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P. T. S. D.  – Veterans

 

Sources:

HelpGuide:

http://www.helpguide.org/articles/ptsd-trauma/ptsd-in-veterans.htm

http://www.helpguide.org/articles/stress/stress-relief-in-the-moment.htm

Veterans’ Administration:

http://www.ptsd.va.gov/public/family/ptsd-and-relationships.asp

 

HelpGuide

PTSD in Military Veterans

 

Symptoms, Treatment, and the Road to Recovery for Post-Traumatic Stress Disorder

Are you having a hard time readjusting to life outside the military? Are you always on edge, always on the verge of panicking or exploding, or, on the flip side, do you feel emotionally numb and disconnected from your loved ones? Do you believe that you’ll never feel normal again? For all too many veterans, these are common experiences—lingering symptoms of post-traumatic stress disorder (PTSD). It’s hard living with untreated PTSD and, with long V.A. wait times, it’s easy to get discouraged. But you can feel better, and you can start today, even while you’re waiting for professional treatment. There are things you can do to help yourself overcome PTSD and come out the other side even stronger than before.

 

What is PTSD?

    Post-traumatic stress disorder (PTSD), sometimes known as shell shock or combat stress, occurs after experiencing severe trauma or a life-threatening event. It’s normal for the mind and body to be in shock after such an event, but this normal response becomes PTSD when your nervous system gets “stuck.”

    The latest research into the brain shows that there are three ways of regulating the nervous system and responding to stressful events:

  • Social engagement is the most evolved strategy for keeping yourself feeling calm and safe. Socially interacting with another person—making eye contact, listening in an attentive way, talking—can quickly calm you down and put the brakes on defensive responses like “fight-or-flight.”
  • Mobilization, otherwise known as the fight-or-flight response, occurs when social engagement isn’t an appropriate response—such as in a combat situation—and you need to either defend yourself or escape the danger at hand. Your heart pounds faster, muscles tighten, blood pressure rises, breath quickens, and your senses become sharper. These physical changes increase your strength and stamina, speed your reaction time, and enhance your focus. Once the danger has passed, your nervous system then calms the body, slowing heart rate, lowering blood pressure, and winding back down to its normal balance.
  • Immobilization. Immobilization occurs when you’ve experienced a traumatic amount of stress—in combat, for example. The physical danger of war has passed but you find yourself “stuck,” your nervous system unable to return to its pre-stress state of balance. This is PTSD.

Who is affected by PTSD?

    Many military veterans develop symptoms of PTSD. In fact, military service is the most common cause of PTSD in men. Close to 30 percent of Afghanistan and Iraq War veterans treated at V.A. hospitals and clinics have been diagnosed with PTSD. For veterans who saw combat, the numbers are even higher, up to 49%.

    The more tours you made and the more combat you experienced, the more likely it is that you’ll develop PTSD. But however isolated or emotionally cut off from others you feel, it’s important to know that you’re not alone and there are things you can do to help yourself.

 

What are the symptoms of PTSD in veterans?

    Symptoms sometimes don’t surface for months or even years after returning from deployment. While PTSD develops differently from veteran to veteran, there are four symptom clusters:

  • Recurrent, intrusive reminders of the traumatic event, including distressing thoughts, nightmares, and flashbacks where you feel like it’s happening again. Experiencing extreme emotional and physical reactions to reminders of the trauma (panic attacks, uncontrollable shaking, heart palpitations, etc.).
  • Extreme avoidance of things that remind you of the traumatic event, including people, places, people, thoughts, or situations you associate with the bad memories. Withdrawing from friends and family and losing interest in everyday activities.
  • Negative changes in thoughts and mood, such as exaggerated negative beliefs about yourself or the world and persistent feelings of fear, guilt, or shame. Diminished ability to experience positive emotions and feeling detached from others.
  • Being on guard all the time, jumpy, and emotionally reactive, as indicated by irritability, angry outbursts, reckless behavior, difficulty sleeping, trouble concentrating, hypervigilance, and an exaggerated start response.

Suicide prevention in veterans with PTSD

    Suicidal thoughts and feelings are common symptoms of PTSD among military veterans. Feeling suicidal is not a character defect, and it doesn't mean that you are crazy, weak, or flawed.

    If you are thinking about taking your own life, seek help immediately. Please read Suicide Help, talk to someone you trust, or call a suicide helpline:

  • In the U.S., call 1-800-273-TALK (8255).
  • In the UK, call 08457 90 90 90.
  • In Australia, call 13 11 14.

    Or visit IASP to find a helpline in your country.

 

Self-help for PTSD in veterans

    While it’s common for veterans with PTSD to have to endure long waits for treatment at the V.A., there are plenty of things you can do for yourself to start feeling better.

    The job of recovery is to transition out of the mental and emotional war zone you’re still living in and help your nervous system return to its pre-war state of balance. As discussed above, the best way to regulate your nervous system is through social engagement—interacting with another human being, be it a loved one, a family member or a professional therapist. However, as a veteran with PTSD, you need to first become “unstuck” and move out of the immobilization stress response.

