POSTTRAUMATIC STRESS DISORDER: PART 2
| PSYCHOPHARMACOLOGY FOR POSTTRAUMATIC STRESS DISORDER— Frank Schoenfeld, MD, Professor
Emeritus, Department of Psychiatry, University of California, San Francisco, School of Medicine, and Veterans
Affairs Medical Center, San Francisco
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| Introduction: with or without treatment, 30% of people with posttraumatic stress disorder (PTSD) develop chronic
condition that is unremitting and difficult to moderate
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| Early intervention: better; a few studies have looked at pharmacotherapy in emergency departments (EDs); one
study found that benzodiazepines given in ED did not prevent development of PTSD; more recent study found propranolol
(160 mg/day for 10 days) did not prevent development of PTSD, but did eliminate physiologic response to
script-driven reminder of trauma
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| Acute stress disorder: more severe variant of acute stress response; same symptoms as PTSD, with addition of
significant dissociative symptoms; occurs early in course after traumatic event; few open or closed trials of medication
treatment; most research done in pediatric burn units, where imipramine found to help control pain and to reduce
symptoms of acute stress disorder; in study, fluoxetine shown as effective as imipramine
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| Treatment of PTSD: few studies of medication treatment during 1 to 3 mo after trauma; in most studies, cognitive
behavioral treatments shown effective; medication may provide sedation and relieve agitation; early psychosocial
and psychopharmacologic intervention may reduce chronicity; medications to consider include β-adrenergic blockers,
α2 -adrenergic agonists, antidepressants, benzodiazepines, and mood stabilizers; all data on use of medications
(except for propranolol) based on clinical experience, not on studies; no single agent reliably effective
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| Goals of pharmacotherapy for PTSD: reduce or ameliorate target symptoms; improve mood and emotional
numbing; reduce phasic and tonic hyperarousal; improve sleep; reduce impulsivity; reduce psychotic and/or dissociative
symptoms; treat comorbid psychiatric disorders
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| Antidepressants: many studied in randomized placebo-controlled trials, but sample sizes usually small and size of
treatment effect modest; some studies included only victims of military trauma, some only civilian trauma, and
some mixed; in general, victims of military trauma less responsive to most interventions, including medications
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 | Selective serotonin reuptake inhibitors (SSRIs): sertraline and paroxetine approved by Food and Drug Administration
(FDA) for treatment of PTSD; in studies, SSRIs had positive effect on all 3 symptom clusters of PTSD; all other categories
of antidepressants had no effect on numbing and avoidance symptoms; typical drug studies lasted 4 to 12 wk,
but one sertraline open-label study extended to 24 wk and showed improvements on Clinician Administered PTSD
Scale (CAPS); discontinuation phase of same study showed significant decline in benefit when drug discontinued
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| Other antidepressants: trazodone—commonly added to SSRI to help with sleep; speaker discourages its use as
stand-alone agent because of sedative effects; bupropion—can be helpful as adjunctive agent in persistent comorbid
depression that does not respond to primary antidepressant; venlafaxine—6-mo study showed no further
improvement after first 3 mo of treatment; less helpful than sertraline for arousal symptoms; mirtazapine—large
study under way for use in PTSD
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| Antianxiety agents: “remarkably little research done on the use of benzodiazepines for the treatment of PTSD”; only
one study done (with alprazolam), which showed that benzodiazepine did help with anxiety in PTSD; buspirone—
“looks promising,” but almost no work done for treatment of PTSD
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| Adrenergic inhibiting agents: propranolol used infrequently in chronic PTSD, due to side-effect profile; guanfacine
not shown to improve PTSD symptoms; in one study, prazocin found to help with sleep disturbance, changing
subjective quality of nightmares
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| Atypical antipsychotic agents: not routinely used for PTSD, except in cases in which patient has unremitting dissociative
symptoms, psychotic symptoms, and/or impulsive aggressive behavior; in studies, olanzapine had positive
influence on PTSD symptoms, even in absence of psychosis; risperidone showed similar results, as well as
improvement of comorbid psychoses; quetiapine used to help with sleep (lack of evidence)
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| Mood stabilizers: use based on hypothesis that limbic system particularly vulnerable to kindling from repeated
stimuli; however “in practice we are using them for affective lability, impulsive aggressive behavior, and
co-occurring mood-swing disorder”
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| Comorbidity: >80% of people with PTSD have one other psychiatric diagnosis, and >50% have ≥3; choose medication
most likely to help PTSD and comorbidity, while having most favorable side-effect profile and fewest interactions
with other drugs; most common comorbidity with PTSD major depression (major depressive disorder or
bipolar disorder); comorbid anxiety disorders include panic disorder and phobias; substance abuse common (almost
50% in civilian studies); psychotic symptoms seen in 40% of hospitalized patients in one Veterans Affairs
study; rapid escalation to anger common and “needs to be addressed”
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| Stage-based pharmacotherapy for PTSD: during first hours, reduce terror and neuronal imprinting with adrenergic
blockers; during first days, reduce sensitization and memory consolidation with adrenergic blockers and/or
mood stabilizers; during first months, reduce symptoms with SSRIs and low-dose trazodone for sleep; after first
