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Trauma and Post-Traumatic Stress Disorder

I. Overview

A. The puzzling, and disturbing effects of psychological trauma on human functioning has been described for generations, as far back as Homer's Iliad. In more recent times, large numbers of American Civil War veterans complained of generalized weakness, heart palpitations and chest pain-thought to be a result of the physical stress of war, and referred to as 'soldier's heart'. In the First World War, psychologically disabled veterans were thought to have suffered from brain damage, or 'shell shock.' Kardiner treated World War Two veterans, describing a syndrome that foreshadowed the current diagnosis of post-traumatic stress disorder, he labeled it a 'traumatic neurosis of war', and made the point that the syndrome was physiological in nature. Post-traumatic stress was virtually ignored until after the Vietnam War when both veterans groups and the feminist movement spoke out about psychological trauma. Horowitz helped to formulate the diagnosis that found its way into the DSM-III. Earlier in the century Freud and Janet became interested in how psychological trauma lead to post-traumatic stress disorder, rape syndrome, post-rape syndrome, sexual assault, posttraumatic stress disorder, post-tramatic, posttramatic stress disorder. Freud proposed that childhood sexual abuse was linked to symptoms of hysteria, an idea he later abandoned. This idea was ignored for almost the rest of the century, until 

B. Since its inception in the DSM-III, the diagnosis of post-traumatic stress disorder (PTSD) has helped researchers study the connection between psychological trauma and psychiatric morbidity. Initially it was thought that PTSD described a normal, expectable response to trauma. It was felt that the severity and chronicity of the syndrome might be directly related to the nature of the trauma. Subsequent research has shown that the diagnostic criteria for PTSD describe several phenomena; an initial, expectable response to trauma, an initial pathological response, and a more prolonged, pathological state. The development of PTSD following a trauma is the

C. Acute and long-term responses to traumatic events are varied and multi-determined. Nearly every person can be expected to have some disruption in their mental functioning following a significantly traumatic event, a 'normal' stress response. On average, most people are able to adapt following a traumatic event and return to their previous level of functioning, with or without some chronic symptoms. When the symptoms following a trauma impair functioning, they often appear as syndromes, labeled in the DSM-IV as Acute Stress have a significant impact on the individual.

II. Posttraumatic Stress disorder

The DSM-IV criteria for PTSD are listed below and define 'trauma' and the three central groups of post-traumatic symptoms; intrusive/reexperiencing, avoidance/numbing and hyperarousal. If these symptoms are pervasive, prolonged and debilitating enough, they reach threshold for a diagnosis. A typical post-traumatic response may involve alternating symptoms of avoidance and reexperiencing as the person struggles to come to terms with the

A. The DSM-IV defines "trauma" in a specific way

1.' Trauma' involves a physical threat to life or bodily integrity, examples include:

a. Exposure to military combat, violent assault, including rape and robbery, domestic violence, automobile accidents, childhood physical and sexual abuse or neglect, natural disasters and sudden catastrophic medical illness.

b. Witnessing a traumatic event

c. Being told about a trauma experienced by a loved one.

2. A defining characteristic of a traumatic event, according to the DSM-IV, is that the person's response involves "intense fear, helplessness or horror." Because of the intensity of the feelings associated with a trauma, perception of the event may be distorted; it may be experienced as fragments of sensations, time may be slowed or accelerated. Feelings may be

B. Intrusive, reexperiencing symptoms are a hallmark of PTSD.

Traumatic memories are often quite disruptive; they are vivid, sensory experiences, that can intrude unbidden. Nightmares are common, often repetitive, lifelike and disruptive to sleep; patients begin to dread sleep and will 'fight it', to avoid the frightening nightmares. Flashbacks, hallucinations and other experiences of reliving the trauma can occur. Intense emotional distress and physiological reactivity,

C. Avoidance of reminders of the trauma and psychological numbing can be the most disabling symptoms following a

Following a trauma, persons may avoid anything that may remind them of the trauma, including thoughts or feelings, activities, places or people that are associated with the event. There can be amnesia for the trauma itself. Numbing symptoms include an overall sense of

D. Hyperarousal symptoms can create interpersonal problems. These symptoms include, marked sleep difficulty, irritability and anger outbursts, difficulty with concentration, hypervigilance and an 

DSM-IV Diagnostic criteria for Post-traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or other

(2) The person's response involved intense fear helplessness or 

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1)Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.

