Recognition and Treatment of Posttraumatic Stress Disorder

The reports on posttraumatic stress disorder (PTSD) in this issue of THE JOURNAL^{1 - 3} draw attention to 3 important facts: PTSD is a worldwide problem, reaching alarming proportions in countries torn by violent conflict; it is associated with persistent disability and comorbidity for many people; and treatments can produce a meaningful reduction in distress. These studies, which tell clinicians not to forget about PTSD, provide the opportunity to focus on what is known about PTSD as a medical problem, and its presentation, recognition, and management. Perhaps the 3 main lessons to be learned are that PTSD often presents in medical disguise, it is largely unrecognized, and it can be treated successfully.

Posttraumatic stress disorder was first introduced as a diagnosis in 1980,⁴ but it has been slow to gain general acceptance. It has undergone some diagnostic modifications^{5 - 6} but remains in its essential features a disorder in which 1 or more traumatic events give rise to 4 symptom clusters: recurrent and painful reexperiencing of the event, phobic avoidance of trauma-related situations and memories, emotional numbing and withdrawal, and hyperarousal. In the US population, lifetime prevalence rates are in the range of 8%,⁷ with women affected twice as often as men. However, studies from other countries and studies of high-risk populations have reported widely ranging prevalence rates from a low of 1.3% in Germany⁸ to 37.4% in Algeria.³ It has been estimated that, on average, a person with PTSD will endure 20 years of active symptoms and will experience almost 1 day a week of work impairment, perhaps resulting in a $3 billion annual productivity loss in the United States.⁹ Rates of attempted suicide are as high as 19%.¹⁰

Besides being associated with increased risk for depression, anxiety, and alcohol or substance use disorders,⁷ PTSD is associated with higher rates of hypertension, bronchial asthma, and peptic ulcer¹⁰ and with other diseases of the cardiovascular, digestive, musculoskeletal, endocrine, respiratory, and nervous systems, as well as increased rates of infectious disease for up to 20 years following exposure to major trauma and after controlling for other variables.¹¹ Adult survivors of childhood abuse, many of whom are likely to have experienced PTSD, have higher rates of smoking, sexually transmitted disease, severe obesity, ischemic heart disease, cancer, chronic obstructive pulmonary disease, fractures, and liver disease than the general population.¹² The cost of PTSD exceeds that of all other anxiety disorders, and much of this expenditure is accounted for by direct costs of treatment seeking and medical evaluation.¹³

People with PTSD might be expected to seek mental health treatment. However, evidence suggests that this is relatively uncommon¹⁴ and that, even in academic and community mental health settings,^{15 - 16} rates of recognition may be low with clinical diagnosis of PTSD occurring in as few as 4% of individuals with the disorder. In a national cohort of Israeli primary care patients, 9% met criteria for current PTSD, but only 2% of actual cases were recognized by their treating physicians. Although 49% of physicians recognized the existence of psychological distress, this rate was still far less than the 88% frequency of self-rated distress in the sample.¹⁷ In a US primary care survey,¹⁸ 11.8% of patients met diagnostic criteria for full or partial PTSD. These findings are important since more than 70% of respondents with PTSD symptoms in the general population have used general medical services in the past 6 months.¹⁴

The question then arises as to how PTSD might be recognized and what are the likely disguises behind which it might be found. An unusually high rate of somatization disorder¹⁰ suggests that individuals with PTSD may be marked and persistent somatizers, a finding subsequently borne out in a study of women with a history of physical or sexual abuse who were seen in a gastrointestinal disorders clinic.¹⁷ Musculoskeletal, genitourinary, dermatologic, respiratory, panic, sleep-related, and appetite disturbances were commonly seen. The number of symptoms, as well as severity of abuse, explained much of the variance, accounting for subsequent physician visits during the next year. Such patients made 3 to 8 more health care visits per year than did women without abuse. High rates of PTSD also have been reported in association with irritable bowel syndrome.²⁰

The notion that PTSD at times may be associated with "hypervigilance to symptoms" has been advanced and receives some support from a study of abuse survivors with gastroesophageal reflux who showed lower cutaneous sensitivity thresholds and hypervigilance in labeling stimuli as being painful. Their pain-coping mechanisms were considered to be poor.²¹ Another study²² has shown that heavy smoking is much more likely in trauma survivors with PTSD compared with those who had experienced similar trauma but did not have PTSD. Thus, in the health care system, PTSD or the role of trauma should be considered in patients experiencing prominent chronic pain or persistent somatization, especially when these symptoms are not otherwise fully accounted for.