year, reduce symptoms and comorbidity with SSRIs, adrenergic blockers, and/or mood stabilizers
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| Future directions: adrenergic antagonists at time of exposure to traumatic event; corticotropin-releasing factor antagonists;
neuropeptide Y enhancers; substance P antagonists; N-methyl-D-aspartate (NMDA) facilitators; reversible
monoamine oxidase inhibitors (MAOIs); mixed adrenergic and serotonergic agents
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| CONJOINT TREATMENT FOR PTSD—Candice M. Monson, PhD, United States Department of Veterans Affairs;
Associate Professor of Psychiatry, Boston University School of Medicine; and Deputy Director, Women’s Health
Services Division, National Center for PTSD, Boston, MA
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| Introduction: all trauma occurs in interpersonal context; by definition, human-caused trauma completely interpersonal,
and technologic and natural disasters usually experienced by group of people
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| Relationship quantity: defined as likelihood of marrying and divorcing; compared to individuals without PTSD,
those with PTSD equally likely to marry but 1.5 times more likely to divorce; study of veterans 15 yr after Vietnam
war showed those with PTSD less likely to marry and twice as likely to divorce; in Canadian study, couples in which
one partner had PTSD 4 times more likely to be distressed than couples without mental health diagnosis, and PTSD
was second most frequent diagnosis to be associated with marital distress; clinical studies that recruit patients with
PTSD find these individuals have relationship conflicts in more areas (eg, sex, parenting); couples with PTSD less cohesive,
spend less close time together, have less emotional expressiveness, and less engagement in relationship
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| Reevaluation of veterans of Iraq and Afghanistan: authors studied active-duty and reserve soldiers 3 to 6 mo
after deployment; 58% of them married (higher than in previous wars, due to extensive use of reservists); from time
soldiers arrived home until assessment 3 to 6 mo later, interpersonal conflict increased 4-fold; authors concluded
that spouses and partners “a major portal to treatment”; therapists could use spouses and partners to get people with
PTSD and their significant others into treatment
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| Domestic violence: 33% of Vietnam veterans with PTSD perpetrated physical aggression against partner in previous
year, compared to about half that many without PTSD; greater the severity of PTSD, greater the frequency and
severity of acts of violence
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| Characteristics of family with PTSD: little empiric data, but anecdotal literature finds systemic compensation
(ie, partner who does not have PTSD picks up much of caregiving burden and sometimes financial burden); these
families also tend to have more stereotypical opinions about gender roles and to have rigid expectations and boundaries
for all family members; major problems identified in these families include depression, anxiety, diminished
quality of life, and feeling demoralized
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| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV): defines 3 clusters of symptoms
associated with PTSD; cluster C symptoms, especially emotional numbing, most associated with problems in intimate
relationships; patient unable to feel love for or primary connections to significant other; hyperarousal symptoms
(cluster D) most associated with acts of aggression; important to rule out alcohol consumption as cause of
aggression; National Vietnam Veterans Readjustment Study (NVVRS) found high frequency of drinking and high
quantity of alcohol, low frequency of drinking and high quantity of alcohol, and low frequency of drinking and low
quantity of alcohol associated with increased aggression; surprisingly, high frequency of drinking and low quantity
of alcohol associated with decreased aggression (but “I’d be slow to recommend many days’ use of alcohol at low
quantities to my patients”)
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| Take-home messages from NVVRS: 1) PTSD (as opposed to just being exposed to trauma) is mechanism identified
as increasing aggression; 2) in trying to determine whether particular veteran at higher risk for perpetrating aggression
against intimate partner, important to determine how much he or she perceives threat in domestic environment
(combat exposure may be protective factor; in study, the more combat exposure experienced, the less incidence of intimate-partner
violence)
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| Nonveteran populations: speaker and group studied women within 3 mo of experiencing large flood in Midwest; all
symptom clusters seemed to be associated with relationship satisfaction, suggesting emotional numbing may be due to
chronicity of PTSD rather than to acute stages of trauma exposure; additional stressors in this study included relocation
and insurance issues; in short term, these were associated with more relationship satisfaction, which in turn decreased
likelihood of individual experiencing symptoms of PTSD
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| Conjoint therapy: spouse or partner often spurs person with PTSD into getting help; stigma associated with seeking
mental health services, especially among military personnel, and significant other may be able to help patient
overcome stigma; 25% to 50% of people in treatment for PTSD drop out, and speaker speculates that having significant
other involved with treatment may help lower that incidence; in addition, conjoint therapy may help improve
relationship functioning; studies show conventional treatment improved PTSD symptoms but not social functioning;
in literature, patients who came from families with high expressed emotion did not do as well as those from
families with low expressed emotion; conjoint therapy shown to be effective for diagnoses other than PTSD, and
speaker posits that it will be as effective for families with PTSD
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| Speaker’s conjoint therapy: not partner-coaching model, mainly because those with PTSD often partner with
