Post Traumatic Stress Disorder
PTSD Resources

Treatment Approaches

Cognative/behaviour therapy involves focusing on ways of correcting the survivor’s painful and often intrusive patterns of behavior and thoughts. This is achieved through teaching them relaxation techniques and examining their mental process. This can involve exposing the survivor to certain triggers in a controlled environment until they are "desensitized" to the trigger and is no longer afraid of the situation.

Psychodynamic psychotherapy tends to focus on helping the survivor to look closely at the way behavior and experience during their traumatic experience violated them. Often the way a survivor differentiated between their individual personal values and the reality of what they experienced during the traumatic event can result in PTSD. This therapy aims to resolve the conscious and unconscious conflicts that evolved from the trauma. They also work on building self confidence and esteem, self control and an all round renewed pride in themselves and their abilities.

Pharmacotherapy: Drugs can be used to help with the side effects of PTSD, like helping sleeplessness or hyper arousal. Unfortunately there is no simple clear cut solution for such a complex phenomenon. I firmly believe that survivors have to confront what has happened to them, and by repeating this confrontation, learn to accept the trauma as part of their past. There is no magic wand. However counseling and therapy can help to find an easier path through the trauma and set you on the path to healing.

Source: Survive- UK

Three major treatment approaches are currently available for PTSD patients: cognitive-behavioral therapy, pharmacotherapy, and more traditional individual and group dynamic psychotherapy. Relatively few randomized clinical trials have been published to date, and serious methodological questions can be raised about some of the studies that have been completed. In short, treatment outcome research on PTSD is at an early stage.

Source: Matthew Friedman- American College of Neuropsychopharmacology

Cognitive-behavioral therapy (CBT) is currently regarded as the most successful treatment for PTSD. Foa, Rothbaum, and associates have consistently achieved excellent results providing this treatment to adult female rape victims with PTSD (18,19,67). This technique is currently being tested with other traumatized groups (military veterans, survivors of child abuse, traffic accident survivors), but such data have yet to be published. A CBT approach consists of two components: exposure therapy and anxiety management strategies. Exposure therapy is a process designed to extinguish the powerful influence of fear conditioning among PTSD patients. Through sustained exposure (usually through a vivid imaginal focus on the traumatic event), the patient's fear-response to trauma-related stimuli becomes markedly reduced. In addition to extinction of the fear response, the patient's SNS/adrenergic hyperreactivity to trauma-related stimuli is also reduced. Anxiety management training strategies include acquisition of skills for reducing anxiety such as relaxation training, stress inoculation training, biofeedback training, social skills training, distraction techniques, and cognitive restructuring. Cognitive restructuring is probably the most important of these techniques (20). It is a technique for correcting the distorted appraisal process exhibited by PTSD patients, in which they have a great tendency to perceive danger, even in neutral and innocuous situations. Although CBT was provided as individual therapy for the rape victims treated by Foa, Rothbaum, and associates, it can also be provided in a group therapy context. Indeed, Resick and associates (66) have reported on a group psychotherapy technique which consists of psychoeducation, exposure, and cognitive processing therapy. Our research group is currently testing a similar approach in a group therapy context for Vietnam veterans with PTSD. From the psychobiologic perspective presented earlier, it appears that CBT directly addresses a number of the key abnormalities in PTSD patients. There is great reason to hope that it will prove equally effective with patients whose PTSD is due to a wide variety of traumatic events.

