressed by adults. Children who are known to have had traumatic experiences in the past and/or exhibit some of the symptoms cited in Quick Guide should be referred to a psychiatrist specializing in children and adolescents for a definitive diagnosis.

Emergency department

Progression to PTSD can be prevented by treatment of acute stress disorder. If an emergency department physician encounters a patient acutely after experiencing a traumatic event, a psychiatrist should be consulted for evaluation and to establish the proper treatment to be administered as an outpatient or during inpatient hospitalization (when necessary) to prevent progression from acute stress disorder to PTSD.

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Contributor Information and Disclosures
Author

T Allen Gore, MD, MBA, CMCM, DFAPA  Assistant Professor, Department of Psychiatry, Howard University School of Medicine; Senior Psychiatrist and Director, Medical Education, Comprehensive Psychiatric Emergency Program, District of Columbia Department of Mental Health

T Allen Gore, MD, MBA, CMCM, DFAPA is a member of the following medical societies: American College of Managed Care Medicine, American Psychiatric Association, and National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Joel Z Lucas, MD  Senior Medical Writer, Reckitt Benckiser Pharmaceuticals, Inc

Joel Z Lucas, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and Student National Medical Association

Disclosure: Johnson & Johnson Salary Employment

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Additional Contributors

The authors would like to thank all colleagues and students who contributed to this article. We are especially grateful to the following individuals:

Georgianna M Richards-Reid, MD, Staff Physician, Department of Neurology, Howard University Hospital, Howard University College of Medicine

Zachary Osborne, MD; Ross University School of Medicine

Bobbi Adams, BS; University of Alabama

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