PTSD in DSM 5
PTSD in DSM 5
PTSD in DSM 5
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened
serious injury, or actual or threatened sexual violence, as follows: (one required)
1.
Direct exposure.
2.
Witnessing, in person.
3.
Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event
involved actual or threatened death, it must have been violent or accidental.
4.
Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of
professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed
to details of child abuse). This does not include indirect non-professional exposure through
electronic media, television, movies, or pictures.
Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this
symptom in repetitive play.
2.
Traumatic nightmares. Note: Children may have frightening dreams without content related to the
trauma(s).
3.
Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to
complete loss of consciousness. Note: Children may reenact the event in play.
4.
5.
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event:
(one required)
1.
2.
Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to
head injury, alcohol, or drugs).
2.
Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g.,
"I am bad," "The world is completely dangerous").
3.
Persistent distorted blame of self or others for causing the traumatic event or for resulting
consequences.
4.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5.
6.
7.
2.
3.
Hypervigilance
4.
5.
Problems in concentration
6.
Sleep disturbance
Criterion F: duration
Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.
Criterion H: exclusion
Disturbance is not due to medication, substance use, or other illness.
Specify if:
2.
Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").
Specify if:
Full diagnosis is not met until at least six months after the trauma(s), although
onset of symptoms may occur immediately.
References
1.
American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders,
(5th ed.). Washington, DC: Author.
Ruth Lanius, MD, PhD, Mark Miller, PhD, Erika Wolf, PhD, Bethany Brand, PhD,
Paul Frewen, PhD, Eric Vermetten, MD, PhD, & David Spiegel, MD
The role of dissociation as the most direct defense against overwhelming
traumatic experience was first documented in the seminal work of Pierre Janet.
Recent research evaluating the relationship between Posttraumatic Stress
Disorder (PTSD) and dissociation has suggested that there is a dissociative
subtype of PTSD, defined primarily by symptoms of derealization (i.e., feeling as
if the world is not real) and depersonalization (i.e., feeling as if oneself is not
real). Confrontation with overwhelming experience from which actual escape is
not possible, such as childhood abuse, torture, as well as war trauma challenges
the individual to find an escape from the external environment as well as their
internal distress and arousal when no escape is possible. States of
depersonalization and derealization provide striking examples of how
consciousness can be altered to accommodate overwhelming experience that
allows the person to continue functioning under fierce conditions.
Similarly, states of derealization during which individuals experience that things are not real; it is
just a dream create the perception that this is not really happening to me and are often associated
with the experience of decreased emotional intensity.
Rationale
The recognition of a dissociative subtype of PTSD as part of the DSM-5 PTSD
diagnosis was based on three converging lines of research: (1) symptom
assessments, (2) treatment outcomes, and (3) psychobiological studies. Even
though dissociative symptoms such as flashbacks and psychogenic amnesia are
included as part of the core PTSD symptoms, evidence suggests that a subgroup
of PTSD patients exhibits additional symptoms of dissociation, including
depersonalization and derealization, thus warranting a subtype of PTSD
specifically focusing on these two symptoms. Recognizing a dissociative subtype
of PTSD has the potential to improve the assessment and treatment outcome of
PTSD.
Evidence
The addition of a dissociative subtype of PTSD in the upcoming DSM-5 was
based on three lines of evidence:
1.
Several studies using latent class, taxometric, epidemiological, and confirmatory factor analyses
conducted on PTSD symptom endorsements collected from Veteran and civilian PTSD samples
indicated that a subgroup of individuals (roughly 15 - 30%) suffering from PTSD reported symptoms
of depersonalization and derealization (1-3). Individuals with the dissociative subtype were more
likely: to be male, have experienced repeated traumatization and early adverse experiences, have
comorbid psychiatric disorders, and evidenced greater suicidality and functional impairment (4). The
subtype also replicated cross-culturally.
2.
3.
Early evidence suggests that symptoms of depersonalization and derealization in PTSD are
relevant to treatment decisions in PTSD (reviewed in Lanius et al., 2012;5). Individuals with PTSD
who exhibited symptoms of depersonalization and derealization tended to respond better to
treatments that included cognitive restructuring and skills training in affective and interpersonal
regulation in addition to exposure-based therapies (7,8). Additional research is needed to more fully
evaluate the effects of depersonalization and derealization on treatment response.
Assessment
The Clinician-Administered PTSD Scale (CAPS) includes items assessing
depersonalization ("Have there been times when you felt as if you were outside
of your body, watching yourself as if you were another person?") and
derealization ("Have there been times when things going on around you seemed
unreal or very strange and unfamiliar?"). In addition, there are several self-report
rating scales that assess dissociative symptomatology. These include the
Increased psychiatric comorbidity, in particular specific phobia and borderline and avoidant
personality disorders among women, but not men
Treatment concerns
Treatment studies specifically designed to examine clinical outcomes of
psychological and pharmacological treatment of PTSD in those with versus
without the dissociative subtype are needed. However, we do know that
individuals with dissociative PTSD may require treatments designed to directly
reduce depersonalization and derealization. For such individuals, exposure
treatment can lead to further dissociation and inhibition of affective response,
rather than the goal of cognitive behavioural/exposure therapy, which is
desensitization and cognitive restructuring.
There is preliminary evidence that relative to exposure-based therapies alone,
individuals with PTSD who exhibited symptoms of depersonalization and
derealization responded better to treatments that also included cognitive
restructuring and skills training in affective and interpersonal regulation (5,7,8).