(2) Recurrent distressing dreams of the event.

(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated).

(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) Inability to recall an important aspect of the trauma

(4) Marked diminished interest or participation in significant activities

(5) Feeling of detachment or estrangement from others

(6) Restricted range of affect (eg, unable to have loving feelings)

(7) Sense of a foreshortened future (eg, does not expect to have a career. Marriage, children, or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) Difficulty falling or staying asleep

(2) Irritability or outbursts of anger

(3) Difficulty concentrating

(4) Hypervigilance

(5) Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important area of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

III. Stress Disorder

This disorder describes an acute response to trauma. It includes the criteria for PTSD but adds and emphasizes dissociative symptoms. An acute stress disorder may follow any trauma, but a typical example includes a soldier responding to battle, becoming acutely disoriented, and being in a "daze." Acute Stress Disorder appears to be a good predictor of subsequent PTSD; the presence or absence of the diagnosis predicted PTSD at 6 months in 83% of cases in one study. The diagnostic criteria are listed below.

DSM-IV Diagnostic criteria for Acute Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness or horror

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

(1) subjective sense of numbing, detachment or absence of emotional responsiveness

(2) a reduction of awareness of his or her surroundings (eg, "being in a daze")

(3) derealization

(4) depersonalization

(5)dissociative amnesia (inability to recall an important aspect of the trauma)

C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts feelings, conversations activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition, is not better accounted for by a Brief Psychotic Disorder, and is not merely an exacerbation of a preexisiting Axis I or Axis II disorder.

IV. Epidemiology

A. Prevalence of PTSD in General Population

1. Results range from 1% to 14%. The Epidemiological Catchment Area Study showed lifetime PTSD rates of around 1.3% at two sites. More subjects reported sub-clinical symptoms following a trauma, around 15%.

2. A survey of 1,007 young adults in an HMO in Detroit showed that 39% were exposed to a traumatic event, 23.6% of those subjects developed PTSD, leading to a lifetime prevalence of 9.2%, 6.0% for males and 11.3% for females.

B. Prevalence of PTSD Following Specific Traumas

1. The rates of PTSD following natural disasters vary. Following the  volcano eruption of Mt. St. Helen, a population sample of those exposed showed lifetime prevalence of PTSD of 3.6% compared to 2.6% in controls. Following a dam break and subsequent flood at Buffalo Creek, researchers found a 59% lifetime prevalence of PTSD, 25% still met criteria at 14-year follow-up.

2. For war veterans, rates can vary according to traumatic exposure. Overall, lifetime PTSD rates for Vietnam veterans is 15%. Those exposed to median levels of combat showed rates of 28% compared to 65% among those exposed to the highest levels of combat. For political prisoners and prisoners of war, rates can range from 30% to more than 70%. For torture victims, rates can be as high as 90/3.

3. Among individuals who suffer a violent assault, there is a 20% rate of PTSD.

Victims of rape have been found to have rates of PTSD near 50% in some studies.

Witnessing a person being killed or seriously injured confers a risk of 7%.

4. Following a traffic accident, 10 to 30% still have PTSD 6 to 18 months following the accident.

5. In a group of individuals who experienced a sudden, unexpected death of a close friend or relative, 14% developed PTSD.

6. The likelihood of developing PTSD is twofold higher in females than males overall. This is due to females' greater vulnerability to assaultive violence.

V. Longitudinal Course of PTSD

A. PTSD can be a chronic illness. Of the Vietnam Veterans who had developed PTSD following the war, 50% of males and 32% of the females still suffered from the syndrome in 1988. In World War II prisoners of war, 50% had PTSD 40 years after the trauma.