    With these recovery steps, you’ll learn how to deal with your combat stress and also learn skills that can benefit the rest of your post-war life. You’ll learn how to feel calm again, reconnect with others, deal with nightmares and flashbacks, cope with feelings of depression, anxiety, or guilt, and restore your sense of control. And when you do get to see a doctor or therapist at the V.A., you’ll be in a better position to benefit from professional treatment as well.

 

The Road to PTSD Recovery for Veterans, 7 Steps:

1)  The road to PTSD recovery step 1: Get moving

   Getting regular exercise has always been important for veterans with PTSD. As well as helping to burn off adrenaline, exercise can release endorphins and make you feel better, both mentally and physically. However, new research suggests that by really focusing on your body and how it feels as you exercise, you can actually help your nervous system become “unstuck” and move out of the immobilization stress response.

    Any exercise that engages both your arms and legs—such as running, swimming, basketball, or even dancing—will work well if, instead of continuing to focus on your thoughts as you exercise, you focus on how your body feels instead. Try to notice the sensation of your feet hitting the ground, for example, or the rhythm of your breathing, or the feeling of the wind on your skin. Many veterans find rock climbing, boxing, or martial arts especially effective as these activities make it easier to focus on your body movements—after all, if you don’t, you could get seriously hurt.                             

 

2)  The road to PTSD recovery step 2: Connect with others

   Social interaction with someone who cares about you is an effective way to calm your nervous system. For any veteran with PTSD, it’s important to find someone you can connect with face to face—someone you can talk to for an uninterrupted period of time, someone who will listen to you without judging, criticizing, or continually being distracted by the phone or other people. That person may be your significant other, a family member, one of your buddies from the service, or a civilian friend.

   You may feel like the civilians in your life can’t understand you since they don't know what it's like to be in the military or to have seen the things you have. But people don't have to have gone through the exact same experiences to understand and relate to painful emotions and be able to offer support. What matters is that the person you're turning to cares about you, is a good listener, and is able to be there for you as a source of strength and comfort.

    If you're not ready to open up about the details of what happened, that's perfectly okay. You can talk about how you feel without going into a blow-by-blow account of events.

    You can also tell the other person what you need or what they can do to help, whether it's just sitting with you, listening, or doing something practical. Comfort comes from someone else understanding your emotional experience. You’ll also find that people who care about you welcome the opportunity to help. Listening is not a burden for them but an opportunity.

How PTSD can get in the way of connecting with others

    Many veterans find that PTSD can leave them feeling disconnected, withdrawn and, while their nervous system is still stuck, make it tough to connect with other people. No matter how close they are to the person, or how helpful that person tries to be, they just don’t feel any better after talking with them. If that describes you, there are some things you can do to help the process along.

      Before you’re due to sit down with a friend over a alcohol or coffee, for example, take some time to exercise, as described in step 1 above. As well as calming you when you’re feeling anxious, irritable or on edge, physical movement can also open your nervous system’s pathway to social engagement. Think of it as shaking loose all the blockages to connecting with people.

    If working out isn’t practical, find a quiet place and take a few minutes before you meet your friend to move around, jump up and down, swing your arms and legs—in other words, flail around like you did as a three year old. A few minutes of that and you’ll be breathing heavily, your head will feel clearer, and you’ll be in a better place to connect.

    It may sound weird, but vocal toning is also a great way to open up your nervous system to social engagement—even if you can’t sing or consider yourself “tone-deaf.” Again, find a quiet place before hooking up with a buddy and, with your lips together and teeth slightly apart, simply make “mmmm” sounds. Change the pitch and volume until you experience a pleasant vibration in your face. Practice for a few minutes and notice if the vibration spreads to your heart and stomach as well.

Other ways to connect with others

    Many veterans find it helpful to join a PTSD support group or to connect with other veterans or trauma survivors. Listening to others' stories and struggles may help you feel less isolated.

    You can also volunteer in the community, which can help you feel more connected and useful, especially if you’re not currently working.

 

3)  The road to PTSD recovery step 3: More ways to calm your nervous system

    Just as loud noises, certain smells, or the feel of sand in your clothes  can instantly transport you back to the trauma of a combat zone, so too can sights, sounds, smells, and other sensory input quickly calm you down. The key is to find the sensory input that works for you.

    Think back to your time on deployment: what brought you comfort at the end of the day? Perhaps it was looking at photos of your family? Or maybe it was the taste of candy in a care package from home, or listening to a favorite song, or smelling a certain brand of soap or cologne? Or maybe petting an animal works quickly to make you feel calm and centered?

    Everyone responds to sensory input a little differently, so experiment to find what works best for you.

   

4)  The road to PTSD recovery step 4: Take care of your body

    The symptoms of PTSD can be hard on your body so it’s important to put a priority on sleep, exercise, healthy food, and relaxing activities.

    You may find it very difficult to relax at first. It’s common for veterans to be drawn to behaviors that pump up adrenaline. After being in a combat zone, that’s what feels normal. Without the rush, you feel strange or even dead inside. Things you may turn to for that familiar adrenaline rush include energy drinks, coffee, drugs, cigarettes, violent video games, and daredevil sports. If you recognize these urges for what they are, you can make better choices that will calm and care for your body and mind.

