"Diagnosis and Management of Posttraumatic Stress Disorder in Returning"
CLINICAL PRACTICE Diagnosis and Management of Posttraumatic Stress Disorder in Returning Veterans Roy R. Reeves, DO, PhD As the conflict in Iraq continues, public health authorities in Stressors Faced By Soldiers in Modern Warfare the United States anticipate that many returning soldiers American soldiers face a number of stressors that may con- will suffer from posttraumatic stress disorder (PTSD). Ini- tribute to the development of PTSD, many of which are unique tially, most of these veterans are likely to consult their pri- to modern warfare. Stressful war experiences described by mary care physicians about health problems. However, the veterans returning from the conflict in Iraq include the fol- diagnosis of PTSD is often missed in primary care settings. lowing: The author encourages physicians to become better pre- pared to recognize this disorder in their patients and ini- ▫ combat exposure—including such experiences as firing tiate proper treatment or appropriate referral. Current diag- weapons and being fired upon; being in danger of injury or nostic approaches and treatment modalities for loss of life; seeing destroyed villages and refugees; and combat-related PTSD are reviewed—with an emphasis on being exposed to the sights, sounds, and smells of human clinical procedures for the primary care physician. death J Am Osteopath Assoc. 2007;107:181-190 ▫ life-threatening events, including fear and sustained antic- ipatory anxiety about exposure to combat ▫ concerns about possible exposure to biological, chemical, S ince the terrorist attacks on the United States on September 11, 2001, the US military has become involved in two major military conflicts in the Middle East. The conflicts in and radiological weapons, including fears about the long- term health effects of such exposures Afghanistan and Iraq could be prolonged struggles. As ▫ difficult living and working conditions, including lack of patients’ initial clinical contacts, primary care physicians desirable food, lack of privacy, poor living arrangements, across the country undoubtedly will be seeing increasing uncomfortable weather, cultural differences, long working numbers of patients with combat-related mental health dis- hours, and boredom orders, including posttraumatic stress disorder (PTSD). Thus, ▫ concerns about how deployment may adversely affect career, physicians need to be prepared to diagnose these disorders family, and other personal matters and treat these patients. Unfortunately, the diagnosis of PTSD ▫ unpredictability of length of deployment, including the pos- is often missed in the primary care setting. sible ongoing redeployment for National Guard and In a study involving 746 veterans, Magruder et al1 found US Army Reserve troops that physicians in primary care clinics recognized PTSD in ▫ sexual and gender harassment, particularly among enlisted only 40 (46.5%) of 86 patients who were identified with this women diagnosis by the Clinician Administered PTSD Scale for ▫ ethnocultural stressors for minority soldiers, particularly DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, those of Arabic descent or faith2 4th Edition). The present article reviews mental health problems that In addition to these stressors, soldiers also face concerns are commonly seen by primary care physicians as a result of regarding terrorist tactics. As widely noted in the public media, patients’ participation in combat, focusing on approaches to soldiers in these settings often have difficulty determining the diagnosis and management of PTSD, which is the most whether the civilians they encounter are would-be suicide prominent of these disorders. bombers.3 Because of the changing nature of warfare in the 21st century,4 the “frontline” has subsumed individuals in many active-duty support roles that, when compared to combat- From the G.V. (Sonny) Montgomery VA Medical Center in Jackson, Miss, and ready troops, had previously been considered “safe” (eg, truck the University of Mississippi School of Medicine in Jackson. Address correspondence to Roy R. Reeves, DO, PhD, Chief of Mental drivers, medical personnel).2 Finally, soldiers currently serving Health, G.V. (Sonny) Montgomery VA Medical Center (11M), 1500 E Woodrow in the Middle East combat theater also confront the potential Wilson Dr, Jackson, MS 39216-5116. of abuse or execution if captured as well as the possible muti- E-mail: email@example.com lation and desecration of their bodies by the hands of enemy Submitted January 3, 2006; accepted May 4, 2006. combatants. Reeves • Clinical Practice JAOA • Vol 107 • No 5 • May 2007 • 181 CLINICAL PRACTICE Psychiatric Disorders