B. PTSD can be acute, if symptoms last less than 3 months; chronic if symptoms last for more than three months; and delayed, if there is an onset of symptoms at least 6 months after the stressor. PTSD symptoms can be intermittent and residual. It is not uncommon for PTSD to be reactivated, years after it has apparently resolved.

C. If the stressor involves interpersonal violence, victims are at greater risk for chronic PTSD.

VI. Risk Factors for Developing PTSD

A. The nature of the traumatic stressor remains the most important risk factor for developing PTSD. However not every person will develop PTSD after exposure to a traumatic event, even a severe one. As well, even 'mild trauma' can trigger PTSD in some individuals. The stressors most likely to cause PTSD are (Tomb ! 994):

1. Severe, unexpected, prolonged, intentional and repetitive

2. Involve threat to physical integrity of self or loved one

3. Isolating, demeaning, or in conflict with one's self-concept

B. Personal vulnerability is an important risk factor, especially in less severe trauma. Risk factors include:

1. Previous psychiatric history, including major depression, anxiety disorders, conduct disorder, neurotic personality, antisocial and narcissistic personality disorder

2. History of previous trauma, including childhood sexual abuse

3. Low intelligence

4. Limited social support

5. Childhood separation from parents, or divorce of parents in early childhood

6. family history of major depression or anxiety disorders, which suggests a genetic component to PTSD

C. Dissociative symptoms experienced during or shortly after a traumatic event appear to predict the later development of PTSD.

D. The presence of severe symptoms early on appears to predict more severe symptoms later on.

VII. Associated Syndromes and Comorbidity

A. Children exposed to physical or sexual abuse, or adults exposed to prolonged and repeated trauma may develop long standing problems in psychological and interpersonal functioning. The younger the person the more vulnerable they may be to long term difficulties. Although not yet recognized as a distinct diagnosis in the DSM, this syndrome is know in the literature as Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified. The syndrome describes a

1. Difficulty with affect regulation, including problems managing anger, self destructive behavior, impulsive and risk-taking behavior

2. Dissociative symptoms and amnesia

3. somatization

4. a range of characterological difficulties including; a damaged sense of self, chronic guilt and shame, a feeling of ineffectiveness, idealization of the perpetrator, difficulty in establishing and maintaining trusting relationships, a tendency to be revictimized or victimize others, and a chronic sense of 

B. Although studies continue to show that PTSD is a distinct syndrome, comorbidity is frequently the rule rather than the exception; typical comorbid conditions include major depression, other anxiety disorders and substance abuse.

C. Exposure to trauma that dose not result in PTSD can create long-standing symptoms, including depressed and anxious mood, and damage to the victim's sense of self. However, in the absence of PTSD, exposure to trauma itself does not appear to be a risk factor for specific psychiatric diagnoses.

D If a person develops PTSD following a trauma, he or she is at far greater risk of developing other psychiatric disorders such as major depression, other anxiety disorders or substance abuse, as compared with a person who was exposed to the trauma, but did not develop PTSD

E Major depressive disorder is a risk factor for PTSD, and PTSD is a risk factor for major depressive disorder. Often they can develop at the same time.

F. Epidemiological Area Catchment Studies showed 60-80% lifetime comorbidity with PTSD cases compared to 15% in controls.

G. In a study on Vietnam veterans, 50% of veterans with current PTSD met criteria for another DSM-III diagnosis 6 months prior to an assessment versus 11.5% of veterans without PTSD. Another study showed that lifetime comorbidity in Vietnam veterans with PTSD is near 99%, including substance abuse, depression, anxiety disorders and antisocial personality disorder.

VIII. Neurobiology of PTSD

The neurobiology of PTSD is a rapidly advancing field of study. Although there is no single model that completely explains the pathophysiology of the disorder, data support the fact that PTSD is a discrete illness with biological correlates.

A. Review of the Neurobiology of the Normal Stress Response

1. Norepinephrine plays a role in orienting to new stimuli, selective attention and autonomic arousal. The locus caeruleus, located in the Pons, contains a large number of the brain's noradrenergic cell bodies that project throughout the brain.

2. Cortisol stimulates metabolic processes that prepare the body for fight or flight, cortisol also modulates the stress-response by counter-acting catecholamines and restoring homeostasis; cortisol provides negative feedback for the stress response.