Source: Matthew Friedman- American College of Neuropsychopharmacology

Given our expanding knowledge of the many neurobiological abnormalities associated with PTSD (22), pharmacotherapy appears to have a place in PTSD treatment. From a practical perspective, there is no question that drugs can provide some symptomatic relief of anxiety, depression, and insomnia, whether or not they ameliorate core PTSD intrusive and avoidant/numbing symptoms. At this time, no particular drug has emerged as a definitive treatment for PTSD, although medication is clearly useful for symptom relief, thereby making it possible for patients to participate in group, psychodynamic, cognitive-behavioral, or other forms of psychotherapy. Almost all randomized drug trials have been carried out with antidepressants (imipramine, amitriptyline, phenelzine, and fluoxetine) and not with other classes of drugs. Results have been mixed and generally quite modest in magnitude. Patients with severe and chronic PTSD appear to be refractory to pharmacotherapy. A number of promising trials with selective serotonin reuptake inhibitors have raised hopes, recently, that these drugs may prove to be effective drugs for PTSD treatment. There have also been promising results in uncontrolled trials with antiadrenergic agents such as clonidine and propranolol and with anticonvulsant/antikindling agents such as carbamazepine and valproate (25), indicating that further testing is warranted with these drugs. When considered from the psychobiologic perspective proposed throughout this chapter, one might conclude that results have been unimpressive thus far because the wrong drugs have been tested. Even though PTSD is biologically distinct from MDD (based on elegant research on the HPA system in both disorders [88]), most drug trials with PTSD patients have involved antidepressants. There have been no randomized clinical trials with antiadrenergic agents and no trials with drugs that have a primary action on the HPA system. I have suggested elsewhere (27) that the most effective pharmacotherapeutic approach to PTSD should be with drugs that address the unique pathophysiology of this disorder. In this regard, I believe that one potential focus for future research might be on corticotropin releasing factor (CRF), because CRF activates both the HPA and SNS/adrenergic systems in response to stress. Therefore, CRF antagonists currently being developed by several pharmaceutical companies for human trials may prove to be a very promising family of drugs for treating PTSD patients in the future.

Source: Matthew Friedman- American College of Neuropsychopharmacology

Clinical studies on selective serotonin reuptake inhibitors and related antidepressants for treatment of Posttraumatic Stress Disorder have focused on fluoxetine, sertraline, venlafaxine, mirtazapine, and nefazodone.

One systematic review found that paroxetine improved symptoms of post-traumatic stress disorder compared with placebo at 3 months. It found that fluoxetine and sertraline improved symptoms compared with placebo at 3–7 months but this did not quite reach significance for sertraline. The review found no significant difference in symptom severity between venlafaxine and placebo. We found insufficient evidence to compare mirtazapine versus placebo, or sertraline versus nefazodone. One subsequent RCT found that fluoxetine was more effective than placebo at reducing rates of relapse.

Source: BMJ Clinical Evidence

Zoloft (sertraline hydrochloride) is the first FDA-approved drug for PTSD. Before its approval in December, 1999 for post-traumatic stress disorder, Zoloft was already approved for treating depression, panic disorder, and obsessive-compulsive disorder. Its effectiveness for PTSD is in line with its benefit for depression and the other disorders. Studies show that about two-thirds of PTSD patients improve with Zoloft, while one-third improve when taking a placebo. Zoloft's approval for PTSD was based on two 12-week studies of the drug that demonstrated its effectiveness. While Zoloft's benefit over placebo was clear in women patients, little effect was seen in the male group. Scientists aren't certain why the gender difference exists, but some have theorized that PTSD in veterans, a mostly male population, might differ somehow from the disorder in the mostly female population of sexual assault victims. Doctors sometimes prescribe other drugs in the same class as Zoloft for PTSD. These selective serotonin reuptake inhibitors, or SSRI's, include Paxil (paroxetine), Prozac (fluoxetine), Luvox (fluvoxamine), and Celexa (citalopram). Based on an individual patient's medical circumstances, a doctor may in some cases choose to prescribe other types of antidepressants or anti-anxiety medications.