Author Note: Dr. Ruth Lanius is a Professor of Psychiatry at Western University of
Canada; Drs. Mark Miller and Erika Wolf are Psychologists at the National Center
for PTSD at VA Boston Healthcare System; Dr. Bethany Brand is a Professor of
Psychology at Towson University; Dr. Paul Frewen is an Assistant Professor of
Psychiatry at Western University of Canada; Dr. Eric Vermetten is the Head of
Research Military Mental Health, Department of Psychiatry, University Medical
Center and Rudolf Magnus Institute of Neuroscience in Utrecht; Dr. David
Spiegel is Professor of Psychiatry at Stanford University.
References
1.
Steuwe, C., Lanius, R. A., & Frewen, P. A. (2012). The role of dissociation in civilian posttraumatic
stress disorder: Evidence for a dissociative subtype by latent class and confirmatory factor
analysis. Depression and Anxiety, 29,689-700. doi: 10.1002/da.21944
2.
Wolf, E. J., Lunney, C. A., Miller, M. W., Resick, P. A., Friedman, M. J., & Schnurr, P. P. (2012).
The dissociative subtype of PTSD: A replication and extension. Depression and Anxiety, 29, 679688. doi: 10.1002/da.21946
3.
Wolf, E. J., Miller, M. W., Reardon, A. F., Ryabchenko, K. A., Castillo, D., & Freund, R. (2012). A
latent class analysis of dissociation and posttraumatic stress disorder: Evidence for a dissociative
subtype. [Research Support, N.I.H., Extramural Research Support, U.S. Gov't, NonP.H.S.]. Archives of General Psychiatry, 69, 698-705. doi: 10.1001/archgenpsychiatry.2011.1574
4.
Stein, D. J., Koenen, K. C., Friedman, M. J., Hill, E., McLaughlin, K. A., Petukhova, M., Ruscio, A.
M., Shahly, C., Spiegel, D., Borges, G., Bunting, B., Calsa-de-Almeida, J. M., de Girolamo, G.,
Demyttenaere, K., Florescu, S., Haro, J. M., Karam, E. G., Kovess-Masfety, V., Lee, S., Matshinger,
H., Mladenova, M., Posada-Villa, J., Tachimori, H., Viana, M. C., & Kessler, R. C.
(2013). Dissociation in posttraumatic stress disorder: Evidence from the world mental health
surveys., 73, 302-312. doi: 10.1016/j.biopsych.2012.08.022
5.
Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The dissociative
subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and
implications. Depression and Anxiety, 29, 1-8. doi: 10.1002/da.21889
6.
Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., &
Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a
dissociative subtype. American Journal of Psychiatry, 167, 640-647. doi:
10.1176/appi.ajp.2009.09081168
7.
Cloitre, M., Petkova, E., Wang, J., & Lu Lassell, F. (2012). An examination of the influence of a
sequential treatment on the course and impact of dissociation among women with PTSD related to
childhood abuse.Depression and Anxiety, 29, 709-717. doi: 10.1002/da.21920
8.
Resick, P. A., Suvak, M. K., Johnides, B. D., Mitchell, K. S., & Iverson, K. M. (2012). The impact of
dissociation on PTSD treatment with cognitive processing therapy. Depression and Anxiety,
29, 718-730. doi: 10.1002/da.21938
Michael Scheeringa, MD
A challenge for the Diagnostic and Statistical Manual (DSM) taxonomy has
always been to consider developmental differences in the expressions of
disorders in different age groups. Research has suggested that individuals of
different ages may express features of the same criteria somewhat differently.
Furthermore, there may be sufficient differences in the expressions of some
disorders to justify an age-related subtype of the disorder. This is important to
consider particularly in Posttraumatic Stress Disorder (PTSD) because, although
PTSD has been widely reported in children and adolescents, the DSM-IV criteria
were developed before substantial numbers of studies had been conducted on
young children (1).
The Fifth Edition of the DSM (DSM-5) includes a new developmental subtype of
PTSD called Posttraumatic Stress Disorder in preschool children. As the first
developmental subtype of an existing disorder, this represents a significant step
for the DSM taxonomy. Since an alternative diagnostic set of criteria was initially
proposed by Michael Scheeringa and Charles Zeanah (2), the criteria have been
refined empirically (3,4), and endorsed by a task force of experts on early
childhood mental health (5). While the bulk of the empirical research that
supports this disorder was conducted on three- to six-year-old preschool
children, the studies often included one- to two-year-old toddlers. These studies
showed that when a developmentally-sensitive set of criteria were used
approximately three to eight times more children qualified for the diagnosis
compared to the DSM-IV (3,6).
Abuse (7)
Dog bites
The major change was to require only one symptom in either the avoidance
symptoms or negative alterations in cognitions and mood, instead of the DSM-IV
threshold of three symptoms. The number of these symptoms that are possible to
detect is simply fewer compared to adults. The symptoms of "loss of interests,"
"restricted range of affect," "detachment from loved ones," and "avoidance of
thoughts or feelings related to the trauma" manifest in young children but are
consistently ranked as some of the least frequent among the PTSD symptoms
(15). The symptoms of "sense of a foreshortened future" and "inability to recall an
important aspect of the event" were deleted because of the developmental
challenges in manifesting and/or detecting them.
The wording of two symptoms was modified to enhance face validity and
symptom detection. Diminished interest in significant activities may manifest as
constricted play. Feelings of detachment or estrangement may be manifest more
behaviorally as social withdrawal.
Increased arousal symptoms
Being the most behavioral and observable types of symptoms, few changes
seem to be needed for these problems. The symptoms "irritability or outbursts of
anger" was modified to include "extreme temper tantrums" to enhance face
validity.
References
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(1998). Posttraumatic Stress Disorder Field Trial: Evaluation of the PTSD construct - criteria A
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childhood: an empirical assessment of four approaches. Journal of Traumatic Stress, 25 (4), 359367.
4.
Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2003). New findings on alternative
criteria for PTSD in preschool children. Journal of the American Academy of Child and Adolescent
Psychiatry, 42 (5), 561-570. doi: 10.1097/01.CHI.0000046822.95464.14.
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Task Force on Research Diagnostic Criteria: Infancy and Preschool. (2003). Research diagnostic
criteria for infants and preschool children: The process and empirical support. Journal of the
American Academy of Child and Adolescent Psychiatry, 42, 1504-1512.
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Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in children and adolescents:
Towards an empirically based algorithm. Depression and Anxiety, 28 (9), 770-782.
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Scheeringa, M. S., & Zeanah, C. H. (2008). Reconsideration of harm's way: Onsets and
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procedural, criterion, and discriminant validity for PTSD in early childhood. Journal of the American
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Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM5. Depression and Anxiety, 28 (9), 750-769.
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children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52 (8), 853-860.
The three clusters of DSM-IV symptoms are divided into four clusters in DSM-5: intrusion,
avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.
DSM-IV Criterion C, avoidance and numbing, was separated into two criteria: Criteria C (avoidance)
and Criteria D (negative alterations in cognitions and mood). The rationale for this change was
based upon factor analytic studies, and now requires at least one avoidance symptom for PTSD
diagnosis.
Criteria D (negative alterations in cognitions and mood): persistent and distorted blame of
self or others, and persistent negative emotional state
Criterion A2 (requiring fear, helplessness, or horror happen right after the trauma) was removed in
DSM-5. Research suggests that Criterion A2 did not improve diagnostic accuracy (2).
A clinical subtype "with dissociative symptoms" was added. The dissociative subtype is applicable
to individuals who meet the criteria for PTSD and experience additional depersonalization and
derealization symptoms (3).
Separate diagnostic criteria are included for children ages 6 years or younger(preschool subtype)
(4).
Prevalence rates
Based on initial analyses of the DSM-5 criteria, the prevalence of PTSD will be
similar to what it is currently in DSM-IV (5,6). Research also suggests that
similarly to DSM-IV, prevalence of PTSD for DSM-5 was higher among women
than men, and prevalence increased with multiple traumatic event exposure (6).
National estimates of PTSD prevalence suggest that DSM-5 rates were slightly
lower than DSM-IV (6). Discordant findings in diagnostic prevalence were
attributable to three major changes in the DSM-5 criteria for PTSD:
The revision of Criterion A1 in DSM-5 narrowed qualifying traumatic events such that the
unexpected death of family or a close friend due to natural causes is no longer included. Research
suggests this is the greatest contributor (>50%) to discrepancy for meeting DSM-IV but not DSM-5
PTSD criteria.
Splitting DSM-IV Criterion C into two criteria in DSM-5 now requires that a PTSD diagnosis must
include at least one avoidance symptom.
Criterion A2, response to traumatic event involved intense fear, hopelessness, or horror, was
removed from DSM-5.
Sources
1.
2.
Friedman, Matthew J; Resick, Patricia A; Bryant, Richard A; Brewin, Chris R (Sep 2011).
Considering PTSD for DSM-5. Depression and Anxiety 28. 9 : 750769. http://www.ptsd.va.gov/professional/articles/article-pdf/id35490.pdf
3.
Lanius, R., Brand, B., Vermetten, E., Freewn, P. A., & Spiegel, D. (2012). The dissociative
subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and
implications. Depression and Anxiety, 29, 701-708. doi: 10.1002/da.21889
4.
Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in children and adolescents:
toward an empirically based algorithm. Depression and Anxiety, 28, 770-782. doi:10.1002/da20736
5.
Miller, Mark W; Wolf, Erika Jane; Kilpatrick, Dean G; Resnick, Heidi S; Marx, Brian P; et al. (Sep
3, 2012). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder
symptoms in U.S. national and veteran samples. Psychological Trauma: Theory, Research,
Practice, and Policy. http://www.ptsd.va.gov/professional/articles/article-pdf/id39382.pdf
6.
Kilpatrick, D., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J.
(2013). National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV
and Proposed DSM-5 Criteria[Manuscript submitted for publication].
Symptoms included in the "D" or negative cognitions and mood criterionreflect persistent
alterations in beliefs or mood that have developed after exposure to the traumatic
event. People with PTSD often have erroneous cognitions about the causes or
consequences of the traumatic event which leads them to blame themselves or
others. A related erroneous appraisal is the common belief that one is
inadequate, weak, or permanently changed for the worse since exposure to the
traumatic event or that one's expectations about the future have been
permanently altered because of the event (e.g., "nothing good can happen to
me," "nobody can be trusted," "the world is entirely dangerous," "people will
always try to control me"). In addition to negative appraisals about past, present
and future, people with PTSD have a wide variety of negative emotional states
such as anger, guilt, or shame. Dissociative psychogenic amnesia is included in
this symptom cluster and involves cutting off the conscious experience of traumabased memories and feelings. Other symptoms include diminished interest in
significant activities and feeling detached or estranged from others. Finally,
although individuals with PTSD suffer from persistent negative emotions, they
are unable to experience positive feelings such as love, pleasure or enjoyment.
Such constricted affect makes it extremely difficult to sustain a close marital or
otherwise meaningful interpersonal relationship.
Symptoms included in the "E" or alterations in arousal or reactivity criterion most closely
resemble those seen in panic and generalized anxiety disorders. While
symptoms such as insomnia and cognitive impairment are generic anxiety
symptoms, hypervigilance and startle are more characteristic of PTSD. The
hypervigilance in PTSD may sometimes become so intense as to appear like
frank paranoia. The startle response has a unique neurobiological substrate and
may actually be the most pathognomonic PTSD symptom. DSM-IV's Criterion
D2, irritability or outbursts of anger, has been separated into emotional (e.g., D4)
and behavioral (e.g., E1) components in DSM-5. Irritable and angry outbursts
may sometimes be expressed as aggressive behavior. Finally reckless and selfdestructive behavior such as impulsive acts, unsafe sex, reckless driving and
suicidal behavior are newly included in DSM-5, as Criterion E2.