Healthy habits for veterans with PTSD

Here are some active steps you can take to improve your PTSD symptoms:

  • Take time to rest and restore your body’s balance. Relaxation techniques such as massage, meditation, yoga, and tai chi are powerful defensive weapons against the symptoms of PTSD.
  • Avoid alcohol and drugs (including nicotine). It can be tempting to turn to drugs and alcohol to numb painful feelings and memories and get to sleep. But substance abuse can make the symptoms of PTSD worse and compound your problems. The same goes for cigarettes.
  • Find safe ways to blow off steam. Pound on a punching bag, pummel a pillow, go for a hard run, sing along to loud music, head to the gym for a vigorous workout, go somewhere private where you can scream at the top of your lungs, or vent in your journal or to someone you trust.
  • Support your body with a healthy diet. Eat plenty of complex carbohydrates, such as potatoes and whole grains, to support mental clarity and physical stamina. Limit processed sugars, which can exacerbate mood swings and energy fluctuations.
  • Get plenty of sleep. Sleep deprivation exacerbates anger, irritability, and moodiness. Aim for somewhere between 7 to 9 hours of sleep each night. Develop a relaxing bedtime ritual (listen to calming music, watch a funny show, or read something light) and make your bedroom as soothing as possible. Use curtains to block outside light and if noise is a problem, try using a sound machine.

 

5)  The road to PTSD recovery step 5: Deal with flashbacks, nightmares, and intrusive thoughts

    Flashbacks usually involve visual and auditory memories of combat or other trauma you experienced. It feels as if it’s happening all over again so it’s vital for you to accept and reassure yourself that your traumatic experience is not occurring in the present.

    One effective technique is to state to yourself (either out loud or in your head) the reality that while you feel as if the trauma is currently happening, you can look around and recognize that you’re safe. Here’s a simple script you can use when you awaken from a nightmare or start to experience a flashback or intrusive thought:

    “I am feeling [panicked, overwhelmed, etc.] because I am remembering [traumatic event], but as I look around I can see that the event isn’t happening right now and I’m not actually in danger.”

    Other techniques that can be helpful in bringing you back to the present include tapping your arms or describing what you see when look around (name the place where you are, the current date, and three things you see when you look around).

 

Tips for grounding yourself during a flashback

If you’re starting to disassociate or experience a flashback, try using your senses to bring you back to the present and "ground" yourself. Experiment to find what works best for you.

Movement:  Move around vigorously (run in place, jump up and down, etc.); rub your hands together; shake your head    

Touch :  Splash cold water on your face; grip a piece of ice; touch or grab on to a safe object; pinch yourself; play with worry beads or a stress ball

Sight:  Blink rapidly and firmly; look around and take inventory of what you see          

Sound :  Turn on loud music; clap your hands or stomp your feet; talk to yourself (tell yourself you’re safe, that you’ll be okay)

Smell:  Smell something that links you to the present (coffee, mouthwash, your wife’s perfume) or a scent that has good memories         

Taste :  Suck on a strong mint or chew a piece of gum; bite into something tart or spicy; drink a glass of cold water or juice

 

6)  The road to PTSD recovery step 6: Work through survivor's guilt

    Feelings of guilt are very common among veterans with PTSD. You may have seen people injured or killed, often your friends and comrades. You may ask yourself questions such as:

  • Why didn’t I get hurt?
  • Why did I survive when others didn’t?
  • Could I have done something differently to save them?

    You may end up blaming yourself for what happened and believing that your actions (or inability to act) led to someone else’s death. You may feel like others deserved to live more than you—that you’re the one who should have died. This is survivor’s guilt.

 

Healing from survivor's guilt

    Healing doesn’t mean that you’ll forget what happened or those who died. And it doesn’t mean you’ll have no regrets. What it does mean is that you’ll look at your role more realistically. Remember, you are only human.

The following questions can help you “reality test” your guilty feelings:

  • Is the amount of responsibility you’re assuming reasonable?
  • Could you really have prevented or stopped what happened? 
  • Could you really have reacted differently?
  • Are you judging your decisions based on full information about the event, or just your emotions?
  • Did you do your best at the time, under challenging circumstances?
  • Do you truly believe that if you had died, someone else would have survived?

     Honestly assessing your responsibility and role can free you to move on and grieve your losses. Instead of punishing yourself, you can redirect your energy into honoring those you lost and finding ways to keep their memory alive. And in those cases where you truly believe you did something wrong, you can make amends. Even when you can’t make amends directly, there is always something you can do (such as volunteering for a cause that’s connected in some way to one of the friends you lost). The goal is to put your guilt to positive use, and thus transform tragedy, even in a small way, into something good.

 

7)  The road to PTSD recovery step 7: Seek professional treatment

    Under the guidance of an experienced therapist or doctor, there are several different types of professional treatment for PTSD available.

  • Cognitive-behavioral therapy or “counselling” involves carefully and gradually “exposing” yourself to thoughts and feelings that remind you of the event. Therapy also involves identifying distorted and irrational thoughts about the event—and replacing them with more balanced picture.
  • Medication, such as antidepressants, is sometimes prescribed to people with PTSD to relieve secondary symptoms of depression or anxiety. While antidepressants may help you feel less sad, worried, or on edge, they do not treat the causes of PTSD.
  • EMDR (Eye Movement Desensitization and Reprocessing) incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. These work by helping the nervous system become “unstuck.”