someone who has been traumatized or who has major depression, “so we assume that there’s something problematic
about their interactions that we want to correct [and] that can simultaneously improve their relationship
as well as decrease the PTSD symptoms”; program lasts for 15 sessions of 1 hr 25 min each; it is trauma-
focused but not exposure-based; exposure therapy should be done, but speaker’s program focuses on what
trauma experience means to patient and significant other; first phase of therapy focuses on introduction, psychoeducation,
and safety building; second phase focuses on relationship enhancement and decreasing avoidance;
third phase focuses on cognitive restructuring in dyadic interactions
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| Phase 1: psychoeducation given in interpersonal context, helping family to understand why patient has symptoms
and how they affect relationship (eg, reexperiencing through nightmares may lead couple to stop sleeping together);
role of avoidance in relationship stressed; family encouraged to decrease negatives in relationship and to
increase positives
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| Phase 2: training in behavioral skills that increase listening and paraphrasing, assertiveness, and communication;
couple taught to identify and express emotions, and to externalize and analyze thoughts
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| Phase 3: using benefits that have come from strengthening relationship, decreasing avoidance, and better communications
to make meaning of traumatic event; couple learns importance of disclosure in safe environment to create
resilience; specific themes addressed include safety, trust, power, control, and intimacy; planning for future
struggles in relationship
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| What still needs to be done: longitudinal study of mechanisms of key factors in relationships; investigation of sex
differences; development of prevention techniques that take advantage of social-support mechanisms; exploration
of how to prevent chronic and more pernicious types of PTSD with swift and effective intervention; trials to see if
couple/family interventions can work as well with PTSD as with other conditions
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Suggested Reading
Calhoun PS et al: Objective evidence of sleep disturbance in women with posttraumatic stress disorder. J Trauma
Stress 20:1009, 2007; Ehring T et al: Screening for posttraumatic stress disorder: what combination of symptoms
predicts best? J Nerv Ment Dis 195:1004, 2007; Feldner MT et al: A critical analysis of approaches to targeted
PTSD prevention: current status and theoretically derived future directions. Behav Modif 31:80, 2007; Freedman
SA et al: Predictors of chronic post-traumatic stress disorder. A prospective study. Br J Psychiatry 174:353, 1999;
Gelpin E et al: Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry
57:390, 1996; Gutner CA et al: Changes in coping strategies, relationship to the perpetrator, and posttraumatic distress
in female crime victims. J Trauma Stress 19:813, 2006; Jakupcak M et al: Anger, hostility, and aggression
among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD. J Trauma Stress 20:945, 2007;
Marmar CR et al: New directions in the pharmacotherapy of posttraumatic stress disorder. Psychiatr Q 73:259,
2002; Monson CM et al: Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.
J Consult Clin Psychol 74:898, 2006; Monson CM et al: Cognitive-behavioral couple’s treatment for posttraumatic
stress disorder: initial findings. J Trauma Stress 17:341, 2004; Monson CM et al: Emotional deficits in
military-related PTSD: an investigation of content and process disturbances. J Trauma Stress 17:275, 2004; Monson
CM et al: Cognitive-behavioral therapy for PTSD in the real world: do interpersonal relationships make a real difference?
J Clin Psychol 61:751, 2005; Morey RA et al: Neural systems for executive and emotional processing are
modulated by symptoms of posttraumatic stress disorder in Iraq War veterans. Psychiatry Res 162:59, 2008; Pitman
RK et al: Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry
51:189, 2002; Pitman RK et al: Psychophysiological alterations in post-traumatic stress disorder. Semin Clin Neuropsychiatry
4:234, 1999; Price JL et al: The role of emotional functioning in military-related PTSD and its treatment.
J Anxiety Disord 20:661, 2006; Rotunda RJ et al: Behavioral couples therapy for comorbid substance use
disorders and combat-related posttraumatic stress disorder among male veterans: an initial evaluation. Addict Behav
33:180, 2008; Schoenfeld FB et al: Current concepts in pharmacotherapy for posttraumatic stress disorder. Psychiatr
Serv 55:519, 2004; Sherman MD et al: Domestic violence in veterans with posttraumatic stress disorder who
seek couples therapy. J Marital Fam Ther 32:479, 2006.
Educational Objectives
| The goal of this program is to improve treatment of posttraumatic stress disorder (PTSD). After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Provide pharmacologic treatment in the acute phase of PTSD.
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| 2. Discuss the classes of medications that might be of benefit in the treatment of chronic PTSD.
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| 3. Explain the manner in which PTSD in one family member can affect intimate relationships.
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| 4. Describe the characteristics of families with PTSD.
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| 5. Explore the uses of conjoint therapy in the treatment of PTSD.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care
and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported
nothing to disclose.
Acknowledgements
Dr. Schoenfeld was recorded at PTSD: In an Age of Violence, Terror, and Disaster, held November 9-10, 2007, in San
Francisco, CA, and sponsored by the Veterans Affairs Medical Center, San Francisco, and the University of California,
San Francisco, School of Medicine. Dr. Monson was recorded at the Second Annual Posttraumatic Stress Disorder Symposium,
held November 30, 2007, in Cleveland, OH, and sponsored by the Cleveland Clinic. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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