The "F" or duration criterion specifies that symptoms must persist for at least one
month before PTSD may be diagnosed.
The "G" or functional significance criterion specifies that the survivor must experience
significant social, occupational, or other distress as a result of these symptoms.
The "H" or exclusion criterion specifies that the symptoms are not due to medication,
substance use, or other illness.
Assessing PTSD
Since 1980, there has been a great deal of attention devoted to the development
of instruments for assessing PTSD. Keane and associates (10), working with
Vietnam war-zone Veterans, first developed both psychometric and
psychophysiological assessment techniques that have proven to be both valid
and reliable. Other investigators have modified such assessment instruments
and used them with natural disaster survivors, rape/incest survivors, and other
traumatized individuals. These assessment techniques have been used in the
epidemiological studies mentioned above and in other research protocols.
Neurobiology
Neurobiological research indicates that PTSD may be associated with stable
neurobiological alterations in both the central and autonomic nervous systems.
Psychophysiological alterations associated with PTSD include hyperarousal of
the sympathetic nervous system, increased sensitivity and augmentation of the
acoustic-startle eye blink reflex, and sleep abnormalities. Neuropharmacological
and neuroendocrine abnormalities have been detected in most brain
mechanisms that have evolved for coping, adaptation, and preservation of the
species. These include the noradrenergic, hypothalamic-pituitary-adrenocortical,
serotonergic, glutamatergic, thyroid, endogenous opioid, and other systems.
Structural brain imaging suggests reduced volume of the hippocampus and
anterior cingulate. Functional brain imaging suggests excessive amygdala
activity and reduced activation of the prefrontal cortex and hippocampus. This
information is reviewed extensively elsewhere (11-12).
Longitudinal expression
Longitudinal research has shown that PTSD can become a chronic psychiatric
disorder and can persist for decades and sometimes for a lifetime. Patients with
Questions to consider
Questions that remain about the syndrome itself include: what is the clinical
course of untreated PTSD; are there other subtypes of PTSD; what is the
distinction between traumatic simple phobia and PTSD; and what is the clinical
phenomenology of prolonged and repeated trauma? With regard to the latter,
Herman (14) has argued that the current PTSD formulation fails to characterize
the major symptoms of PTSD commonly seen in victims of prolonged, repeated
interpersonal violence such as domestic or sexual abuse and political torture.
She has proposed an alternative diagnostic formulation, "complex PTSD," that
emphasizes multiple symptoms, excessive somatization, dissociation, changes in
affect, pathological changes in relationships, and pathological changes in identity.
Although this formulation is attractive to clinicians dealing with individuals who
have been repeatedly traumatized, scientific evidence in support of the complex
PTSD formulation is sparse and inconsistent. For this reason, it was not included
in the DSM-5 as subtype of PTSD. It is possible that the Dissociative Subtype,
which has firm scientific support, will prove to be the diagnostic subtype that
incorporates many or all of the symptoms first described by Herman.
PTSD has also been criticized from the perspective of cross-cultural psychology
and medical anthropology, especially with respect to refugees, asylum seekers,
and political torture victims from non-Western regions. Some clinicians and
researchers working with such survivors argue that since PTSD has usually been
diagnosed by clinicians from Western industrialized nations working with patients
from a similar background, the diagnosis does not accurately reflect the clinical
picture of traumatized individuals from non-Western traditional societies and
cultures. It is clear however, that PTSD is a valid diagnosis cross-culturally (15).
On the other hand, there is substantial cross-cultural variation and the expression
of PTSD may be different in different countries and cultural settings, even when
DSM-5 diagnostic criteria are met (16).
policy and public health issue since the massive traumatization caused by the
September 11 terrorist attacks on the World Trade Center, Hurricane Katrina, the
Asian tsunami, the Haitian earthquake, the wars in Iraq and Afghanistan and
other large-scale traumatic events. Currently, there is controversy about which
interventions work best during the immediate aftermath of a trauma. Research on
critical incident stress debriefing (CISD), an intervention used widely, has brought
disappointing results with respect to its efficacy to attenuate posttraumatic
distress or to forestall the later development of PTSD. The National Center for
PTSD and the National Center for Child Traumatic Stress have developed an
alternative early intervention, Psychological First Aid that is available online, but which
has yet to be subjected to rigorous evaluation. On the other hand, brief cognitive
behavioral therapy has proved very effective in randomized clinical trials (23).
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N.,van de Put, W., & Somasundarem, D.J. (2001). Lifetime events and Posttraumatic Stress
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(5th ed.). Washington, DC: Author.
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Keane, T.M., Wolfe, J., & Taylor, K.I. (1987). Post-traumatic Stress Disorder: Evidence for
diagnostic validity and methods of psychological assessment.Journal of Clinical Psychology, 43, 3243. doi: 10.1002/1097-4679(198701)43:1<32::AID-JCLP2270430106>3.0.CO;2-X
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Friedman, M.J., Charney, D.S. & Deutch, A.Y. (1995) Neurobiological and clinical consequences
of stress: From normal adaptation to PTSD. Philadelphia: Lippincott-Raven.
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Shiromani, P. J., Keane, T. M., & LeDoux, J. E. (Eds.). (2009). Post-Traumatic Stress Disorder:
Basic science and clinical practice. New York: Humana Press.
13.
Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011).Considering PTSD for DSM5. Depression and Anxiety, 28, 750-769. doi: 10.1002/da.20767
14.
Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.
15.
Hinton, D. E., & Lewis-Fernandez, R. (2011). The cross-cultural validity of Posttraumatic Stress
Disorder: Implications for DSM-5. Depression and Anxiety, 28, 783-801. doi: 10.1002/da.20753
16.
Marsella, A.J., Friedman, M.J., Gerrity, E. & Scurfield R.M. (Eds.). (1996).Ethnocultural aspects of
Post-Traumatic Stress Disorders: Issues, research and applications. Washington, DC: American
Psychological Association.
17.
Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (Eds.). (2009).Effective treatments for
PTSD, Second Edition. New York, NY: Guilford.
18.
Raskind, M. A., Peterson, K., Williams, T., Hoff, D. J., Hart, K., Holmes, H., Homas, D., Hill, J.,
Daniels, C., Calohan, J., Millard, S. P., Rohde, K., O'Connell, J., Pritzl, D., Feiszli, K., Petrie, E. C.,
Gross, C., Mayer, C. L., Freed, M. C.., Engel, C., & Peskind, E. R. (2013). A trail of prazosin for
combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and
Afghanistan. American Journal of Psychiatry, Advance online publication. doi:
10.1176/appi.ajp.2013.12081133
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Resick, P. A., Nishith, P., & Griffin, M. G. (2003). How well does cognitive-behavioral therapy treat
symptoms of complex PTSD? An examination of child sexual abuse survivors within a clinical
trial. CNS Spectrums, 8, 340-355.
20.
Alvarez, J., McLean, C., Harris, A. H. S., Rosen, C. S., Ruzek, J. I., & Kimerling, R. (2011). The
comparative effectiveness of cognitive processing therapy for male Veterans treated in a VHA
Posttraumatic Stress Disorder residential rehabilitation program. Journal of Consulting and Clinical
Psychology, 79, 590-599. doi: 10.1037/a0024466
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Chard, K. M., Ricksecker, E. G., Healy, E. T., Karlin, B. E., & Resick, P. A. (2011). Dissemination
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sexual violence. New England Journal of Medicine, 368, 2182-219. doi:10.1056/NEJMoa1211853
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Bryant, R.A., Mastrodomenico, J., Felmingham, K.L., Hopwood, S., Kenny, L., Kandris, E., Cahill,
C. & Creamer, M. (2008). Treatment of acute stress disorder: A randomized controlled
trial. Archives of General Psychiatry, 65, 659-667. doi:10.1001/archpsyc.65.6.659
Complex PTSD
Many traumatic events (e.g., car accidents, natural disasters, etc.) are of timelimited duration. However, in some cases people experience chronic trauma that
continues or repeats for months or years at a time. The current PTSD diagnosis
often does not fully capture the severe psychological harm that occurs with
prolonged, repeated trauma. People who experience chronic trauma often report
additional symptoms alongside formal PTSD symptoms, such as changes in their
self-concept and the way they adapt to stressful events.
Dr. Judith Herman of Harvard University suggests that a new diagnosis, Complex
PTSD, is needed to describe the symptoms of long-term trauma (1). Another
name sometimes used to describe the cluster of symptoms referred to as
Complex PTSD is Disorders of Extreme Stress Not Otherwise Specified
(DESNOS)(2). A work group has also proposed a diagnosis of Developmental
Trauma Disorder (DTD) for children and adolescents who experience chronic
traumatic events (3).
Because results from the DSM-IV Field Trials indicated that 92% of individuals
with Complex PTSD/DESNOS also met diagnostic criteria for PTSD, Complex
PTSD was not added as a separate diagnosis classification (4). However, cases
that involve prolonged, repeated trauma may indicate a need for special
treatment considerations.
victim is under the control of the perpetrator and unable to get away from the
danger.
Examples of such traumatic situations include:
Concentration camps
Prostitution brothels
Emotional Regulation. May include persistent sadness, suicidal thoughts, explosive anger, or
inhibited anger.
Self-Perception. May include helplessness, shame, guilt, stigma, and a sense of being
completely different from other human beings.
Distorted Perceptions of the Perpetrator. Examples include attributing total power to the
perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with
revenge.
Relations with Others. Examples include isolation, distrust, or a repeated search for a rescuer.
One's System of Meanings. May include a loss of sustaining faith or a sense of hopelessness
and despair.
disorder. Clinicians should assess for PTSD specifically, keeping in mind that
chronic trauma survivors may experience any of the following difficulties:
Survivors may avoid thinking and talking about trauma-related topics because the feelings
associated with the trauma are often overwhelming.
Survivors may use alcohol or other substances as a way to avoid and numb feelings and
thoughts related to the trauma.
Survivors who have been abused repeatedly are sometimes mistaken as having a "weak
character" or are unjustly blamed for the symptoms they experience as a result of victimization.
References
1.
Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to
political terror. New York: Basic Books.
2.
Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated
features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of
Consulting and Clinical Psychology, 67, 3-12.
3.
van der Kolk, B. (2005). Developmental trauma disorder. Psychiatric Annals, 35(5), 401-408.
4.
Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in
victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic
Stress Disorder. Journal of Traumatic Stress, 10, 539-555.
Epidemiology of PTSD
Jaimie L. Gradus, DSc, MPH
What is epidemiology?
Epidemiology is the study of the distribution and determinants of disease in a
population. Numerous studies have been conducted to assess the prevalence of
PTSD across different populations. Below is a brief review of some of the major
studies that have assessed the prevalence of PTSD in nationally representative
samples as well as in samples of Veterans.
What is prevalence?