Source: Healthlink - MCW

Herman (33) has shown that therapists working with patients who have survived different kinds of traumatic events (war, natural disasters, etc.) generally agree that therapy can be divided into three phases: a) establishing trust, safety, and "earning the right to gain access" to carefully guarded traumatic material (46; p. 806); b) trauma-focused therapy: exploring traumatic material in depth, titrating intrusive recollections with avoidant/numbing symptoms (34); and c) helping the patient disconnect from the trauma and reconnect with family, friends, and society. It should be noted that patients who reach the third phase have achieved some resolution of trauma-specific concerns and are ready to concentrate, almost exclusively, on here-and-now issues concerning marriage, family, work, and other current issues (33,46,71). Marmar and associates (51) have suggested that there are five identifiable post-traumatic syndromes, each requiring a different treatment approach: normal stress response; acute catastrophic stress reaction; uncomplicated PTSD; PTSD co-morbid with other disorders; and post-traumatic personality. The normal stress response occurs when healthy adults who have been exposed to a single discrete traumatic event in adulthood experience intense, intrusive recollections, numbing, denial, feelings of unreality, and arousal. It has become generally (but not universally – see below) accepted that most individuals will achieve complete recovery following rapid post-traumatic individual or group interventions, such as critical incident stress debriefing (CISD) [4,57,64]. Often, a single, two-hour group debriefing experience is all that is needed. Such sessions begin by describing the traumatic event. They then progress to an exploration of survivors' emotional responses to the event. Next, there is an open discussion of symptoms which have been precipitated by the trauma. Finally, there is a resolution, in which survivors' responses are normalized and adaptive coping strategies are identified. Recent studies, however, have challenged the effectiveness of CISD. Kenardy and associates (36) reported that Australian emergency workers did not benefit from debriefing following an earthquake, while Bisson (6) reported that British burn trauma victims randomly assigned to CISD had worse outcomes than those who did not receive debriefing. In view of the general world-wide belief in the efficacy of CISD, and the lack of randomized clinical trials to support this belief, this is a very important area for current and future research.

Acute catastrophic stress reactions are characterized by panic reactions, cognitive disorganization, disorientation, dissociation, severe insomnia, tics and other movement disorders, paranoid reactions, and incapacity to manage even basic self care, work, and interpersonal functions (52). Treatment includes immediate support, removal from the scene of the trauma, use of anxiolytic medication for immediate relief of anxiety and insomnia, and brief, supportive, aggressive, dynamic psychotherapy provided in the context of crisis intervention (51).

Uncomplicated PTSD may respond to group, psychodynamic, cognitive behavioral, pharmacological, or combination approaches. During the past ten years, we have come to appreciate the powerful therapeutic potential of positive peer group treatment as practiced in Vet Centers for military veterans and in rape crisis centers for sexual assault and domestic violence victims. Peer groups provide an excellent therapeutic setting for trauma survivors, because their post-traumatic emotions, memories, and behaviors are validated, normalized, understood, and de-stigmatized. They are able to risk sharing traumatic material in an atmosphere of safety, cohesion and empathy of fellow trauma survivors. It is often much easier to accept confrontation from a fellow sufferer who has impeccable credentials as a trauma survivor than from a professional therapist who never went through those experiences first-hand. When group members achieve greater understanding and resolution of traumatic themes, they must next integrate such themes with their current lives and focus on the present rather than the past (33,71). In brief psychodynamic psychotherapy, trauma survivors focus on the traumatic event itself. Through the retelling of the traumatic event to a calm, empathetic, compassionate and non-judgmental therapist, the patient achieves a greater sense of self-cohesion, develops more adaptive defenses and coping strategies, and more successfully modulates intense emotions that emerge during therapy (51). The therapist needs to constantly address the linkage between post-traumatic and current life stress by helping the patient identify current life situations that set off traumatic memories and exacerbate PTSD symptoms.

PTSD comorbid with other DSM-IV Axis I disorders is actually much more common than uncomplicated PTSD. As noted earlier, PTSD is usually associated with at least one other major psychiatric disorder such as depression, alcohol/substance abuse, panic disorder, and other anxiety disorders (37). Sometimes the co-morbid disorder is the presenting complaint that requires immediate attention. At other times, the PTSD appears to be the major problem. In general, the best results are achieved when both PTSD and the co-morbid disorder(s) are treated concurrently rather than one after the other. This is especially true for PTSD and alcohol/substance abuse (1,39). Treatment previously described for uncomplicated PTSD should also be used for these patients.