 

 

 

Veterans’ Administration

Relationships and PTSD

 

How does trauma affect relationships?

    Trauma survivors with PTSD may have trouble with their close family relationships or friendships. The symptoms of PTSD can cause problems with trust, closeness, communication, and problem solving. These problems may affect the way the survivor acts with others. In turn, the way a loved one responds to him or her affects the trauma survivor. A circular pattern can develop that may sometimes harm relationships.

 

How might trauma survivors react?

    In the first weeks and months following a trauma, survivors may feel angry, detached, tense or worried in their relationships. In time, most are able to resume their prior level of closeness in relationships. Yet the 5% to 10% of survivors who develop PTSD may have lasting relationship problems.

    Survivors with PTSD may feel distant from others and feel numb. They may have less interest in social or sexual activities. Because survivors feel irritable, on guard, jumpy, worried, or nervous, they may not be able to relax or be intimate. They may also feel an increased need to protect their loved ones. They may come across as tense or demanding.

    The trauma survivor may often have trauma memories or flashbacks. He or she might go to great lengths to avoid such memories. Survivors may avoid any activity that could trigger a memory. If the survivor has trouble sleeping or has nightmares, both the survivor and partner may not be able to get enough rest. This may make sleeping together harder.

    Survivors often struggle with intense anger and impulses. In order to suppress angry feelings and actions, they may avoid closeness. They may push away or find fault with loved ones and friends. Also, drinking and drug problems, which can be an attempt to cope with PTSD, can destroy intimacy and friendships. Verbal or physical violence can occur.

    In other cases, survivors may depend too much on their partners, family members, and friends. This could also include support persons such as health care providers or therapists.

     Dealing with these symptoms can take up a lot of the survivor's attention. He or she may not be able to focus on the partner. It may be hard to listen carefully and make decisions together with someone else. Partners may come to feel that talking together and working as a team are not possible.

 

How might loved ones react?

    Partners, friends, or family members may feel hurt, cut off, or down because the survivor has not been able to get over the trauma. Loved ones may become angry or distant toward the survivor. They may feel pressured, tense, and controlled. The survivor's symptoms can make a loved one feel like he or she is living in a war zone or in constant threat of danger. Living with someone who has PTSD can sometimes lead the partner to have some of the same feelings of having been through trauma.

    In sum, a person who goes through a trauma may have certain common reactions. These reactions affect the people around the survivor. Family, friends, and others then react to how the survivor is behaving. This in turn comes back to affect the person who went through the trauma.

 

Trauma types and relationships

Certain types of "man-made" traumas can have a more severe effect on relationships. These traumas include:

  • Childhood sexual and physical abuse
  • Rape
  • Domestic violence
  • Combat
  • Terrorism
  • Genocide
  • Torture
  • Kidnapping
  • Prisoner of war

    Survivors of man-made traumas often feel a lasting sense of terror, horror, endangerment, and betrayal. These feelings affect how they relate to others. They may feel like they are letting down their guard if they get close to someone else and trust them. This is not to say a survivor never feels a strong bond of love or friendship. However, a close relationship can also feel scary or dangerous to a trauma survivor.

 

Do all trauma survivors have relationship problems?

    Many trauma survivors do not develop PTSD. Also, many people with PTSD do not have relationship problems. People with PTSD can create and maintain good relationships by:

  • Building a personal support network to help cope with PTSD while working on family and friend relationships
  • Sharing feelings honestly and openly, with respect and compassion
  • Building skills at problem solving and connecting with others
  • Including ways to play, be creative, relax, and enjoy others

 

What can be done to help someone who has PTSD?

    Relations with others are very important for trauma survivors. Social support is one of the best things to protect against getting PTSD. Relationships can offset feelings of being alone. Relationships may also help the survivor's self-esteem. This may help reduce depression and guilt. A relationship can also give the survivor a way to help someone else. Helping others can reduce feelings of failure or feeling cut off from others. Lastly, relationships are a source of support when coping with stress.

    If you need to seek professional help, try to find a therapist who has skills in treating PTSD as well as working with couples or families. For resources, please see our Where to Get Help for PTSD page.

Many treatment approaches may be helpful for dealing with relationship issues. Options include:

  • One-to-one and group therapy
  • Anger and stress management
  • Assertiveness training
  • Couples counseling
  • Family education classes
  • Family therapy
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A Clinicians’ Guide to

Medications for Combat PTSD

by Matt Jeffreys, M.D.

 Sources:

Veterans’ Administration:

http://www.ptsd.va.gov/professional/treatment/overview/clinicians-guide-to-medications-for-ptsd.asp

 

 

Veterans’ Administration

A Clinician's Guide to Medications for Combat PTSD

by Matt Jeffreys, M.D.

Overview

    Posttraumatic Stress Disorder (PTSD) has biological, psychological, and social causes and implications. Medications can be used to ameliorate the biological basis for PTSD symptoms along with co-morbid psychiatric diagnoses, and may benefit psychological and social symptoms as well. Studies suggest that cognitive behavioral therapies such as prolonged exposure (PE) therapy and Cognitive Processing Therapy (CPT) have greater effects on PTSD symptoms than medications, but some people may prefer medications or may benefit from receiving a medication in addition to psychotherapy.