Prevalence is the proportion of people in a population that have a given disorder
at a given time. It represents the existing cases of a disorder in a population or
group. Prevalence estimates can be influenced by many factors including
disorder occurrence (if new disorder occurrences increase, prevalence will
increase) and the duration of the disorder (the longer people live with a disorder,
the higher the prevalence). These estimates can also differ by demographic
factors such as age and gender. It is important to qualify prevalence estimates
with the time at which they were measured, as prevalence estimates can shift
over time. Similarly, when interpreting prevalence estimates, it is important to
keep in mind that prevalence is dynamic - it can change over people, places, and
time.
Often prevalence is discussed in terms of lifetime prevalence. Other times,
statistics will be given on current prevalence of PTSD in a given time frame,
usually one year. At the end of this fact sheet you will find descriptions of other
terms commonly used in epidemiology.
Prevalence of PTSD
U.S. National Comorbidity Survey Replication
The National Comorbidity Survey Replication (NCS-R), conducted between
February 2001 and April 2003, comprised interviews of a nationally
representative sample of 9,282 Americans aged 18 years and older. PTSD was
assessed among 5,692 participants, using DSM-IV criteria. The NCS-R
estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%
(1). Current past year PTSD prevalence was estimated at 3.5% (2).The lifetime
prevalence of PTSD among men was 3.6% and among women was 9.7%. The
twelve month prevalence was 1.8% among men and 5.2% among women (3).
These findings are very similar to those of the first National Comorbidity Survey.
The original survey was conducted in the early 1990s and comprised interviews
of a representative national sample of 8,098 Americans aged 15 to 54 years. In
this earlier sample, the estimated prevalence of lifetime PTSD was 7.8% in the
general population. Women (10.4%) were more than twice as likely as men (5%)
to have PTSD at some point in their lives (4).
PTSD among children and adolescents
To date, no population-based epidemiological study has examined the
prevalence of PTSD among children. However, studies have examined the
prevalence of PTSD among high-risk children who have experienced specific
traumatic events, such as abuse or natural disasters. Prevalence estimates from
studies of this type vary greatly; however, research indicates that children
exposed to traumatic events may have a higher prevalence of PTSD than adults
in the general population (5).
Kilpatrick and colleagues (2003) assessed the prevalence of PTSD among
adolescents based on data from the National Survey of Adolescents, which
included a household probability sample of 4,023 adolescents between the ages
of 12 and 17. Using DSM-IV criteria for PTSD, the six-month prevalence was
estimated to be 3.7% for boys and 6.3% for girls (6).
PTSD in other countries
In the late 1990s the World Health Organization (WHO) began collecting
epidemiological information on mental health disorders around the world. As of
2008, the research consortium had collected data from nearly 200,000
respondents in 27 countries (7). Published estimates are available of PTSD
lifetime prevalence in most of the first 17 countries to complete the World Mental
Health Surveys. In general, the estimates for lifetime PTSD prevalence range
from a low of 0.3% in China to 6.1% in New Zealand. However, statistics reported
from various countries are not directly comparable due to methodological
differences in survey administration and sampling strategies.
References
1.
Kessler, R.C., Berglund, P., Delmer, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005).
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 62(6): 593-602.
2.
Kessler, R.C., Chiu, W.T., Demler, O., Merikangas, K.R., & Walters, E.E. (2005). Prevalence,
severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62(6): 617-627.
3.
National Comorbidity Survey. (2005). NCS-R appendix tables: Table 1. Lifetime prevalence of
DSM-IV/WMH-CIDI disorders by sex and cohort. Table 2. Twelve-month prevalence of DSMIV/WMH-CIDI disorders by sex and cohort. Accessed
at: http://www.hcp.med.harvard.edu/ncs/publications.php
4.
Kessler, R.C., Sonnega, A., Bromet, E. Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048-1060.
5.
Gabbay, V., Oatis, M.D., Silva, R.R., & Hirsch, G. (2004). Epidemiological aspects of PTSD in
children and adolescents. In Raul R. Silva (Ed.),Posttraumatic Stress Disorder in Children and
Adolescents: Handbook (1-17). New York: Norton.
6.
Kilpatrick, D.G., Ruggiero, K.J., Acierno, R., Saunders, B.E., Resnick, H.S., & Best, C.L. (2003).
Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity:
results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology,
71(4), 692-700.
7.
Kessler, R.C., & Ustun, T. B. (Eds.). (2008). The WHO World Mental Health Surveys: global
perspectives on the epidemiology of mental disorders. New York: Cambridge University Press, 1580.
8.
Kulka, R.A., Schlenger, W.A., Fairbanks, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., ...
Cranston, A.S. (1990). Trauma and the Vietnam War generation: Report of findings from the
National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
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Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (October 1993). The PTSD Checklist
(PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the
International Society for Traumatic Stress Studies, San Antonio, TX.
10.
Kang, H.K., Natelson, B.H., Mahan, C.M., Lee, K.Y., & Murphy, F.M. (2003). Post-Traumatic
Stress Disorder and Chronic Fatigue Syndrome-like illness among Gulf War Veterans: A populationbased survey of 30,000 Veterans. American Journal of Epidemiology, 157(2):141-148.
11.
Tanielian, T. & Jaycox, L. (Eds.). (2008). Invisible Wounds of War: Psychological and Cognitive
Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND
Corporation.
12.
Exposure-based treatments
The greatest number of studies has been conducted on exposure-based
treatments, which involve having survivors repeatedly re-experience their
traumatic event. There is strong evidence for exposure therapy (7-12), and of the
various approaches, Prolonged Exposure (PE) has received the most attention.
PE (8) includes both imaginal exposure and in vivo exposure to safe situations
that have been avoided because they elicit traumatic reminders.