3. Endogenous opiates increase the pain threshold.

4. Neurotransmitters are linked together in a web of feedback loops; for example, during stress, corticotropin releasing factor (CRF) increases the turnover of norepinephrine (NE), and NE increases concentrations of CRF in the locus caeruleus.

5. Serotonin appears to play a role in regulating the stress response.

6. In this theoretical scenario proposed by Rauch (1998), the limbic system and the cerebral cortex process a stressful event. The thalamus relays information about threat to the prefrontal cortex and amygdala. The amygdala is a limbic structure that is involved in threat assessment, emotional learning, fear conditioning; it attaches emotional significance to incoming stimuli and facilitates the flight or fight response. The amygdala relays information to the hippocampus, paralimbic system, sensory processing systems and other structures. The hippocampus, a limbic structure, is involved in learning and memory, especially verbal information, events, places and facts; it processes contextual information and provides feedback to the amygdala regarding past experience and current context. The anterior cingulate cortex, a part of the paralimbic system, may set priorities between emotional and cognitive processes and may play a role in regulating the amygdala.

B. The Neurobiology of PTSD

1. It is hypothesized that abnormalities in the sympathetic branch of the autonomic nervous system play a role in the symptoms of intrusion and arousal

a. Animal models have shown that severe stress can cause dysregulation of the locus caeruleus, causing hypersensitivity to external stimuli.

b. Combat veterans suffering from PTSD have exaggerated heart rate responses during exposure to combat related stimuli, as compared with combat veterans without PTSD and veterans with other anxiety disorders.

c. Some studies have suggested that urinary excretion of norepinephrine is higher in patients with PTSD as compared with controls.

2. Abnormalities of the hypothalamic-pituitary-adrenal (HPA) axis, especially in regards to cortisol, are a principle finding in PTSD

a. In PTSD, cortisol levels are chronically decreased, there is increased glucocorticoid receptor sensitivity, stronger negative feedback and sensitization of the HPA system. In sharp contrast, in acute and chronic stress and major depression cortisol levels are increased, there is decreased glucocorticoid receptor responsiveness, a decrease in negative feedback, and desensitization of the HPA system. Yehuda (1999)

b. Patients with PTSD can show lower cortisol levels up to 50 years following the initial trauma.

c. Lower cortisol levels immediately following a trauma can be a risk factor for developing PTSD at a later date. Studies have found that following a rape, low cortisol was associated with prior rape or assault, which in turn was the strongest predictor of subsequent PTSD.

d. In animal studies, high levels of cortisol are damaging to the hippocampus.

3. The hippocampus tends to be smaller in subjects with PTSD.

MRI measurement of hippocampal volume in patients with PTSD has been done in a few, very small studies. Findings tentatively suggest that patients with PTSD have slightly smaller hippocampal volumes, correlated with severity of traumatic exposure, cognitive deficits and PTSD symptoms. The significance of these findings is unclear; lower volumes may represent a premorbid risk factor, a result of exogenous toxins, or the result of elevated cortisol.

4. Functional Neuroimaging studies suggest a typical pattern of brain activation in the face of traumatic stimuli in patients with PTSD.

A very small number of subjects have been studied with functional neuroimaging, while stimulated with traumatic material. The findings very tentatively suggest that PTSD is associated with exaggerated activation of the amygdala and deactivation of Broca's area.

5. It has been hypothesized (Rauch 1998), that PTSD may involve a primary hypersensitivity of the amygdala or an inadequate inhibition of the amygdala by the hippocampus or the anterior cingulate. Van der Kolk (1994) has hypothesized that traumatic memories are laid down in the hippocampus under stress, and in this way traumatic memories remain as sensory fragments without an organized narrative.

