Approach Considerations
Secondary prevention of PTSD
Secondary prevention consists of interventions designed to decrease the rate of PTSD in individuals exposed to traumatic events.
While no definitive studies exist, it is commonly believed that Psychological First Aid (PFA) may decrease rates of PTSD following a natural disaster or mass casualty situation. PFA includes emotional support, decreasing stress by reassuring the victim that shelter, food, and access to loved ones is guaranteed. Helping the person find a tolerable meaning for the trauma, reducing ideas leading to shame or guilt, avoiding invalidating comments such as "it's not that bad," and reassuring the victim that their strong emotional reaction is normal and does not mean they are weak or will forever feel this way can all be helpful.
Controlled trials have not found that single individual or group debriefings done in the immediate aftermath of traumas have been successful in preventing the development of PTSD. They also risk flooding victims. Pressuring a victim to participate can retraumatize them. Group treatment of trauma victims runs the risk of victims becoming worse as a result of flooding from hearing the stories of other members. Group treatment for PTSD must have very careful selection of group members to avoid this. Forcing victims to speak about the event, as has happened through required debriefing sessions, can be very harmful.
Brief cognitive-behavioral therapy (CBT) started within a few weeks of a traumatic event has been shown to decrease the rate of subsequent PTSD. Brief CBT appears to have the biggest impact in patients who have the most symptoms.
Attempts to decrease the formation of PTSD through pharmacology continues to be studied. Aggressive pain control is important to avoid increasing the trauma to the individual. Hydrocortisone has been shown to be effective. Individuals with low cortisol levels at the time of the trauma are at greater risk for the development of PTSD. Low cortisol levels lead to increased production of CRF, which increases norepinephrine release by the anterior cingulate. Some research has shown that propranolol given in the first hours after the traumatic event leads to reduced hyperarousal in the future. One study found that PTSD patients who actively recalled their traumatic event under the influence of propranolol showed a substantial decrease in symptom ratings on the Clinician-Administered PTSD Scale (CAPS) and the patient-rated PTSD Checklist–Specific (PCL-S) measures compared with patients who received placebo. [26] Trials of escitalopram, temazepam, and gabapentin have been unsuccessful in preventing PTSD following trauma. Benzodiazepines appear to be harmful.
High levels of emotional support and help with basic needs for shelter, food, clothing, and economic issues likely decrease the risk of PTSD.
Trauma-focused CBT and eye movement desensitization and reprocessing (EMDR) have been shown to be most effective in treating patients with PTSD. [27, 28, 29, 30, 31, 32, 33, 34]
Studies have suggested that even a single CBT session for sleep abnormalities can significantly improve daytime PTSD symptoms, as can pharmacologic treatments for sleep abnormalities. [35, 36]
In 2013, the World Health Organization (WHO) issued new clinical protocols and guidelines for addressing the mental health consequences of PTSD, acute stress, and bereavement. The new protocols allow primary healthcare workers to offer basic psychosocial support to refugees as well as people exposed to trauma or loss in other situations. Types of support offered may include Psychological First Aid, stress management, and helping affected people to identify and strengthen positive coping methods and social supports. Referral for advanced treatments such as CBT or EMDR should also be considered. Benzodiazepine use for the reduction of acute traumatic stress symptoms or sleep problems in the first month after a potentially traumatic event is not recommended. [37, 38]
Treatment of PTSD
Psychotherapy
Trauma-focused psychotherapies appear to be effective treatment for PTSD. A systematic review and meta-analysis of 55 clinical trials found that evidence-based trauma-focused psychotherapy (TFP) outperformed medications when looking at pre-/post-treatment symptoms and at 9-month follow-up. In this meta-analysis, TFP included trauma-focused CBT, prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing (EMDR), and imaginal exposure. There is limited data supporting more generalized CBT approaches such as stress inoculation training and relaxation training. [27, 28, 38, 31, 32, 33, 34]
There are ongoing efforts to assess variations of psychotherapy and psychotherapies that target specific symptoms such as insomnia. A trial study of service members with PTSD caused by the traumatic events of September 11, 2001, or by Operation Iraqi Freedom, found that self-managed, Internet-based CBT led to a greater reduction in PTSD symptoms than did Internet-based supportive counseling. [39] Studies have suggested that even a single CBT session for sleep abnormalities can significantly improve daytime PTSD symptoms. [35, 36]
Trauma-focused CBT is effective in treating PTSD in children and adolescents. There is insufficient evidence, however, to definitively compare one form of psychotherapy to another. [32] The most recent research says therapy shortens the course of those who will recover but does not change the long-term course. [40]
Other research suggests that adding 3,4-methylenedioxymethamphetamine (MDMA), also known as ecstasy, to intensive psychotherapy can significantly mitigate symptoms of PTSD. According to results of an FDA-regulated phase 2 trial of 28 chronic PTSD sufferers, 43% of patients no longer met criteria for PTSD after one month of MDMA-assisted psychotherapy, and 76% of participants no longer had PTSD 12 months after MDMA-assisted psychotherapy. [41]
Psychopharmacology
Recommendations for pharmacological treatment vary depending on the source. The United Kingdom’s National Institute for Health and Care Excellence (NICE) and the World Health Organization (WHO) do not recommend any medications as first-line treatment for PTSD. The American Psychiatric Association and the US Department of Veterans Affairs and Department of Defense Clinical Practice Guidelines both recommend antidepressants (particularly SSRIs) as first-line treatment for PTSD. Both organizations also support the use of prazosin for trauma-related nightmares and insomnia. Benzodiazepine use for the reduction of acute traumatic stress symptoms or sleep problems after a potentially traumatic event is not recommended. [37, 38] Although benzodiazepines may be popular with patients and lead to a transient decrease in anxiety symptoms, research indicates that they not only are not effective, but may prolong the course of PTSD.
Inpatient care
Inpatient care may be necessary if the patient becomes an acute danger to themselves or others. Individuals with severe PTSD from childhood abuse may need inpatient care to help learn emotional regulation and then treat the PTSD.
Long-Term Monitoring
Active treatment should occur until symptoms have abated. In addition to monitoring symptoms and social and occupational functioning, providers should continue to assess for the emergence of suicidal ideation or substance abuse. Some traumas (such as childhood sexual abuse) may result in delayed exacerbations as individuals reach developmental milestones such as marriage or having children.
Consultations
Mental health providers who encounter individuals with PTSD need to assess for the common comorbidities and may have to consult other clinicians in order to provide comprehensive care. Providers who are not trained in the specific trauma-focused psychotherapies should refer patients to those who are competent in them. General psychiatrists and other mental health providers may need to consult child and adolescent psychiatrists and psychologists when encountering younger victims of trauma.
Complications
Activity
It is important for people with PTSD to try to stay active lest their lives become increasingly restricted and things they fear increase.
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Brain structures involved in dealing with fear and stress.
