Evidence-Based Reviews

PTSD: A systematic approach to diagnosis and treatment

Current Psychiatry. 2018 April;17(4):35-43

References

1. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association; 1980.
2. North CS, Surís AM, Smith RP, et al. The evolution of PTSD criteria across editions of the DSM. Ann Clin Psychiatry. 2016;28(3):197-208.
3. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013
4. Downs DL, North CS. Trauma-related disorders. Overview of posttraumatic stress disorder. https://www.deckerip.com/products/scientific-american-psychiatry/table-of-contents/. Published July 2017. Accessed February 27, 2018.
5. North CS. Disaster mental health epidemiology: methodological review and interpretation of research findings. Psychiatry. 2016; 79(2):130-146.
6. North CS, Yutzy SH. Goodwin and Guze’s Psychiatric Diagnosis, 6th ed. New York, NY: Oxford University Press; 2010.
7. North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282(8):755-762.
8. North CS, Pfefferbaum B. Mental Health Response to Community Disasters: A Systematic Review. JAMA. 2013;310(5):507-518.
9. North CS, Pollio DE, Smith, RP, et al. Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center. Disaster Med Public Health Prep. 2011;5(suppl 2):S205-S213.
10. North CS, Oliver J, Pandya A. Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters. Am J Public Health. 2012;102(10):e40-e48.
11. Whitman JB, North CS, Downs DL, et al. A prospective study of the onset of PTSD symptoms in the first month after trauma exposure. Ann Clin Psychiatry. 2013;25(3):163-172.
12. North CS, Oliver J. Analysis of the longitudinal course of PTSD in 716 survivors of 10 disasters. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1189-1197.
13. Jeffreys M, Capehart B, Friedman MJ. Pharmacotherapy for posttraumatic stress disorder: review with clinical applications. J Rehabil Res Dev. 2012;49(5):703-715.
14. Lee DJ, Schnitzlein CW, Wolf JP, et al. Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: systemic review and meta-analyses to determine first-line treatments. Depress Anxiety. 2016;33(9):792-806.
15. Foa EB, Keane T, Friedman MJ. Effective treatments for PTSD: practice guidelines from the International Society for traumatic stress studies. New York, NY: The Guilford Press; 2000.
16. Ursano RJ, Bell C, Eth S, et al; Work Group on ASD and PTSD. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association Publishing; 2004.
17. National Collaborating Centre for Mental Health. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London, UK: Gaskell and the British Psychological Society; 2005.
18. Foa EB, Keane TM, Friedman MJ, eds; The Board of Directors of the International Society for Traumatic Stress Studies. Effective treatments for PTSD. 2nd ed. Oakbrook Terrace, IL: The Guilford Press; 2005.
19. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guidelines. Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/. Published June 2017. Accessed February 26, 2018.
20. Phoenix Australia -Centre for Posttraumatic Mental Health. Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne, Australia: Phoenix Australia Centre for Posttraumatic Mental Health; 2013.
21. World Health Organization. Guidelines for the management of conditions specifically related to stress. Geneva, Switzerland: World Health Organization Press; 2013.
22. Benedek DM, Friedman MJ, Zatzick D, et al. Guideline watch (March 2009): practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Focus. 2009;7(2):201-213.
23. Stein DJ, Ipser J, McAnda N. Pharmacotherapy of posttraumatic stress disorder: a review of meta-analyses and treatment guidelines. CNS Spectr. 2009;14(suppl 1):25-31.
24. Forbes D, Creamer M, Bisson JI, et al. A guide to guidelines for the treatment of PTSD and related conditions. J Trauma Stress. 2010;23(5):537-552.
25. Nash WP, Watson PJ. Review of VA/DOD clinical practice guideline on management of acute stress and interventions to prevent posttraumatic stress disorder. J Rehabil Res Dev. 2012;49(5):637-648.
26. Birur B, Moore NC, Davis LL. An evidence-based review of early intervention and prevention of posttraumatic stress disorder. Community Ment Health J. 2017;53(2):183-201.
27. Breslau N, Davis GC. Posttraumatic stress disorder in an urban population of young adults: Risk factors for chronicity. Am J Psychiatry. 1992;149(5):671-675.
28. North CS, Pfefferbaum B, Kawasaki A, et al. Psychosocial adjustment of directly exposed survivors seven years after the Oklahoma City bombing. Compr Psychiatry. 2011;52(1):1-8
29. Rasco SS, North CS. An empirical study of employment and disability over three years among survivors of major disasters. J Am Acad Psychiatry Law. 2010;38(1):80-86.

