New Treatment for Post-Traumatic Stress Disorder

All of us have had experiences that are sufficiently upsetting that we go over and over them in our minds, but with post traumatic stress disorder (PTSD), it's an order of magnitude worse. It can be a very severe kind of illness that limits people to an extent that is completely foreign to most of us.

In a given year, more than 10 million Americans (about 4%) will experience the life-disrupting symptoms of PTSD, which was first widely recognized during World War I and known as "shell shock" or "battle fatigue." Other "manmade" tragedies such as criminal assaults or sexual attacks can provoke PTSD symptoms, as can a fire, earthquake, or other natural disasters. Accidents -- car and airplane crashes, for example -- are also common precipitators of PTSD.

By definition, the disorder can only develop in response to a traumatic event, says Edna Foa, Ph.D., director of the University of Pennsylvania's Center for the Treatment and Study of Anxiety. It can't arise from other seriously stressful occurrences that are less extreme -- losing a job, or going through a divorce.

And, while not all life stressors are traumatic enough to lead to a PTSD diagnosis (but instead might cause "generalized anxiety"), not everyone who experiences a trauma will develop post-traumatic stress disorder, either. As many as 70% of American adults have been through at least one major trauma, according to the "Expert Consensus Treatment Guidelines for Post-Traumatic Stress Disorder: A Guide For Patients and Families," a guide written by Foa and others based on a survey of 100 PTSD experts. But, according to Foa, most people who go through a traumatic event may be more frightened and act more cautiously than they used to, even if they don't develop symptoms that disrupt their daily life in a significant way or render them dysfunctional.

• Re-experiencing the traumatic event. Re-experiencing can refer to having intrusive memories of the ordeal, flashbacks when awake, recurring nightmares, and exaggerated emotional and physical responses to triggers that remind the person of the event.
• Avoidance. After a trauma, people may lose interest in and avoid certain activities, places, and thoughts and feelings related to the trauma.
• Emotional detachment. Foa's patients have told her, "I'm not the person I used to be. I don't trust people. I can't feel loving anymore.
• Increased arousal. This symptom can show itself in difficulty sleeping, irritability or angry outbursts, difficulty concentrating, and unusually startled reactions in certain situations.

People can have wide-ranging reactions to a certain stressor. Some people will have no long-lasting effects, while on the other end of the spectrum, people can have problems that last for months or years. The symptoms must last for at least a month to be classified as post-traumatic stress disorder. While symptoms usually begin immediately after a trauma or within the following few weeks, sometimes they can show up months or years later.

• How severe and long-lasting was the trauma?
  The more intense and long-lasting the traumatic experience, the more likely it is that the victim will develop PTSD.
• How close was the person to the trauma, and how dangerous did it seem?
  A person injured in a factory explosion is more vulnerable to PTSD than if he had been across the street, merely heard the bang, and only later found out about the explosion's tragic consequences. One recent study that found that women who perceived their lives to be in danger during a rape had 2.5 times the incidence of PTSD than did others who didn't fear for their lives during the rape.
• Has the person been traumatized in the past, if so, how many times?
  One of Foa's patients didn't develop PTSD until the third sudden death in her circle of friends and acquaintances. The third time was it, says the therapist. "Now she's thinking, ' Next it will be me.'"
• Was the trauma inflicted by other people?
  PTSD is more likely after a rape or other manmade trauma than after an earthquake, hurricane, flood, or other naturally occurring disaster. Psychologically, it seems to matter whether the trauma is intentionally aimed at the victim or is random and suffered by many people together.
• What is the person's coping style--does he or she tend to stay enraged? And, does the person get support from friends and family?
  People are less likely to have PTSD if they think about the trauma, talk to other people about it, and let go of their anger over the incident. Foa encourages people to face the trauma: "Talk to someone you trust, write about it, do anything but push it away." And, she says, if the symptoms still cause suffering after several months, professional help should be sought.

Drugs for PTSD
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.

Psychotherapy for PTSD
As an alternative to medication or coupled with it, some patients opt to rely on group or individual psychotherapy to manage their PTSD symptoms. Three types are considered especially effective, according to the expert consensus guidelines:

• Exposure therapy. To help patients confront the everyday reminders of their trauma, therapists sometimes use "exposure in the imagination" or "exposure in reality." In the first type, patients imagine the trauma and recount the memories in detail, over and over again, with a therapist they trust and at home between sessions. The goal is to reprocess what happened until the thoughts lose their distressful impact. With exposure in reality, therapists ask patients to gradually expose themselves to situations or places they had been avoiding because they are reminders of the trauma.
• Cognitive behavioral therapy. With CBT, therapists work on changing victims' irrational beliefs, such as self-blame for a rape, criminal assault, or accident.
• Anxiety management. This includes techniques such as slow abdominal breathing to relax and avoid hyperventilation, and positive thinking and self-talk to replace negative thoughts.

Therapist Foa, who at her University of Pennsylvania clinic uses exposure therapy, sometimes combined with other types, estimates that 80% of patients accomplish significant improvement in their lives over the 12 weeks or so of therapy. She acknowledges that it's difficult to directly face a traumatic memory that one has been avoiding, sometimes for years. But getting help is critical, she says, if the stifling symptoms of PTSD do not resolve themselves pretty quickly after a trauma. Immediately after the trauma, it's normal to experience emotional swings, but if your symptoms begin to appear chronic, at four to six months, she says, they're not likely to improve on their own.

Have you experienced or witnessed a life-threatening event that caused you to feel intense fear, helplessness, or horror? Do you re-experience the event in at least one of the following ways?
-Repeated, distressing memories and/or dreams
-Flashbacks, or a sense of reliving the event
-Intense physical and/or emotional distress when exposed to things that remind you of the event

Do you avoid reminders of the event and feel numb, compared with the way you felt before, in three or more of the following ways? -Avoiding thoughts, feelings, or conversation about it
-Avoiding activities, places, or people who remind you of it
-Being unable to remember important parts of it
-Losing interest in significant activities in your life
-Feeling detached from other people
-Feeling that your range of emotions is restricted
-Feeling as if your future has shrunk (for example, you don't expect to have a career, marriage, children, or a normal lifespan)

Are you troubled by two or more of the following? -Problems sleeping
-Irritability or outbursts of anger
-Problems concentrating
-Feeling "on guard"
-An exaggerated startle response

Do your symptoms interfere with your daily life? Have your symptoms lasted at least a month?

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.