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A Clinical Update: Post-Traumatic Stress
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By Edward G. Morhauser, M.D.
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Sometime
ago a new patient—I’ll call her Sally—visited my office complaining
of persistent panic attacks. She was obsessed with the idea that she was
going to die imminently. This feeling apparently resulted from a recent
severe sinus infection from which Sally had fully recovered. But instead
of being relieved by her complete recovery, she was terrified of dying. At
first I was puzzled by Sally’s overreaction to this illness, so I asked
her what she thought was causing her concern. She told me she couldn’t
imagine what the problem was because there was nothing wrong with her. Slowly
Sally began to tell me the story of her life. She confided that for
several years as a child she and her family had been trapped in a war
zone. As traumatic as this experience was, Sally had lived a pleasant and
fulfilling life as a professional woman, wife, and mother. Then, without
warning, her father, with whom she was very close, died in her arms. A few
months later, her husband suffered a sudden fatal heart attack. The next
year her brother committed suicide, and the most painful of all, her son
was killed in an accident. In another few months, her mother died as well.
Five members of her immediate family died within a six-year period. But it
was the sinus infection that brought all the trauma of those last few
years to the surface and caused Sally to face her own mortality. Sally was
exhibiting the symptoms of classic Post Traumatic Stress Disorder. I
first became aware of this condition in soldiers flown directly to our
U.S. Navy hospital in Boston from the combat zone in Vietnam. Then we
called their symptoms “shell shock” and “battle fatigue,” but we
didn’t really know what we were dealing with. Post-traumatic
stress disorder (PTSD) is a condition that can develop in anyone who
experiences, or merely witnesses, a traumatic incident or series of
incidents where they feel their safety is threatened. Not everyone reacts
to these incidents in the same way. Not all PTSD occurs immediately after
the causal incident, but may be triggered even years later. Most people
who suffer a traumatic incident will experience symptoms immediately
afterward but soon will go on with their lives. Predisposed persons, with
higher levels of anxiety, make the trauma the focus of their lives. When
this focus moves from the trauma itself to the physical disabilities
caused by their reactions to the trauma—chronic anxiety, insomnia,
depression, sometimes substance abuse, unemployment—the patient is said
to be suffering from chronic PTSD. One study showed that the rate of full
remission of chronic PTSD was only 18 percent (Zlotnick et al. 1999). It
is estimated that currently 5 percent of the population of the United
States has PTSD and 8 percent has had PTSD at some point in their lives;
occurrence is consistently higher among women. The
tragedy of September 11, 2001, brought PTSD into the public spotlight and
created new opportunities to study this disabling condition. Recent
research has shown that if therapy can be started within 24 hours of the
incident, the condition can sometimes be lessened or even blocked. A Specific Disorder PTSD
describes a specific disorder. It can become a chronic psychiatric
disorder and can persist for decades or sometimes for life. It is
estimated that the economic burden of PTSD in the United States is $3
billion a year. Symptoms most often begin within three months after the
event and can occur in clusters including For
those PTSD patients who are mildly to moderately affected, group therapy
has been perhaps the most helpful. Patients can discuss traumatic
memories, symptoms, and functional deficits with others who have been
affected similarly. More
severe cases may need multiple therapies including the following: PSYCHOPHARMACOLOGY:
•
Selective serotonin reuptake inhibitors (SSRI):
Prozac, Zoloft, Paxil •
Tricyclic antidepressants •
Benzodiazepines •
Anticonvulsants •
Antipsychotics •
Adrenergic inhibitors Where
early intervention is possible, within hours after the trauma— •
adrenaline blocking agent (propranolol) based on an adrenaline
model of prolonged terror. •
debriefing, which is controversial because of possible adverse
effects. Medication
is helpful in easing associated symptoms of depression and anxiety and
aids sleep. Drug therapy appears to be highly effective for some
individuals and is helpful for many more. PSYCHOTHERAPY: Cognitive-behavioral
therapy (CBT): working with
cognition to change emotions, thought patterns, and behaviors. •
learning to cope with anxiety, •
managing anger, •
preparing for stress reactions, •
handling future trauma symptoms, •
addressing urges to use alcohol or drugs, •
communicating and relating effectively with people, social skills,
marital therapy. Exposure
therapy: a type of cognitive-behavioral therapy,
which uses repeated, detailed imagining of the trauma (exposure) in a
safe, controlled context to help the survivor face and gain control of the
fear and distress that was overwhelming during the trauma. Eye
Movement Desensitization and Reprocessing (EMDR):
Psychodynamic
Psychotherapy: focus on the
emotional conflicts caused by the traumatic event, particularly as they
relate to early life experiences. Through the retelling of the traumatic
event to a calm, empathic, compassionate, and nonjudgmental therapist, the
patient achieves a greater sense of self-esteem, develops effective ways
of thinking and coping, and learns to deal more successfully with intense
emotions. The therapist helps the survivor identify current life
situations that set off traumatic memories and worsen PTSD symptoms.
EDUCATION
AND SUPPORTIVE MEASURES: Informing
patient about the expected responses to trauma, strategies for decreasing exposure to
traumatic event, stress-reduction techniques, emphasizing the importance of self-care
and mental activity, and early referral if symptoms persist. PTSD
is not a new illness, but the therapies and medications for treating it
are continuing to evolve and improve.
Dr.
Morhauser is a psychiatrist in San Mateo. References: The
Expert Consensus Guideline Series: Treatment of Post-traumatic Stress
Disorder, J Clin Psychiatry 1999; 60 (suppl 16). Foa EB, Davidson
JRT, Frances A, eds. Posttraumatic Stress Disorder, Grand Rounds Case Conference, Morhauser, EG.
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