Post-traumatic personality disorder is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. These individuals often meet DSM-IV criteria for diagnoses such as borderline personality disorder, somatoform disorder, and dissociative identity disorder (multiple personality disorder). Such patients exhibit behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), emotional difficulties (such as affect lability, rage, depression, panic), and cognitive difficulties (such as fragmented thoughts, dissociation, and amnesia). Treatment generally focuses on behavioral and affect management in a here-and-now context, with emphasis on family function, vocational rehabilitation, social skills training, and alcohol/drug rehabilitation. Long-term individual and group treatments have been described for such patients (see 33,41,71). Dialectical behavior therapy, a cognitive behavioral group approach developed by Linehan and her associates for chronically suicidal borderline patients (47), may also have a role in the treatment of post-traumatic personality disorder. Trauma-focused treatment should only be initiated after long therapeutic preparation. Inpatient treatment may be needed to provide adequate safety and safeguards before undertaking therapeutic exploration of traumatic themes. The three phases of treatment, described earlier, apply to these patients as well as those with uncomplicated PTSD, but treatment may take much longer, may progress at a much slower rate, and may be fraught with much more complexity than with other traumatized patients.

Source: Matthew Friedman- American College of Neuropsychopharmacology

Eye Movement Desensitization and Reprocessing (EMDR)

This site provides information on Eye Movement Desensitization and Reprocessing (EMDR) including an overview and general description. It also includes a section on training, publications, controlled studies and clinician referrals. It is maintained by the EMDR Institute.

New Virtual PTSD Treatment

A new therapy for combat related Post Traumatic Stress Disorder - PTSD - being fine-tuned at Madigan Army Medical Center.

Trauma Incident Reduction (TIR)

TIR is a brief, one-on-one, non-hypnotic, person-centered, simple and highly structured method for permanently eliminating the negative effects of past traumas. It involves repeated viewing of a traumatic memory under conditions designed to enhance safety and minimize distractions. The client does all the work; the therapist or counselor offers no interpretations or negative or positive evaluations, but only gives appropriate instructions to the client to have him view a traumatic incident thoroughly from beginning to end. List of practitioners available through their website.

Thought Field Therapy (TFT)

What some view as a placebo (ie: the power of suggestion is really at work here), this technique was developed by Dr. Roger Callahan, a cognitive psychologist.

The Counting Method

A technique for modulating and mastering traumatic memories. Reported improvement in the frequency and intensity of traumatic memory.

Hadassah Medical Center

Hadassah research reveals PTSD may be predicted through a simple blood test.

Effects of the glucocorticoid dexamethasone on verbal declarative memory function in patients with PTSD.

Alterations in the hypothalamic–pituitary–adrenal (HPA) axis and hippocampal-based memory have been associated with posttraumatic stress disorder (PTSD), and the administration of exogenous glucocorticoids has been shown to result in a transient verbal declarative memory impairment in healthy human subjects. The purpose of this study was to assess the effects of the glucocorticoid dexamethasone on verbal declarative memory function in patients with PTSD. Forty-two men and women with (n=14) and without (n=28) PTSD received placebo or dexamethasone (1 and 2 mg on two successive days) in a double-blind, randomized fashion. Declarative memory was assessed with paragraph recall at baseline (day 1) and day 3. There was a significant interaction between diagnosis and drug (dexamethasone vs. placebo) on paragraph recall related to a relative detrimental effect of dexamethasone on memory function in healthy subjects, but not those with PTSD. These findings are consistent with an altered sensitivity of declarative memory function in PTSD to regulation by glucocorticoids, possibly explainable by alterations in glucocorticoid receptors in the hippocampus or other brain regions mediating declarative memory.

Neuroendocrine Regulation of Sleep Disturbance in PTSD

This abstract explores the hypothalamic (neurohormonal) and extrahypothalamic (neurotransmitter) corticotropin releasing factor (CRF) associated with decreased delta sleep activity in PTSD patients.

DCS- Amygdala and the Hippocampus; The Biological Underpinnings of Paralyzing Fears

US News and World Report cites D-Cycloserine (DCS) as an effective and lasting treatment for anxiety disorders without side effects.