    It is crucial to consider the level of evidence available for specific medication interventions being considered. Trials which are randomized, placebo-controlled, and double blinded are the gold standard for guiding pharmacotherapy decision making. Less strongly supported evidence includes open trials and case reports. It is vital for the clinician to question the level of evidence supporting the medications being prescribed for PTSD, because there are a variety of influences on prescribing, including marketing, patient preferences, and clinical custom, all of which can be inconsistent with the evidence base.

    The current evidence base is strongest for the selective serotonin reuptake inhibitors (SSRIs), and currently only sertraline (Zoloft) and paroxetine (Paxil) are approved by the Food and Drug Administration (FDA) for PTSD (1, 2). All other medication uses are off label, though there are differing levels of evidence supporting their use. For example, there is strong evidence for the SSRI fluoxetine (Prozac) and for the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor) which are first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD. However, Veterans whose PTSD symptoms have been present for many years pose a special challenge. Studies indicate they are more refractory to the beneficial effects of medications for PTSD symptoms (3).

 

What core PTSD symptoms are medications targeting?

The four main PTSD symptom clusters of the DSM-5 criteria are listed below:

  • Intrusion. Examples include nightmares, unwanted thoughts of the traumatic events, flashbacks, and reacting to traumatic reminders with emotional distress or physiological reactivity.
  • Avoidance. Examples include avoiding triggers for traumatic memories including places, conversations, or other reminders.
  • Negative alterations in cognitions and mood. Examples include distorted blame of self or others for the traumatic event, negative beliefs about oneself or the world, persistent negative emotions (e.g., fear, guilt, shame), feeling alienated, and constricted affect (e.g., inability to experience positive emotions).
  • Arousal and reactivity. Examples include angry, reckless, or self-destructive behavior, sleep problems, concentration problems, increased startle response, and hypervigilance.

 

What is the current understanding of the biological disturbances found in PTSD?

    The biological disturbances in PTSD can be conceptualized as a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and the balance between excitatory and inhibitory brain neurocircuitry. There is a resultant dysregulation of adrenergic mechanisms that mediate the classical fight-flight or freeze response. Yehuda and others have found that patients with PTSD have hypersensitivity of the HPA axis as compared to patients without PTSD and have a much greater variation in their levels of adrenocorticoids (4).

    Other researchers have found differences between patients with PTSD and those without in both brain structures and brain circuits that process threatening input. It is not known for certain whether these changes were present before the traumatic event and predisposed the person to developing PTSD or if these changes were the result of the PTSD. The fear circuitry becomes hypersensitive in PTSD and is no longer integrated well with the executive planning and judgment centers in the prefrontal cortex (5). Even minor stresses may then trigger the "fight or flight" response, which leads to increased heart rate, sweating, rapid breathing, tremors, and other symptoms of hyperarousal in patients with PTSD.

 

How do medications help regulate these responses?

    The medications prescribed for treating PTSD symptoms act upon neurotransmitters related to the fear and anxiety circuitry of the brain including serotonin, norepinephrine, GABA, and dopamine, among many others. There is great interest in developing agents with novel and more specific mechanisms of action than are currently available to target the PTSD symptoms described earlier while also minimizing potential side effects.

    Studies show that a number of medications are helpful in minimizing PTSD symptoms. Most of the time, medications do not entirely eliminate symptoms but provide a symptom reduction and are sometimes more effective when used in conjunction with an ongoing program of trauma specific psychotherapy for patients, such as PE or CPT.

 

What are current clinical tools to measure treatment outcomes?

    There are a number of self-rating scales and structured clinical interviews to monitor the effects of treatment. Two examples include the Post-Traumatic Stress Disorder Checklist (PCL) and the Clinician-Administered PTSD Scale (CAPS). The PCL is an example of a patient self-rating form without stressor information, while the CAPS is an example of a structured clinical interview including Criterion A stressor information recorded on the Life Events Checklist. For further information or to obtain these measures, see Assessments.

    While the CAPS is preferred for initial evaluation, there is literature supportive of a strong correlation between the two measures, and the PCL has the advantage of being quick and easy to administer as a follow up measure for PTSD symptom severity. Both the PCL and the CAPS provide a quantitative measure of the patient's PTSD symptoms and response to treatment over time. This information enhances the clinical assessment and interview with the patient.

 

What is the evidence for specific classes of medications used for PTSD treatment?

Selective Serotonin Reuptake Inhibitors (SSRIs)

    The neurotransmitter serotonin has a well recognized role in the modulation of a number of mood and anxiety disorders. A deficiency in amygdala serotonin transport has been identified in some individuals with PTSD (6). The level of this neurotransmitter in both the peripheral and central nervous systems can be modulated by the selective serotonin reuptake inhibitors (SSRI's). The SSRI's are the only medications approved by the FDA for PTSD. SSRI's have the strongest empirical evidence for reducing PTSD symptoms with well-designed randomized controlled trials (RCTs), and they are the preferred initial class of medications used in PTSD treatment (1, 2). Exceptions may occur for patients based upon their individual histories of side effects, response, comorbidities, and personal preferences.