6. Other biological models for PTSD include stress sensitization, fear conditioning and learned helplessness.

IX. Evaluation and Treatment Immediately Following a Traumatic Event

A. Immediately following a traumatic event, survivors rarely come to the attention of psychiatrists. Victims of trauma focus on practical concerns such as reestablishing safety, obtaining information, responding to medical or legal concerns, securing food, shelter, and connection with family and other social supports. Most people adapt to traumatic events without professional help and often decline an offer of such help. There is a great deal of interest in determining whether or not acute psychological intervention can have an impact on the subsequent development of post-traumatic symptoms. A variety of debriefing strategies have been developed and research findings are mixed. Some studies suggest that well-trained clinicians, working in teams, can implement a highly structure debriefing process in a group setting that can diminish the development of PTSD symptoms. Other studies suggest that such interventions can actually worsen

1. The goal of any intervention shortly following a traumatic event should be to help the individual regain a sense of mastery and control. Communicate a sense of hope and expectation of recovery.

2. Encourage the use of existing supports and refer for psychological treatment only those at high risk, although the option of follow-up should be made to all.

3. Pay attention to the practical and immediate concerns brought about by the traumatic event. Tell the patient any information available about the event.

4. Assess the patient's mental status to determine if he or she can manage safely with current available support. Dissociation can be pronounced, and can be an important risk factor for the subsequent development of PTSD.

5. Gently encourage the patient to review the trauma and surrounding events. If possible, identify the aspect of the trauma that was most distressing to the patient. However, the patient's capacity to tolerate the retelling must be considered. It is not necessarily helpful and can be harmful for the patient to become overwhelmed in recounting the trauma. The need for the

6. Assess the patient for risk factors for PTSD. Those at highest risk may need ongoing treatment.

7. Victims of rape, for example, need specialized follow-up. They will need a medical work-up that evaluates their physical well-being, appropriately documents findings for any legal proceedings, and provides a sense of safety. Referral for specialized psychological services, such as a rape-crisis center, can provide support, treatment, and assistance with legal issues.

8. Assess whether or not the patient is at risk for ongoing trauma, a victim of child or spousal abuse, for example. Children need immediate protection with the help of social service agencies. Victims of domestic violence come from all socio-economic groups; they will need encouragement to seek help and often are reluctant to acknowledge the extent of their danger. Patients who face persistent threat should be encouraged to write out a safety plan that details concrete steps they will take to avoid future trauma. These steps may include involving local law enforcement authorities. Although the clinician can encourage the patient to take step to protect him or herself it is ultimately the patient who must make that decision.

9. Tolerate the patient's feelings and help put them into context. It can be greatly reassuring for a patient to know that feelings of fear, helplessness, guilt, shame and anger are expectable responses to a traumatic event. The patient may need to be reassured that he or she is not "going crazy".

10. Educate the patients about the common responses to trauma, which can help them feel more in control of their experiences. Patients should be told that they may experience insomnia, nightmares, intrusive memories and irritability in the first few months or so after the trauma but these symptoms should then begin to subside.

11. Educate patients about possible maladaptive responses to trauma. Alcohol abuse is common as patients attempt to manage hyperarousal and intrusive symptoms.

12. Use medication sparingly. There is no long-term benefit from heavily sedating a patient following a trauma. Severe anxiety, agitation and insomnia may be treated with low-dose benzodiazepines. Supplies should be given for not more than several days and are contraindicated in patients with alcohol or substance abuse.

X. Evaluation of Patients with PTSD

Patients are evaluated for PTSD in a variety of settings; the evaluation may be part of a general psychiatric evaluation in which the PTSD is not yet diagnosed, or part of a course of treatment specific for PTSD. The evaluation needs to be tailored to the needs of the current circumstances. An

A. The time course of the patient's symptoms has important clinical implications. Symptoms may cause clinically significant impairment in the first month, as acute stress disorder, or in the following two months as post-traumatic stress disorder. One group of patients will improve and return to an acceptable level of functioning; while another group will go on to have chronic PTSD. After 3 months PTSD is a chronic psychiatric illness.

B. In a general psychiatric evaluation, screen for exposure to traumatic events throughout the life cycle. It may be more effective to ask about specific traumas rather than to ask about trauma in general, but introduce questions in a normalizing and non-judgmental manner. For example, a clinician might say," It is not uncommon for people to have been touched in ways they didn't want while they were growing up. Did you ever have the experience of being touched in a sexual or harsh way while you were a child?"