Posttraumatic stress syndrome can only be diagnosed if the existence of a traumatic event has been established. However, clinical suspicion may be warranted based on symptoms or behaviors even if no such event has yet been established. To elicit this information may in some cases be relatively straightforward. But in other cases, it will be more difficult, requiring the establishment of trust and confidence between patient and physician and requiring the physician's unwillingness to accept initial denial as being the final answer in some cases. Suggested approaches to uncovering a trauma have been described.^{23 - 24} For example, in the case of suspected domestic violence, the physician, when alone with the patient, should raise the concern that the patient's medical problems might be related to injury inflicted by another person. The patient may be asked if he or she feels safe at home. Routine questioning about trauma has been suggested along the lines of inquiring about whether a traumatic event has ever been experienced and whether the experience is still upsetting to the patient. The use of brief screening instruments may also be helpful, including clinician administered scales such as the Primary Care Evaluation of Mental Disorders (PRIME-MD),²⁵ the MINI-International Neuropsychiatric Interview,²⁶ the PTSD Checklist,²⁷ and the self-rated startle, physiological arousal, anger, and numbness (SPAN) scale.²⁸

Accurate diagnosis is essential for effective treatment.²⁹ Of all disorders, PTSD requires that physicians give patients adequate time for disclosing their stories. Brief treatment does not mean rushed treatment. Education involves explaining to survivors and their families about the nature of PTSD and responses to stress and it involves encouraging them to speak about their traumatic experience with family or friends to the extent that they wish to do so yet not in a pressured way. Advice about health behaviors and avoidance of use of alcohol, other drugs, and tobacco is often needed. Primary care physicians are ideally placed to provide front-line support to patients in the first weeks after exposure to a trauma and to offer symptomatic treatment as indicated.

What effect can treatment with medication make? After a series of studies in the 1980s, mostly in combat veterans, the effect of medications appeared modest at best. Although imipramine hydrochloride, amitriptyline hydrochloride, and phenelzine sulfate were all more effective than placebo in treating severe forms of PTSD, residual morbidity was considerable.^{30 - 31} An early trial of fluoxetine hydrochloride also showed modest benefits of the drug in a population that included many combat veterans.³² A later study with fluoxetine³³ showed that a selective serotonin reuptake inhibitor (SSRI) could have a very substantial impact on the symptoms of PTSD. In a population of civilian women, mostly traumatized through interpersonal violence, more than 40% reached a state of clinical remission (ie, absence of PTSD symptoms) at the end of 12 weeks. The drug was also found to improve resilience, a potentially important finding for a disorder that is often characterized by low levels of resilience in the face of stress. More recently, 2 larger multicenter trials of sertraline hydrochloride have demonstrated good benefit across the full range of PTSD symptoms, as well as quality of life and disability.^{34 - 35} Selective serotonin reuptake inhibitors modulate affects, memories, and impulses in PTSD, conferring protection against their overwhelming intensity on one hand and loosening excessive inhibitions on the other, and they often act rapidly.

Beyond the short term, what can be said for maintenance pharmacotherapy in PTSD? Here the data are scant, but such a chronic disorder is likely to require maintenance pharmacotherapy for at least 12 months. One report³⁶ has shown that continued use of sertraline for 9 months can progress to symptom remission in a substantial number of patients. Twenty-five percent of the PTSD symptom improvement obtained and 31% of the improvement attained in quality of life occurred after 12 weeks of treatment. Also, 54% of those who had failed to respond at 12 weeks became responders with the continuation of treatment. Therefore, 12 weeks of treatment with an SSRI may not be an adequate trial. On the other hand, if there has been no improvement within 4 weeks at an adequate dose, continued treatment with an SSRI is unlikely to be beneficial.³⁷ Little work exists about predicting who will do well in the long term following short-term pharmacotherapy. In one trial,³⁸ the strongest predictor of 1-year outcome after fluoxetine treatment was the degree of response at week 12, suggesting that the practitioner should make every effort in the acute phase to retain patients by engaging them in treatment and to use drugs to their maximal advantage. Effect sizes of SSRI vs placebo in PTSD are moderate to strong,³⁷ and this class of drugs now receives consensus opinion as first-line medication in PTSD.³⁹ Evidence for the benefit of other drug classes is extremely sparse, and their study remains critical.

Reports, which so far have been mostly uncontrolled and based on small samples, have suggested benefit for paroxetine (however, several unpublished placebo-controlled studies that have shown paroxetine to be beneficial in treating PTSD may result in FDA approval within the next 2 to 3 months),⁴⁰ citalopram hydrochloride,⁴¹ fluvoxamine maleate,⁴² nefazodone hydrochloride,⁴³ trazodone hydrochloride,⁴⁴ bupropion hydrochloride,⁴⁵ mirtazapine,⁴⁶ clonidine,⁴⁷ and propranolol.⁴⁷ Non-SSRI drugs are now considered second-line or augmenting treatments, and trazodone has been suggested for managing insomnia in PTSD.³⁹ Disappointing results have been reported for buspirone hydrochloride⁴⁸ and inositol niacinate.⁴⁹ Mood stabilizers have some utility.^{50 - 52} The only placebo-controlled trial evaluating an antipsychotic agent showed no benefit.⁵³ Benzodiazepines are probably not helpful and can be harmful when given as monotherapy for any length of time,^{54 - 56} but they may be useful in the acute phase as short-term treatment or as adjuncts in chronic PTSD.