Resulting From Exposure Acute Stress Disorder to Military Conflict In the acute phase of abnormal response to trauma ( 4 weeks Modern warfare—with its atmosphere of confusion, uncer- after trauma), the cluster of symptoms is referred to as acute tainty, and the always-present potential for injury and stress disorder.8 This disorder is rarely seen by primary care death—could easily result in mental distress and mental physicians. Based on the criteria established in the Text Revi- disorders for soldiers. A survey of more than 11,400 vet- sion of the DSM-IV,8 a patient diagnosed with acute stress erans of the 1991 Persian Gulf War revealed that approxi- disorder must, following a traumatic event, have at least three mately 10% of returning veterans had symptoms of PTSD.5 dissociative symptoms (eg, depersonalization or derealiza- In a 2004 US Army study of more than 3,600 veterans tion, dissociative amnesia), one or more symptoms of reex- returning from Afghanistan or Iraq, researchers found that periencing the trauma (eg, flashback episodes), symptoms of the percentage of veterans meeting screening criteria for anxiety or increased arousal (eg, exaggerated startle response), major depression, generalized anxiety, or PTSD was 9.3% for and marked avoidance of stimuli-arousing recollections of those who served in Afghanistan and 17.1% for those who the trauma. These symptoms must cause clinically significant were stationed in Iraq.6 difficulties in functioning and persist from 2 days to 4 weeks.8 The psychiatric differential diagnosis for military Acute stress disorder is considered a precursor to PTSD.8 patients is broad and varies depending on several factors, including the type and severity of traumatic exposure and Posttraumatic Stress Disorder the time that has passed since the precipitating event.7 Fol- When the pathologic response to trauma lasts more than 4 lowing exposure to severe trauma, mental disorders tend to weeks, it is referred to as PTSD.8 Patients with PTSD develop occur in three sequential phases.7 In the immediate phase— symptoms in three categories: reexperiencing the trauma, during or immediately after traumatic events—individuals avoiding stimuli associated with the trauma, and increased may experience feelings of anxiety, confusion, disbelief, fear, autonomic arousal.8 Trauma may be reexperienced as dis- and numbness. Such problems as acute stress disorder, tressing recollections and dreams, flashbacks (in which the adjustment disorders, brief psychotic disorder, substance patient may feel and act as if the trauma were recurring), and abuse, and exacerbation of preexisting mental illness are psychologic or physiologic stress reactions upon exposure to considerations.7 In the delayed phase (generally up to 2 stimuli associated with the trauma. Symptoms of avoidance weeks after trauma), individuals may experience apathy, include efforts to refrain from thoughts or activities related autonomic arousal, grief, intrusive thoughts, social with- to the trauma, reduced capacity to remember events related to drawal, or somatic symptoms. Differential diagnoses at this the trauma, anhedonia, blunted affect, feelings of detachment point include anxiety disorders, depressive disorders, psy- or derealization, and a sense of a foreshortened future. Symp- chotic disorders, somatoform disorders, and substance abuse, toms of increased arousal include exaggerated startle response, as well as early PTSD.7 Later, in the chronic phase (months hypervigilance, insomnia, irritability, and outbursts of anger.8 to years after precipitating events), patients may report feel- To be diagnosed with PTSD, a patient must exhibit at least one ings of disappointment, resentment, sadness, and persis- symptom of reexperiencing, three symptoms of avoidance, tent intrusive symptoms. Diagnoses to consider in this phase and two symptoms of increased arousal—and these symp- include PTSD; depression, dysthymia, and other mood dis- toms must persist for more than 1 month.8 In addition, the orders; schizophrenia and other psychotic disorders; and diagnosis of PTSD requires that the patient’s disturbance cause substance abuse or dependence.7 “clinically significant distress of impairment in social, occu- Veterans seeking treatment in the civilian sector will usu- pational, or other important areas of functioning.”8 The DSM- ally be in the chronic phase of illness.7 Thus, the present article IV-TR criteria for a diagnosis of PTSD are shown in Figure 1. focuses on PTSD and related disorders, which are the most common mental health problems expected to occur in this Assessment of PTSD in Primary Care Settings cohort.7 Although this article focuses on treatment of veterans Returning veterans will