Eye movement desensitization and reprocessing (EMDR) therapy has emerged as a popular trauma-focused therapy with documented effectiveness. During EMDR, the patient attends to emotionally disturbing material in brief sequential doses (which varies with individual patients) while simultaneously focusing on an external stimulus, typically therapist-directed lateral eye movements. Critics of EMDR point out that the theoretical concepts and therapeutic maneuvers (eg, finger movements to guide eye gaze) in EMDR are not consistent with current understanding of the neurobiological processes involved in PTSD. Further, studies testing separate components of the therapy have not established independent effectiveness of the therapeutic maneuvers beyond the therapeutic effects of the psychotherapy components of the procedure.⁴

Other psychotherapies might also be beneficial, but not enough research has been conducted to provide evidence for their effectiveness.⁴Non-trauma–focused psychotherapies used for PTSD include supportive therapy, motivational interviewing, relaxation, and mindfulness. Because these therapies have less evidence of effectiveness, they are now widely considered second-line options. Psychological first aid is not a treatment for PTSD, but rather a nontreatment intervention for distress that is widely used by first responders and crisis counselors to provide compassion, support, and stabilization for people exposed to trauma, whether or not they have developed PTSD. Psychological first aid is supported by expert consensus, but it has not been studied enough to demonstrate how helpful it is as a treatment.⁶

Comorbidities require careful consideration

PTSD in the presence of other psychiatric disorders may require a unique and specialized approach to pharmacotherapy and psychotherapy. For instance, for a patient who has a comorbid substance use disorder, acute substance withdrawal can exacerbate PTSD symptoms. Sertraline is considered a medication of choice for these patients,¹³ and having a substance abuse specialist on the treatment team is desirable.^4,13 A patient with comorbid traumatic brain injury (TBI) may have reduced tolerance to medications, and may require an individually-tailored and elongated titration strategy. Additionally, stimulants sometimes used to improve cognition for patients with comorbid TBI can exacerbate symptoms of hyperarousal, and these patients may need stabilization before beginning PTSD treatment. Antidepressant treatment for PTSD among patients with comorbid bipolar disorder has the potential to induce mania. Psychiatrists must consider these issues when formulating treatment plans for patients with PTSD and specific psychiatric comorbidities.^4,6

PTSD symptoms can be chronic, sometimes lasting many years or even decades.²⁷ In a longitudinal study of 716 survivors of 10 different disasters, 62% of those diagnosed with PTSD were still symptomatic 1 to 3 years after the disaster, demonstrating the enduring nature of PTSD symptoms.¹² Similarly, a follow-up study of survivors of the Oklahoma City bombing found 58% of those with PTSD and 39% of those without PTSD were still reporting posttraumatic stress symptoms 7 years after the incident.²⁸ Remarkably, these same individuals reported substantially improved functioning at work, with family and personal activities, and social interactions,²⁸ and long-term employment disability specifically related to PTSD is highly unusual.²⁹ Even individuals who continued to report active posttraumatic stress symptoms experienced a return of functioning equivalent to levels in individuals with no PTSD.²⁸ These data suggest that treating psychiatrists and other mental health clinicians can be optimistic that functioning can improve remarkably over the long term, even if posttraumatic stress symptoms persist.

Bottom Line

A thorough understanding of the criteria for posttraumatic stress disorder (PTSD) is necessary for accurate diagnosis and treatment. Evidence-based treatment options for adults with PTSD include certain antidepressants and trauma-focused psychotherapies.

Related Resources

Bernadino M, Nelson KJ. FIGHT to remember PTSD. Current Psychiatry. 2017;16(8):17.
Koola MM. Prazosin and doxazosin for PTSD are underutilized and underdosed. Current Psychiatry. 2017;16(3):19-20,47,e1.

Drug Brand Names

Amitriptyline • Elavil, Endep
Fluoxetine • Prozac, Sarafem
Mirtazapine • Remeron
Nefazodone • Serzone
Paroxetine • Paxil
Phenelzine • Nardil
Prazosin • Minipress
Sertraline • Zoloft
Venlafaxine • Effexor

PTSD: A systematic approach to diagnosis and treatment

References

Comorbidities require careful consideration

Bottom Line

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