PTSD: Treating the Wounds We Do Not See

Dr. Zanni is a psychologist and health systems consultant based in Alexandria, Virginia.

Originally called shell shock or battle fatigue, most people associate posttraumatic stress disorder (PTSD) with military service for good reason: up to 29% of combat veterans and 78% of prisoners of war develop PTSD.¹ Regardless, psychologically and functionally impairing PTSD can arise from any traumatic situation.

After trauma, extreme fear, helplessness, or anxiety are normal short-term reactions that generally dissipate over time, as individuals cope and adjust. Approximately 33% of acute trauma sufferers, however, develop symptoms lasting longer than 30 days. Symptom duration distinguishes PTSD from normal acute stress reactions.

PTSD's hallmark symptoms include re-experiencing the trauma, avoidance and/or emotional numbness, and hyperarousal.² Table 1³ lists PTSD's diagnostic criteria. PTSD's categories include acute (duration <3 months), chronic (duration ≥3 months), and delayed onset where symptoms emerge more than 6 months after trauma is experienced. Most adult victims develop symptoms within 3 months of the event.⁴

Table 1

PTSD's prevalence ranges from 8% to 10%, with 3.6% of adult Americans suffering from PTSD within any given year.^4,5 Longer, more severe trauma increases PTSD risk. Among the general population, PTSD is most commonly associated with automobile accidents (56%), followed by personal assault (35%).¹ PTSD is more common among women, but men present with more irritability and are more likely to increase alcohol consumption.¹ Up to 30% of PTSD patients develop a chronic, lifelong form.⁶

Along with military combat service, workers who see trauma daily, such as rescue and emergency personnel, are at risk. Other situations associated with PTSD risk include:

• Terrorist attacks
• Natural disasters, such as fire, floods, hurricane, tornado, and earthquake
• Child sexual or physical abuse
• Unexpected death of others
• Sudden life-threatening illnesses
• Adult sexual or physical assault
• Horrific accidents^7,8

In most cases, PTSD sufferers are the victims; however, people who cause catastrophic events also are at risk. Families of PTSD victims may likewise be affected.

Treatment

Early intervention can hasten the generally gradual recovery process. Treatment reduces the average duration of symptoms from 64 to 36 months.⁴ Treatment generally lasts 3 to 6 months, but those with comorbid mental health problemsmay require longer treatment.⁷ Interventions generally include medication management and psychotherapy. Treatment planning is complicated, partly because symptoms of PTSD wax and wane.

The FDA-approved selective serotonin reuptake inhibitors sertraline (Zoloft) and paroxetine (Paxil) are first-line treatments. Sertraline is especially useful for women who experienced physical or sexual trauma. Paroxetine targets all symptomclusters (re-experiencing the event, avoidance behaviors, and hyperarousal). Agents used to target specific symptoms include benzodiazepines for anxiety; anticonvulsants for impulsivity and emotional lability; beta-blockers for hyperarousal; and clonidine for nightmares. Monoamine oxidase inhibitors effectively reduce re-experiences, but have minimal impact on avoidance symptoms.⁴ Table 2 includes pharmacotherapy options for PTSD.

Cognitive behavior therapy helps patients recognize and change thought patterns associated with troublesome emotions and memories; it is particularly effective.^5,9

Table 2

Counseling Tips

Avoidance symptoms of PTSD create counseling challenges; consequently, pharmacists must pace counseling to the patient's comfort level. Along with medication counseling, the following guidelines help pharmacists address core issues:

• Avoid statements that patients may perceive as accusatory, such as "You are always on guard." Rather, soften statements with "I think..." or "I wonder if?"
• Emphasize that stress reactions are normal and expected, noting that sometimes memories get stuck through no fault of the patient. It is neither shameful nor a sign of weakness.
• Explain that PTSD is a real physical experience linked to decreased brain activity, decreased hippocampus volume, and abnormal amygdala activation^4,6
• Debunk myths that one can "merely snap out of it"
• Point out that exercise often helps minimize stress, as do support groups
• Recommend "watchful waiting" for patients unmotivated to seek treatment. Advise them to seek help if things do not improve within 3 months.
• Offer opportunities for follow-up questions
• Cultivate PTSD suspicion in those with depression, anxiety, or substance abuse
• Pharmacists wishing to update their understanding of PTSD will find the National Center for PTSD's free online course at www.ncptsd.va.gov/ncmain/index.jsp helpful

Final Thought

Nearly 50% of PTSD sufferers refuse to seek treatment, fearing what others might think and/or are concerned that their condition might negatively affect their employment.^4,7 Pharmacists, like all health care professionals, must work toward eradicating the stigma associated with PTSD?all the more reason for thorough counseling.

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References

• Green B. Post-traumatic stress disorder: symptom profiles in men and women. Curr Med Res Opin. 2003;19(3):200-204.
• Stevens LM, Lynm C, Glass RM. JAMA patient page. Posttraumatic stress disorder. JAMA. 2006;296:614.
• Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. American Psychiatric Association; Washington, DC: 2000.
• Gore TA, Richards-Reid GM. Posttraumatic stress disorder. eMedicine Web site. www.emedicine.com/med/TOPIC1900.HTM. Accessed May 30, 2008.
• Post-traumatic stress disorder. Web MD Web site. www.medscape/viewarticle/472332. Accessed May 30, 2008.
• Hamblen JA. What is PTSD? A handout from the National Center for PTSD. www.ncptsd.va.gov/ncmain/information/what_is.jsp. Accessed May 30, 2008.
• Frequently Asked Questions. National Center for PTSD Fact Sheet. www.ncptsd.va.gov/~. Accessed May 30, 2008.
• Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0. Washington, DC: Veterans Health Administration, Department of Defense; 2004 Jan. www.guidelines.gov/summary/summary.aspx~. Accessed May 30, 2008.
• Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007:18(3):CD003388.