often seek care from physicians or of modern warfare, the same principles of diagnosis and treat- other clinicians who are not mental health professionals. ment may apply to any patient with PTSD, regardless of the Because these patients may be experiencing symptoms of type of stressor that induced the disorder. PTSD, it is important that physicians be able to detect the dis- Response to traumatic stress varies from person to person. order in the primary care setting. In many cases, the symptoms Yet, under sufficient stress, anyone can succumb to mental will not be apparent unless specifically sought, but primary disturbance. It is normal to have time-limited posttraumatic care providers may have limited time to perform detailed stress responses that do not persist or impair functioning.7 queries.9 In response to this problem, the United States Depart- Such responses are often necessary for survival. However, ment of Veteran Affairs’ National Center for PTSD9 has devel- when catastrophic stress overwhelms adaptive coping oped a four-question Primary Care PTSD Screen to enable responses, posttraumatic psychiatric disorders result.7 physicians and other clinicians to detect PTSD in patients 182 • JAOA • Vol 107 • No 5 • May 2007 Reeves • Clinical Practice CLINICAL PRACTICE Figure 1. Criteria for a diagnosis of posttraumatic stress disorder.8 Checklist A. The person has been exposed to a traumatic event in which both of the following were present: Patients with PTSD may seek consultation in a variety 1. The person experienced, witnessed, or was confronted of ways. Although some patients will want to talk about their with an event(s) that involved actual or threatened experiences, most patients will have difficulty discussing their death or serious injury, or a threat to the physical thoughts and feelings about what happened to them.2 It is integrity of self or others important not to press traumatized patients too soon or too 2. The person’s response involved intense fear, helplessness, or horror intensely to talk about their experiences. Rather, patients should be allowed to discuss their traumatic experiences when B. The traumatic event is persistently reexperienced in one or they are ready to do so. The National Center for PTSD2 rec- more of the following ways: ommends that physicians begin the assessment process by 1. Recurrent and intrusive distressing recollections of the concentrating on the immediate needs of the patient and by event, including images, thoughts, or perceptions being prepared to explore the traumatic exposure later in the 2. Recurrent distressing dreams of the event assessment process. Thus, assessment should start with sta- 3. Acting or feeling as if the event were recurring bilization and proceed in the following sequence2: 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 1. Address symptoms that require emergency intervention, 5. Physiological reactivity on exposure to internal or such as suicidal or homicidal thoughts or acute psychotic external cues that symbolize or resemble an aspect of symptoms. the traumatic event 2. Address symptoms that are most disruptive to the patient, such as those that interfere with psychosocial functioning. C. Persistent avoidance of stimuli associated with the trauma 3. Develop a case formulation and a comprehensive treat- and numbing of general responsiveness as indicated by three or more of the following behaviors: ment plan. Several psychosocial and pharmacologic inter- 1. Efforts to avoid thoughts, feelings, or conversations ventions may be considered.2 associated with the trauma 2. Efforts to avoid activities, places, or people that arouse Treatment Modalities and Psychosocial Interventions recollections of the trauma Psychologic and social interventions may be the treatment of 3. Inability to recall an important aspect of the trauma first choice for many patients with PTSD. In some cases, these 4. Markedly diminished interest or participation in interventions are more valuable than medications.10 In most significant activities cases, they should be an important part of the patient’s treat- 5. Feelings of detachment or estrangement from others ment. Establishing a trusting relationship between the patient 6. Restricted range of affect and healthcare provider is always the first step in the initiation 7. Sense of a foreshortened future of any treatment, but developing such a relationship may be especially challenging with those patients who have experi- D. Persistent symptoms of increased arousal, as indicated by two or more of the following: enced traumatic stress. Physicians should work from a patient- 1. Difficulty falling or staying asleep centered perspective to determine the current concerns of the 