C. Be aware of how the interview is affecting the patient. Especially in regards to trauma, straightforward questions may evoke a sudden eruption of powerful and overwhelming feelings. Work with the patient to establish a tolerable level of distress appropriate for the circumstances of the interview. For example a clinician might say, "I realize that some of these questions may bring up strong feelings, let me know if this is something that might be difficult to talk about". If the patient cannot tolerate talking about the trauma itself, it may be useful for the clinician to shift the focus to the effects of the traumatic event on various aspects of the individual's life.

D. Offer the patient an opportunity to recount the traumatic event. Note the patient's capacity to tell the story. Some patients will find it helpful to talk about the event, some will be so overwhelmed they think or speak of nothing else, others will not be able to speak of the trauma at all.

E. Review the symptoms of PTSD and assess the intensity and the frequency of the patient's symptoms. Patients will frequently report intrusive and hyperarousal symptoms but rarely the avoidance and numbing symptoms that can be so disabling. Ask the patient how they cope with symptoms. Are there ways he or she has learned to come out of a flashback or to manage the irritability of hyperarousal?

F. Evaluate the patient's overall psychological, social, and occupational functioning. Has the patient been able to resume his or her usual activities? Is there difficulty resuming activities which the patient associates to the trauma? How is the patient relating to family and friends? Is there an increase in social isolation or feelings of alienation? Assess the patient's premorbid functioning; has the trauma

J. Evaluate the patient's strengths, and note the efforts made to successfully adapt to the trauma. Patients may present for treatment due to a precipitating factor that disrupts previously successful adaptation to a traumatic event.

K. Assess the patient's safety. Is there a risk for ongoing trauma?

XI. Guidelines for the Treatment of PTSD

Patients with PTSD vary in the severity of their illness and the time course of their recovery. Some patients utilize treatment to overcome overwhelming trauma, others appear to make little progress at all. For some patients, the passage of time and life events offer a chance for recovery; for other patients the trauma has made it impossible to move forward in life. The symptoms of PTSD can create a cycle that traps the patient within a world of the trauma. Traumatic memories, vivid, sensory and timeless, threatened to overwhelm the survivor. Efforts are made to cope with such powerful and disorganized memories; the threat from within is that any intense feeling may trigger a traumatic memory, the threat from without is that so many stimuli

A. Treatment generally involves an integration of several therapeutic approaches, including psychodynamic and cognitive-behavioral. Medication often plays an important adjunctive role.

B. Treatment is phase oriented; the initial goal is to stabilize the patient and address acute symptoms, the second phase involves working through the trauma, and the last phase focuses on reestablishing social relationships.

C. Stabilization can be a prolonged phase, and in some cases comprise the entire treatment. Education about post-traumatic experiences is the cornerstone of therapy. If patients can anticipate expectable post-traumatic responses they can feel less helpless. Identifying feelings and putting words to bodily experiences begins to organize a chaotic emotional world. As patients learn to notice how symptoms come

D. Treat comorbid disorders

E. Patients can work through the trauma in several different ways. Patients can learn to tolerate the traumatic memories and environmental triggers and become desensitized, thereby diminishing avoidance. As well, patients can begin to create a narrative of the traumatic event and understand its personal meaning. The reality of the trauma and its impact becomes integrated into the survivor's sense of self.

F. Ultimately, the patients must return to daily life in the community. Facilitating the development of social relationships is an important part of recovery from trauma.

G. Treating patients with PTSD can put the therapist under significant emotional strain. Hearing about the traumatic event and witnessing the patient's distress can be traumatic for the therapist, as well. It can be difficult for the therapist to maintain the necessary balance between seeing the patient as a helpless victim and as a survivor capable of taking responsibility.

H.  The therapist must balance the need for the patient to review the traumatic event with the danger that the patient will be traumatized by the retelling.

I. Patients with a history of childhood sexual abuse or patients with complex PTSD are often challenging to treat. These patients often have significant difficulties with affect regulation and trust. It may take years for a patient to develop a relationship with the therapist sufficiently robust to manage the exploration of the trauma. For such a patient learning impulse control, affect regulation, boundary management and basic positive self regard are prerequisites for exploration of the trauma itself.

