Symptoms Help Determine the Best Treatment for PTSD

Post-Traumatic Stress Disorder (PTSD) is a complex medical problem rooted in some of humankind's most primal responses to life-threatening events. PTSD can be triggered by all sorts of traumatic occurrences, from car crashes to criminal assaults to combat horrors, and its symptoms range widely in their nature and severity.

"What the title 'post-traumatic stress disorder' says is that someone has a strong psychological reaction to a bad trauma, says H. Steven Moffic, MD, Medical College of Wisconsin Professor of Psychiatry and Behavioral Medicine.

"Generally, there seems to be two different kinds of post-traumatic stress disorder, and actually within them there are differing degrees of severity. One is called an acute stress disorder. That's a stress disorder with some of the symptoms that occur after a bad trauma, but one that occurs fairly quickly, within a few days, and does not last longer than a month. Acute stress disorder was fairly common after 9/11, for example. The symptoms might last a few weeks and either go away on their own or sometimes go away with help.

"When symptoms don't go away after a month or so, they can lead to the full-blown post-traumatic stress disorder. This kind of post-traumatic stress disorder can come after an acute stress disorder, or it can occur after there have been virtually no symptoms for weeks, months, even many years. There have been cases where people have not developed post-traumatic stress disorder until thirty or forty years after the trauma."

Dr. Moffic added that the worst kind of disorder related to the response to bad trauma is in an entirely different diagnostic category, now called dissociative identity disorder and once known as multiple personality disorder.

"That's the most severe post-trauma disorder because it seems to appear after multiple severe childhood trauma, sexual or physical, and the way the child tries to deal with it is by walling off different parts of their personality that relate to trauma at different times," he said. "As an adult they can develop dissociative identity disorder so at different times it can appear that they have different personalities. It is very severe in that sense although a person with it can sometimes lead a very normal day-to-day life."

Symptoms and Patient Preference Determine Treatment
According to Dr. Moffic, finding ways to relieve symptoms - not trying to find a "cure" for PTSD itself - generally informs treatment planning for post-traumatic stress disorder. PTSD symptom management can be highly effective, he said, adding that general practitioners are getting better at recognizing PTSD even when their patients do not bring it up directly.

"For 'routine' post-traumatic stress disorder, we come up with a treatment plan based on the nature of the symptoms, which symptoms are most prominent, and what treatment will fit those symptoms," said Dr. Moffic. "In general, there are two major kinds of treatment. One involves different types of psychotherapy. There are several psychotherapies now that seem to have enough evidence of success that they should be tried first.

"Then there are also medication options, which sometimes help. Sometimes both therapy and medications are used together, sometimes one or the other, especially if the patient has a preference. Patient preference is very, very important in treating post-traumatic stress disorder because what trauma usually does to people is make them feel out of control.

Horrible things have happened to these patients, usually out of the blue, so they feel they've lost control. If they desire a particular type of treatment, say they want to start with just medication and not therapy, fine. We'll start there, and then go on and perhaps they'll be more willing to use therapy later.

"It's not an easy condition to treat, especially if it's gone on for a long time. There is no 'anti-trauma' medication. We have so-called antidepressants, we have so-called anti-anxiety medicines, we have so-called anti-psychotic medicines, but we do not have anti-trauma medicines. That's probably because we haven't progressed far enough in our research, and because the symptoms of post-traumatic stress disorder can be so various that we end up pulling upon different kinds of medicines for different symptoms.

"For instance, going back to the different categories that relate the fight-flight response, if somebody is hyper-aroused, over-stimulated, then we want to use something that can settle them down. If sleep is disrupted, we'll use some kind of sleeping pill. If they are over-aroused during the day we can use a calming agent like a mild anti-anxiety medication or even a small amount of an anti-psychotic to help calm a person down. If they've had the withdrawn, fearful kind of response, then an anti-depressant can be a good medicine to try. If they've had a lot of flashbacks or nightmares, there is a certain type of medicine that seems to help with that."

Getting Help: The Sooner the Better
Along with the better-known triggers of PTSD, it can also present as a result of severe medical problems including heart attacks and complicated childbirths. Dr. Moffic advises anyone who has been through a traumatic experience to be aware that potentially life-threatening events may cause PTSD complications down the road. A rule of thumb he offered is: if you realize you are "suffering too much" from a trauma and it has occurred to you that it is not going away, at the very least bring it up with a doctor as soon as you can.

"Even though the majority of people won't go on to develop post-traumatic stress disorder, especially if the trauma hasn't been too bad, the earlier you can get checked for the potential for PTSD the better," said Dr. Moffic.

"Again, we've even seen this after 9/11. There was a huge outpouring of help, both therapy and medication offered within days and weeks of the event. Now that we've got the research about the outcomes it's been heartwarming in a way to see that the degree or percentage of post-traumatic stress disorder that developed afterwards was less than everybody expected. That was probably because of the early intervention.

"Try to get help from a family physician or a mental health professional, and if possible you want to go to somebody who has experience in this area. If it pops up later out of the blue, weeks or months after the trauma, again try to get in as soon as possible because the longer the symptoms occur the harder it is to treat."

Dan Ullrich
HealthLink Contributing Writer

The January 1, 2007 issue of HealthLink, features Part 1 of Dr. Moffic's discussion on PTSD, Post-Traumatic Stress Disorder Is Based on Individual Response to Danger.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.