In a multisite randomized controlled trial of PE in female Veterans and active-duty
personnel with PTSD, those who received PE experienced greater reduction of
PTSD symptoms relative to women who received present-centered therapy and
were less likely to meet PTSD diagnostic criteria (13). Moreover, PE was more
effective than the combination of PE plus stress inoculation training (SIT), SIT
alone, or a waitlist control in female sexual assault survivors (10). In addition, PE
alone and PE plus cognitive restructuring reduced PTSD and depression relative
to a waitlist control in intention-to-treat and completer samples (11).
Cognitive approaches
Cognitive interventions also are widely supported in treatment guidelines (12, 1517). Cognitive Processing Therapy (CPT; 18), one of the most well-researched
cognitive approaches, has a primary focus on challenging and modifying
maladaptive beliefs related to the trauma, but also includes a written exposure
component.
Veterans with chronic military-related PTSD who received CPT showed better
improvements in PTSD and comorbid symptoms than the waitlist control group
(19). A dismantling study of CPT then examined the relative utility of the full
protocol compared with its components: cognitive therapy alone and written
exposure alone (20). Results indicated significant improvement in PTSD and
depression for participants in all three treatments. However, the cognitive therapy
alone resulted in faster improvement than the written exposure alone, with the
effects of the full protocol of CPT falling in-between (20). Both CPT and PE have
shown great success in outcome research; thus, one logical research question
involves whether one is more effective than the other. In a head-to-head
comparison, CPT and PE were equally effective in treating PTSD and depression
in female sexual assault survivors (7).
Ehlers and Clark have also developed a cognitive therapy for PTSD that involves
three goals: modifying excessively negative appraisals, correcting
autobiographical memory disturbances, and removing problematic behavioral
and cognitive strategies (21). Elements unique to Ehlers and Clark's cognitive
therapy include performing actions that are incompatible with the memory or
engaging in behavioral experiments. Two randomized controlled trials have
compared cognitive therapy to a waitlist, both with positive results (15, 16).
Adding components
Some investigators have added a novel component to an effective treatment in
hopes of further optimizing outcomes (22-27). Three groups of investigators
compared an enhanced treatment to a waitlist control group: Cloitre and
colleagues (23) sequenced skills training in affect and interpersonal regulation
before PE; Falsetti and colleagues (24) developed Multiple Channel Exposure
Therapy, a combination of PE, CPT, and interoceptive exposure techniques for
panic disorder; and Lindauer and colleagues (27) developed Brief Eclectic
Therapy, a combination of psychodynamic and cognitive behavioral therapy.
These studies showed that the combined treatments were effective, but not
whether the additional components enhanced the standard treatments.
Glynn and colleagues (25) compared exposure therapy alone with exposure
therapy followed by behavioral family therapy, and Arntz and colleagues (22)
compared imaginal exposure alone with imaginal exposure plus imagery
rescripting. In both studies, the combined treatment did not result in a greater
reduction of PTSD severity, which suggests that the novel component was not
necessary. However, statistical power may have been too low to compare the
active treatments adequately.
EMDR
In addition to cognitive behavioral therapies, EMDR is recommended in most
practice guidelines. Patients receiving EMDR engage in imaginal exposure to a
trauma while simultaneously performing saccadic eye movements. There is good
evidence that EMDR is more effective than waitlist and nonspecific comparison
conditions (28-30). Further, two well-controlled studies compared EMDR to PE.
One study found equivalent results (29) while the other found PE to be superior
(30). Additional research has investigated the mechanism of action in EMDR, and
there is growing evidence that the theorized eye movements are an unnecessary
component (31), suggesting that perhaps the mechanism of action is exposure.
Other approaches
Other treatments in addition to cognitive behavioral therapy and EMDR may be
effective; however, at this time we do not have enough evidence to confidently
indicate that they are effective. For example, despite the appeal of group
treatments, results of the few randomized controlled trials of group therapy have
been mixed (32-36). In addition, psychodynamic therapy, hypnotherapy, and
trauma desensitization were more effective than a waitlist control group in one
trial (40). Rogerian supportive therapy was less effective in treating symptoms of
PTSD and anxiety than cognitive behavioral therapy in one study (41).
Acceptance and Commitment Therapy (ACT), which is considered a third wave
behavioral therapy, focuses on reducing experiential avoidance and engagement
with maladaptive thoughts and encourages clients to approach activities
consistent with their personal values. Several case studies have documented
support for ACT in the treatment of PTSD (37, 38). However, no trials of ACT for
PTSD have been published to date. Finally, there is also interest in alternative
medicine treatments. For example, acupuncture was as effective as group
cognitive behavioral treatment, and both were more effective than the waitlist
condition (39).
Conclusion
Overall, cognitive behavioral therapies such as Prolonged Exposure and
Cognitive Processing Therapy, as well as Eye Movement Desensitization
Reprocessing, are considered first-line treatments for PTSD and have strong
evidence bases. Components of these treatments have been combined with
other interventions, with no support for improved benefits over the standard
treatments alone. Other interventions, such as group treatment, show promise;
however, more research is needed before drawing firm conclusions about their
effectiveness.
References
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Australian Centre for Posttraumatic Mental Health. (2007). Australian guidelines for the treatment
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Foa, E. B., Keane, T.M., & Friedman, M.J. (2009). Effective treatments for PTSD: Practice
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3.
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management of PTSD in adults and children in primary and secondary care (1-167). London:
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Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of
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Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive behavioral therapy
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Overview
Posttraumatic Stress Disorder (PTSD) has biological, psychological, and social
components. Medications can be used in treatment to address the biological
basis for PTSD symptoms and co-morbid Axis I diagnoses. Medications may
benefit psychological and social symptoms as well. While studies suggest that
cognitive behavioral therapies such as prolonged exposure (PE) and cognitive
processing therapy (CPT) have greater effects in improving PTSD symptoms
than medications, some people may prefer medications or may benefit from
receiving a medication in addition to psychotherapy.