    An example of an exception would be a PTSD patient with comorbid bipolar disorder. In this patient, there is a risk of precipitating a manic episode with the SSRIs which could be mitigated by mood stabilization (with anti-epileptic medications) before prescribing SSRIs. Another example would be intolerable sexual dysfunction or gastrointestinal side effects due to the effects of increased serotonin levels in the peripheral nervous system. Each patient varies in their response and ability to tolerate a specific medication and dosage, so medications must be tailored to individual needs.

    Research indicates that maximum benefit from SSRI treatment depends upon adequate dosages and duration of treatment, and ensuring treatment adherence is key to successful pharmacotherapy for PTSD. Some typical dosage ranges for SSRI's in the treatment of PTSD are listed below: [see website for dosage ranges]

    Note: Only sertraline and paroxetine have been approved for PTSD treatment by the FDA. All other medications described in this guide are being used "off label" and have empirical support and practice guideline support only.

 

Other antidepressants for PTSD

    Antidepressants that affect the balance of serotonergic and noradrenergic neurotransmission or which alter serotonin neurotransmission through other mechanisms of action are also helpful in PTSD. Venlafaxine acts primarily as a serotonin reuptake inhibitor at lower dosages and as a combined serotonin and norepinephrine reuptake inhibitor at higher dosages. It is now a recommended first-line treatment for PTSD in the revised VA/DoD Clinical Practice Guideline for PTSD based upon large multi-site RCTs (7).

    There have been smaller RCTs with mirtazapine as well as open trials (8). Mirtazapine has a unique mechanism of action affecting both serotonin and norepinephrine through blockade of the pre-synaptic alpha 2-adrenergic inhibitory autoreceptor for norepinephrine and blockade of post-synaptic 5-HT2 and 5-HT3 receptors. Because of its mechanism of action, it may cause less sexual dysfunction than the SSRI's. Mirtazapine may be particularly helpful for treatment of insomnia in PTSD. Trazodone is also commonly used for insomnia in PTSD even though there is little empirical evidence available for its use. A large multisite trial of trazadone is currently in progress.

    Nefazodone affects serotonin by blocking the 5-HT2 receptor, and is still available in a generic form but carries a black box warning regarding liver failure (1 per 250,000 patient-years), so liver function tests need to be monitored and precautions taken as recommended in the medication's prescribing information (9,10). Nefazodone has lower levels of sexual dysfunction than the SSRI's and enhances sleep.

    Examples of antidepressants with novel mechanisms of action prescribed for PTSD and some typical dosage ranges are listed below:  [see website for dosage ranges]

    All of the antidepressants described above are also effective in treating comorbid major depressive disorder (MDD) which depending upon the study, accompanies PTSD about fifty percent of the time. While bupropion is useful in treating comorbid MDD, it has not been shown effective for PTSD in controlled trials (11).

 

Mood stabilizers for PTSD

    These medications, also known as anticonvulsants or anti-epileptic drugs, affect the balance between the excitatory neurotransmitter glutamate and the inhibitory neurotransmitter gamma-amino-butyric acid (GABA) by acting at their neuronal receptor sites. Topiramate has demonstrated promising results in randomized controlled trials with civilians and Veterans with PTSD, but currently is listed as having no demonstrated benefit in the VA/DoD Clinical Practice Guideline for PTSD.

    There are two double-blind, placebo-controlled trials evaluating topiramate as monotherapy in civilians with PTSD (13,14). The trial published in 2007 included 38 participants and found no significant difference in total CAPS scores between topiramate and placebo. The 2010 trial included 38 participants and demonstrated a significant decrease in total CAPS scores. There are also two published double-blind, placebo-controlled trials evaluating topiramate as adjunctive treatment for PTSD in Veterans (15,16). The trial published in 2004 included 67 participants and found a significant decrease in the total CAPS score. The 2007 trial included 40 participants and showed no significant decrease in total CAPS scores.

    Based upon the current studies, topiramate could provide a useful option for clinicians in treatment of PTSD symptoms in patients who fail first-line pharmacotherapy. Further studies are needed regarding the place of topiramate in PTSD treatment (17). A recent meta-analysis showed strong support for the use of topirimate in PTSD finding it to be similar to paroxetine in its efficacy (18). Additionally, topiramate has been found helpful in reducing alcohol consumption in those with an alcohol use disorder and could prove beneficial in the PTSD patient dually diagnosed with an alcohol use disorder (19).

    As for other mood stabilizers for PTSD, few published results are negative or mixed. Despite some promising open label data, two RCTs have been negative for divalproex in treating PTSD (20, 21). A small trial of lamotrigine in 15 individuals with PTSD demonstrated possible benefit (22). In summary, the effectiveness of mood stabilizers, as a class, remains uncertain.

    Mood stabilizers are definitely indicated for bipolar disorder whether or not it is comorbid with PTSD, through both mood stabilization of the bipolar disorder and avoiding precipitation of a manic episode with the SSRI's. Divalproex and carbamazepine require regular lab work to monitor side effects, but neither lamotrigine nor topiramate require lab work but must be titrated slowly according to package insert directions to avoid potentially serious side effects. Examples are given below:

  • Carbamazepine (Tegretol). Requires monitoring of white blood cell counts due to risk of agranulocytosis. Will self-induce its own metabolism and increase the metabolism of other medications including oral contraceptives.
  • Divalproex (Depakote). Requires monitoring of liver function tests due to risk of hepatotoxicity and platelet levels due to risk of thrombocytopenia. Target dosage is 10 times the patient's weight in pounds.
  • Lamotrigine (Lamictal). Requires slow titration according to the package insert due to risk of serious rash.
  • Topiramate (Topimax). Requires clinical monitoring for glaucoma, sedation, dizziness and ataxia.