XII. Psycho-Social Treatment Modalities for PTSD

A. Psychodynamic approaches are characterized by the following

1. This approach emphasizes exploration of the personal meaning of the traumatic event for the individual patient.

2. The impact of the trauma on the patient's self concept is explored; often feelings of shame, grief, and helplessness emerge. As the treatment progresses feelings of guilt and anger and fantasies of omnipotent control are frequently encountered.

3. Unresolved conflicts from earlier in life may be exacerbated by the trauma and dealt with in the treatment.

4. The patient's coping styles and defenses are noted. Patients who are experiencing flooding of affects are helped to organize themselves and those who are over-controlled and detached are helped to gain access to feelings. Patients may

B. Cognitive-behavioral approaches are characterized by the following:

1. The goal of treatment is the disruption of the link between trauma-related cues and the intense anxiety responses and avoidance that is typical for PTSD. Patients are taught to distinguish trauma memories and trauma-related emotions from current reality and thereby feel more in control of the world.

2. The technique often stimulates the patient to experience a traumatic memory in order to modify the response to that memory.

3. Patient education about the nature of the symptoms of PTSD establishes a focus of the treatment.

4. Patients identify underlying, distorted, "all-or-nothing" beliefs about the world following the trauma, for example, "I am a helpless person," the world is not a safe place," I am guilty for everything." These distorted thoughts can be addressed and altered.

5. Patients are taught ways to soothe themselves with relaxation techniques and guided imagery in order to manage PTSD symptoms

6. Patients are exposed to traumatic material and learn to respond in new ways, learning to distinguish real from

C. Group Treatment can be an important component of an overall treatment plan, providing support and information. For some patients group settings allow for a diffusion of the strong transference reactions that can impede treatment progress.

D. Eye Movement Desensitization and Reprocessing (EMDR)

1. Shapiro (1999) found that negative responses to disturbing memories and thoughts were attenuated with rapid eye movements. She developed a treatment used for PTSD based on the following technique:

a) Affect laden image of the trauma is constructed along with a summary statement

b) Subjective distress is rated

c) An alternate, positive statement is formulated

d) Eye movements are initiated by the patient following an object moving across the visual field, while the patient holds in mind the traumatic image

e) After 12-24 repetitions, the patient notes his or her subjective distress

f) The cycle is repeated 3-15 times until there is significant reduction in distress

2. The treatment is advocated as an adjunct to other modalities. Proponents suggest that several sessions can 

XIII. Pharmacotherapy of PTSD

A. Medication is an important adjunctive treatment for PTSD. Medication should be tailored to the stage of the illness and targeted for specific symptoms. Some level of anxiety may be necessary for the patient to make use of psychological treatment.

B. There are very few controlled studies of medication for PTSD; most recommendations are generally from open trials and

C. First line treatment includes selective serotonin reuptake inhibitors and anti-adrenergic agents.

1. Fluoxetine has been studied in double-blind, placebo controlled study, and has been found to be effective for intrusive, hyperarousal and numbing symptoms in civilian populations. Other SSRIs are also thought to be effective.

2. Clonidine and propranolol have been found to be effective for intrusive symptoms, especially flashbacks and nightmares, and for hyperarousal symptoms in open studies.

3. Nefazodone has recently been studied and found to be promising in populations of war veterans.

4. Tricyclic antidepressants have shown mixed results in controlled studies, but may be more effective in military veterans.

5. Monoamine oxidase inhibitors have been shown to be effective in intrusive symptoms, but these medications are rarely used because of dietary restrictions and drug interactions.

D. Benzodiazepines can be cautiously and sparingly used for hyperarousal symptoms; dependence and abuse are significant risks. They may also exacerbate dissociative symptoms.

E. Trazodone can be useful for insomnia. Mirtazapine and doxepin can also help with sleep.

F. Mood stabilizers, such as valproate, carbamazepine and lithium have been studied in small, open studies. They can be