Placebo-controlled double-blind randomized controlled trials are the gold
standard for pharmacotherapy. Less strongly supported evidence includes open
trials and case reports. It is important for the clinician to question the level of
evidence supporting the medications prescribed in PTSD treatment. There are a
variety of factors influencing prescribing, including marketing, patient
preferences, and clinical custom, all of which can be inconsistent with the
evidence base.
Currently, the evidence base is strongest for the selective serotonin reuptake
inhibitors (SSRIs). The only two FDA approved medications for the treatment of
PTSD are sertraline (Zoloft) and paroxetine (Paxil) (1, 2). All other medication
uses are off label, though there are differing levels of evidence supporting their
use. In addition to sertraline and paroxetine, there is strong evidence for the
SSRI fluoxetine (Prozac) and for the serotonin norepinephrine reuptake inhibitor
(SNRI) venlafaxine (Effexor) which are considered first-line treatments in the
VA/DoD Clinical Practice Guideline for PTSD. There are a number of biological
changes which have been associated with PTSD, and medications can be used
to modify the resultant PTSD symptoms. 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).
Re-experiencing. Examples include nightmares, unwanted thoughts of the traumatic events, and
flashbacks.
Avoidance. Examples include avoiding triggers for traumatic memories including places,
conversations, or other reminders. The avoidance may generalize to other previously enjoyable
activities.
What is the evidence base for the specific groups of medications used
for PTSD treatment?
Selective Serotonin Reuptake Inhibitors (SSRIs)
These medications are the only FDA approved medications for PTSD. SSRIs
primarily affect the neurotransmitter serotonin which is important in regulating
mood, anxiety, appetite, and sleep and other bodily functions. This class of
medication has the strongest empirical evidence with well designed randomized
controlled trials (RCTs) and is 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, and comorbidities.
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. Each patient varies in their
response and ability to tolerate a specific medication and dosage, so medications must be tailored
to individual needs.
Research has suggested that maximum benefit from SSRI treatment depends
upon adequate dosages and duration of treatment. Treatment adherence is key
to successful pharmacotherapy treatment for PTSD. Examples of the SSRIs and
some typical dosage ranges are listed below:
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 may have empirical support but have not been through the FDA approval
process for PTSD.
Other newer antidepressants for PTSD
Antidepressants that work through other neurotransmitter combinations or
through different mechanisms for altering serotonin neurotransmission 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 (6).
There have been smaller RCTs with mirtazapine as well as open trials (7).
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. Nefazodone is still available in a
generic form but carries a black box warning regarding liver failure, so liver
function tests need to be monitored and precautions taken as recommended in
the medication's prescribing information (8, 9).
Examples of the newer antidepressants for PTSD and some typical dosage
ranges are listed below:
All of the antidepressants described above are also effective in treating comorbid
Major Depressive Disorder (MDD) which often accompanies PTSD. While
bupropion is useful in treating comorbid MDD, it has not been shown effective for
PTSD in controlled trials (10). A recent trial showed superior outcomes on MDD
when mirtazapine was combined initially with antidepressants versus patients
being randomized to monotherapy with fluoxetine (11). This raises important
questions regarding costs, side effects, and patient preferences which merit
further study.
Mood stabilizers for PTSD
These medications, also known as anticonvulsants or anti-epileptic drugs, either
block glutamate or potentiate GABA or do both. 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 (12,13). 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 (14,15). 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 and meta-analyses are needed regarding the
place of topiramate in PTSD treatment (16).
Otherwise, despite some promising open label studies, other RCTs have been
negative for this group of medications in treating PTSD (17). As a group, this
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.
Risperidone (Risperdal) is contraindicated for use as an adjunctive agent - potential harm (side
effects) exceeds benefits.
Prazosin (Minipress)
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 act directly on the GABA system which produces a calming
effect on the nervous system. This is the only potentially addictive group of medications
discussed. Studies have not shown them to be useful in PTSD treatment as they
do not work on the core PTSD symptoms (23, 24). There are several other
concerns with the benzodiazepines including potential disinhibition, difficulty
integrating the traumatic experience, interfering with the mental processes
needed to benefit from psychotherapy, and addiction. Because of their potential
for addiction and disinhibition, they must be used with great caution in PTSD.
Examples are listed below:
Lorazepam (Ativan)
Clonazepam (Klonopin)
Alprazolam (Xanax)
D-cycloserine (DCS) has been used in panic disorder, specifically phobia and
social phobia, to enhance the effects of exposure therapy (26). 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 (27). This line of
research recognizes a paradigm shift in the use of pharmacotherapy to assist
learning during psychotherapy as opposed to directly affecting PTSD symptoms
(28).
Memantine (Namenda) is a drug of much interest in preventing
neurodegeneration by protecting against glutamatergic destruction of neurons. 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.
Current research is looking towards the possibility of one day intervening early in
the course of PTSD with a combination of psychotherapy and pharmacotherapy
that would prevent the development of the pathophysiology of PTSD in the brain.
Keeping several pill bottles and not remembering when the last dosage was taken
Important Considerations
Patients with PTSD or anxiety disorders may be very aware of their somatic reactions, and it is
important to start low and go slow often on dosage adjustments to improve patient adherence.
Be sure to ask female patients of childbearing age about contraception when prescribing
medication.
Once mediations are started, it is crucial that the provider remember to discontinue medications
which are not proving efficacious and to simplify the number and types of medications used
whenever possible.
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