Atypical antipsychotics for PTSD

    While originally developed for patients with a psychotic disorder, there has been an interest in these medications as treatment for many other psychiatric disorders including PTSD. This would seem reasonable given their effects on the balance between dopaminergic and serotonergic neurotransmitter systems. The dopaminergic system has well established effects on reward and gratification and the serotonin system on mood and anxiety. The antipsychotics ameliorate psychotic symptoms in PTSD patients. The real question is whether these medications are useful for core PTSD symptoms when psychotic symptoms are not present.

    Previously, a number of small single-site studies suggested that atypical antipsychotic agents were effective adjunctive treatment for PTSD patients who had poor responses to first-line SSRIs or SNRIs (23). A recent large-scale multi-site trial of risperidone as an adjunctive agent for SSRI poor/partial responders showed that there was no benefit (in comparison with a placebo group) for adjunctive use of this agent (24). As a result the recent VA/DoD PTSD Clinical Practice Guideline has been revised as follows:

    Atypical antipsychotics are not recommended as monotherapy for PTSD.

  • Risperidone (Risperdal) is contraindicated for use as an adjunctive agent - potential harm (side effects) exceeds benefits.

    There is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD.

 

Other medications for PTSD

    There are a number of other medications that can be helpful for specific PTSD symptoms or that have been used as second line agents including the following:

  • Prazosin (Minipress)
  • Tricyclic Antidepressants (such as Imipramine)
  • Monoamine Oxidase Inhibitors (MAOIs) (such as Phenelzine)

    Prazosin has been found to be effective in RCTs in decreasing nightmares in PTSD. This is logical given its blockade of the neurotransmitter norepinephrine at the post-synaptic alpha-1 receptor. Its effectiveness for PTSD symptoms other than nightmares has not been determined at this time (25). However, a recent trial with military personnel using prazosin during the day in addition to bedtime for nightmares shows a significant reduction in daytime PTSD symptoms as well as nightmares (26). This research provides a possible extension of the therapeutic effects of prazosin in PTSD.

    The tricyclic antidepressants and MAOIs act on multiple neurotransmitters including serotonin and norepinephrine. The tertiary tricyclics such as imipramine and amitriptyline which are more serotonergic were thought to be more beneficial in PTSD treatment than the secondary amines such as nortriptyline and desipramine which are more adrenergic (27, 28). However, a recent study demonstrated no difference between desipramine and paroxetine in reducing PTSD symptoms (29). While there are RCTs supporting their use, these medications are not used as first-line agents due to their safety and side effect profiles. This is because tricyclics have quinidine-like effects on the heart and can cause ventricular arrhythmias through QT prolongation especially in overdose. On the other hand, they do not usually cause the sexual side effects seen with SSRIs.

    The MAOI phenezine has been shown to be effective in PTSD. The MAOI's increase a number of neurotransmitters, such as serotonin, norepinephrine, and dopamine, through inhibition of their degradation by the enzyme monoamine oxidase. Careful management of the MAOIs and strict dietary controls are important because they can cause potentially fatal hypertensive reactions when taken with other medications or certain foods rich in tyramine. MAOIs can also provoke the potentially fatal serotonin syndrome when used concurrently with SSRIs.

    Buspirone and beta blockers are sometimes used adjunctively in treatment of hyperarousal symptoms, though there is little empirical evidence in support of their use. Buspirone is an agonist at the pre-synaptic serotonin 5-HT(1A) receptor and a partial agonist at the post-synaptic serotonin 5-HT(1A) receptor and might reduce anxiety in PTSD without sedation or addiction. There are some case reports but no randomized trials supporting its use. Beta blockers block the effects of adrenalin (epinephrine) at the post-synaptic beta-adremergic receptor located on organs such as the heart, sweat glands, and muscles. There is interest in using beta blockers to prevent PTSD, though the evidence at the current time does not support this. Beta blockers reduce the peripheral manifestations of hyperarousal and may reduce aggression as well. They may be used for comorbid conditions such as performance anxiety in the context of social phobia for example.

 

Benzodiazepines and PTSD

    Benzodiazepines enhance activity of GABA at the GABA-A receptor which produces CNS depression. This is the only potentially addictive group of medications discussed. Limited studies have not shown them to be useful in treating the core PTSD symptoms (30, 31). There are several other concerns about the use of benzodiazepines including potential disinhibition, difficulty integrating the traumatic experience, interfering with the mental processes needed to benefit from psychotherapy, increased falls and mental clouding in the elderly, and addiction. In a recent study combining PE and alprazolam, the group receiving alprazolam had a poorer outcome in PTSD symptom reduction than the group receiving PE alone (32). Because of these potentially negative effects, it is recommended that benzodiazepines must be used with great caution in PTSD. When they are used, short term use (e.g., no more than five days) with frequent re-evaluation for side effects is recommended. Examples of commonly used benzodiazepines are listed below:

  • Lorazepam (Ativan)
  • Clonazepam (Klonopin)
  • Alprazolam (Xanax)

 

What are some future research directions for pharmacotherapy?