Given that symptoms which peak within 2 weeks of trauma, may carry a better prognosis than the slow buildup of symptoms of more than 3 months,⁵⁷ vigorous attempts should be made to treat PTSD early and effectively. Initial use of a hypnotic agent, followed up after 3 weeks by an SSRI, has been recommended for persistent acute PTSD symptoms in primary care.²⁹ Early facilitation of normal 24-hour arousal regulation prior to consolidation of changes associated with chronic PTSD may be an important form of secondary prevention immediately following exposure to trauma.⁵⁸ This critical, yet demanding, area of therapeutics demands much more attention than it has so far received.

Few data exist about whether extended pharmacotherapy protects patients against relapse in PTSD, but one report suggests a substantially lower rate of relapse when sertraline is continued for 15 months vs a placebo switch after successful open-label treatment.⁵⁹

Psychosocial treatments are well established and effective in many different PTSD populations. Three factors are considered essential in the successful processing of traumatic events: emotional engagement with the trauma memory, organization of the trauma story, and correction of dysfunctional thoughts that are commonly found following trauma.⁵⁷ Most psychosocial (cognitive-behavioral) approaches make use of exposure and/or anxiety management training. Exposure to details, memories, and feelings of the trauma can be accomplished by imaginal or in vivo (real life) exposure with therapeutic guidance. Anxiety management training includes relaxation and breathing techniques, social skills training, cognitive restructuring, role-play, and positive self-dialogue.⁵⁷ Although both techniques are effective, it may be that exposure is critical for the most efficient use of psychosocial treatment. For example, one study showed that following exposure, 57% of the sample attained a 70% symptom reduction after 9 sessions vs 23% who had received cognitive restructuring and exposure.⁵⁷ Psychosocial treatments benefit PTSD following rape, nonsexual assault, unintentional injury, combat, and other forms of traumatic stress.^{57 ,60 - 63} Eye movement desensitization and reprocessing can also be effective but appears to be less so than prolonged exposure with stress inoculation training.⁶³

An appealing aspect of psychosocial treatments is the low relapse rate found for up to a year after termination of acute treatment.^{60 - 61} On the other hand, limitations of psychosocial treatments include that they are not for everyone, many communities do not have access to skilled practitioners, and no more than 50%, as with medication, achieve full remission in the short term.⁵⁷ To improve the chance of remission, a case could be made for combining medication and psychosocial treatments but no comparative studies have yet been reported using this approach. For the primary care practitioner, it is important to realize the benefits of psychosocial treatment and to make use of accessible referrals. Psychosocial treatments are unlikely to be adopted in primary care unless treatment is considerably modified and simplified. Precedents exist for adapting psychosocial treatments to primary care settings for depression⁶⁴ and social phobia.⁶⁵ One technique that might deserve further study in this context is encouraging patients to write about their traumatic experiences. For example, writing about personal stress or trauma with expression of affect on 3 occasions during 1 week was associated with substantial improvement in bronchial asthma and rheumatoid arthritis,⁶⁶ showing, at the very least, that simple trauma processing techniques can facilitate recovery from chronic medical disorder, even when no ostensible relationship has been demonstrated between the trauma and the disorder. Whether a similar treatment approach for PTSD might be helpful in the medical setting or whether other adaptations of exposure-based treatment are feasible remains to be seen.

Debriefing after trauma may be helpful in coping with acute stress, but it has not convincingly been shown to prevent PTSD²⁹ and is not advocated alone to prevent the disorder.⁶⁷ In the treatment of children, cognitive-behavioral treatment, SSRI, and clonidine are recommended although evidence for the latter 2 is weak.⁶⁸

Despite major advances in the field, there are still many gaps in current knowledge of effective treatment for PTSD,⁶⁹ and the cross-cultural application of treatments deserves more extensive study.

It is clear that the importance of PTSD as a worldwide health problem must be recognized and that it is important for clinicians to be alert to the presence and presentation of PTSD in medical and psychiatric settings. There is no reason PTSD cannot be treated effectively in primary care. The Global Burden of Disease Project⁷⁰ predicted that the following causes of disease burden in the United States would increase in their current ranks by the year 2020: depression, the second highest; road traffic accidents, the third highest; war, the eighth highest; and violence, the 12th highest. Although PTSD was not specifically included as a disease, each one of these conditions is known to carry with it a high risk for or association with the disorder. It is time to heed the wake-up call provided by recent research into PTSD. The disorder should be treated early. It should be treated effectively.