    The pathophysiological mechanism of PTSD in the nervous system is unknown, but there are several interesting neurotransmitters and pathways that could lead to new drug development for the treatment or the prevention of PTSD. There are competing hypotheses about the role of glucocorticoids following trauma and their effects on the brain. It might be possible to intervene at some level in the HPA axis or at the level of the glucocorticoid receptors in the brain to modulate the effects of stress and the development of PTSD. Some research has implicated supplemental cortisol in reducing PTSD symptoms (33).

    In addition to corticotropin releasing factor (CRF) and adrenocorticotropin hormone (ACTH), other neuropeptides such as Substance P and Neuropeptide Y (NPY) have been implicated in PTSD (34). Combat troops exposed to stress have been found to have lower levels of NPY. Perhaps altering this neuromodulator could improve the resiliency of the brain to the effects of trauma. One challenge with this new focus research is dealing with the blood-brain barrier for introducing neuropeptides into the brain, but researchers have delivered the neuropeptide oxytocin intranasally through the olfactory pathway in veterans with PTSD and have demonstrated decrease in hyperarousal symptoms (35).

    D-cycloserine (DCS) has been used in panic disorder, specific phobia and social anxiety disorder, to enhance the effects of exposure therapy (36). It is a partial agonist of the glutamatergic N-methyl-D-aspartate (NMDA) receptor. Based upon animal research supporting the use of DCS to facilitate extinction of conditioned fear, it is hypothesized that use of DCS in conjunction with exposure therapy may reduce the number of psychotherapy sessions required (37). A recent study of DCS did not demonstrate a significant treatment benefit by adding the drug to PE. There were some interesting caveats, though of DCS reducing cortisol and startle reactivity more than placebo when combined with PE requiring further research (32). This line of research recognizes a paradigm shift in the use of pharmacotherapy as the major treatment modality for reducing PTSD symptoms to an adjunctive role of facilitating learning during psychotherapy , especially with regard to prolonged exposure (PE) therapy (38).

    Memantine (Namenda) is a drug of potential interest in preventing neurodegeneration by protecting against glutamatergic destruction of neurons through its antagonism of the NMDA receptor. It has been approved for use in certain neurodegenerative conditions such as Alzheimer's disease. This drug could be potentially useful in preventing hypothesized neurodegneration in the hypothalamus and memory loss in PTSD.

    Ketamine is an anesthetic agent which modulates the balance between glutamanergic activity at the NMDA receptor and serotonergic activity at the 5-HT receptors. This agent is showing promise for treatment of refractory depression in research trials currently (39). A recent trial showed beneficial effects in PTSD as well (40). The limitations so far include a short term benefit of a few weeks and the anesthetic nature of the drug and potential for addiction. However, this could lead to a new line of medication research and to newer agents with mechanisms of action distinct from serotonin and norepinephrine for treatment of PTSD.

    There is ongoing interest in the possibility of early intervention and promoting resiliency following trauma with psychotherapy, pharmacotherapy, or some combination that would prevent the development of PTSD. There are no currently recognized medications which prevent the development of PTSD after trauma.

 

What are common clinical barriers to successful medication treatment in PTSD?

    There are several common barriers to effective medication treatment for PTSD which are listed below. These need to be addressed with patients in an ongoing dialogue with their prescribing clinician. Side effects need to be examined and discussed, weighing the risks and the benefits of continued medication treatment. Patient education about the side effects, necessary dosages, duration of treatment, and adherence can improve outcomes to medications. A simple intervention of setting up a pill organizer weekly can go a long way to improve adherence.

  • Fear of possible medication side effects including sexual side effects
  • Feeling medication is a "crutch" and that taking it is a weakness
  • Fear of becoming addicted to medications
  • Taking the medication only occasionally when symptoms get severe
  • Not being sure how to take the medication
  • Keeping several pill bottles and not remembering when the last dosage was taken
  • Using "self medication" with alcohol or drugs with prescribed medications

Final thoughts about medications for treatment of PTSD

    A more comprehensive discussion of pharmacotherapy can be found online in the VA/DoD PTSD Clinical Practice Guidelines. Based upon current knowledge, most prescribing clinicians view pharmacotherapy as an important adjunct to the evidenced based psychotherapies for PTSD. While there are few direct comparisons of pharmacotherapy and psychotherapy, the greatest benefits of treatment appear to come from evidenced based therapies such as CPT and PE based upon the effect sizes in the literature. Patients need to be informed of the risks and benefits of the differing treatment options. When using a combined approach of medication and therapy, it is important to keep several practices in mind.

    If treatment is being provided by a therapist and a prescriber, it is important for the clinicians to discuss treatment response and to coordinate efforts. It is important for the prescribing clinician to have an ongoing dialogue with the patient about their medications and side effects. It is important for the patient to take an active role in his or her treatment rather than feeling they are a passive recipient of medications to alleviate their symptoms. There is emerging evidence that when given a choice, most patients will select psychotherapy treatment for their PTSD symptoms rather than medications.

 

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