2. Irritability or outbursts of anger patient.10 Practical help with specific issues can then be 3. Difficulty concentrating offered.10 4. Hypervigilance 5. Exaggerated startle response Education for the Whole Patient: Psychoeducational Interventions E. Duration of the symptoms is more than 1 month. Unfortunately, patients may have misconceptions about mental illness and PTSD that can interfere with their ability to accept F. The disturbance causes clinically significant distress or and adhere to effective treatment regimens. Patient education impairment in social, occupational, or other important areas of functioning. can help to remove many misconceptions and improve patients’ levels of self-understanding and symptom recogni- tion, as well as reduce the level of fear and shame they may feel about their symptoms.10,11 Education empowers patients, pro- quickly (Figure 2). Endorsement of any two items on the screen viding them with knowledge about the causes of his or her is associated with a likelihood of a diagnosis of PTSD and symptoms, of what will happen in treatment, and of how indicates the need for additional patient assessment.9 recovery is expected to proceed. Patient education should Reeves • Clinical Practice JAOA • Vol 107 • No 5 • May 2007 • 183 CLINICAL PRACTICE changed perceptions of personal identity caused by partic- Checklist ipation in combat. Exposure therapy may be considered after patients are pre- Have you had any experiences that were so frightening, pared to confront their trauma-related emotions and painful horrible, or upsetting that, in the past month, you: memories. This form of therapy is based on repeated verbal- ization of traumatic memories by patients.11 Patients are repeat- ▫ Have had nightmares about it or thought about it when you edly exposed to their own individualized fear stimuli until did not want to? their fear responses are consistently diminished.11 It is impor- ▫ Tried hard not to think about it or went out of your way to tant that physicians providing this form of treatment have avoid situations that reminded you of it? proper training and experience, however, because it has been found that a patient’s condition may deteriorate if this type of ▫ Were constantly on guard, watchful, or easily startled? therapy is used improperly.11 ▫ Felt numb or detached from others, activities, or your surroundings? Psychopharmacologic Intervention The observation of physiologic alterations (eg, adrenergic hyperactivity), as well as psychologic alterations, associated Figure 2. The four-question Primary Care Posttraumatic Stress Dis- with PTSD has led to the use of pharmacologic agents to order (PTSD) Screen developed by the United States Department of treat patients with this disorder.12 Pharmacotherapy should Veteran Affairs’ National Center for PTSD9 to enable physicians to not be considered the primary modality for managing PTSD; detect this disorder in their patients quickly. Endorsement of any two it is one option among other potential treatment courses pre- items on the screen indicates a likelihood of a diagnosis of PTSD. viously discussed. The most effective intervention for PTSD may involve a combination of pharmacotherapy and psy- chotherapeutic modalities.10 Several medications have been stress the concept that many symptoms of PTSD are the result used to treat patients with PTSD, some of them based on of reactions to stress. Patients should be encouraged to inter- well-designed clinical trials and others apparently based pret their reactions as a response to overwhelming stress rather solely on anecdotal evidence.12 Although, to date, only the than as a personal weakness. This approach will often lessen antidepressants sertraline hydrochloride and paroxetine have the patient’s fears about entering or maintaining treatment.10,11 been approved by the US Food and Drug Administration Coaching in alternative coping mechanisms may provide (FDA) for the treatment of patients with PTSD, clinical obser- patients with practical techniques to deal with the intense vation of psychophysiologic alterations associated with the emotional problems that they might be having. Coping skills disorder has led to the study of other antidepressants, mood- that are commonly taught to patients with PTSD include anger stabilizing agents, adrenergic-inhibiting agents, and antipsy- management, anxiety management, communication improve- chotic agents.12 ment, and relaxation techniques.10,11 Such training helps Antidepressants—The most frequently prescribed and most patients regain a sense of control over their emotions and carefully studied pharmacologic agents used to treat patients related physical symptoms. with PTSD.12 A growing body of literature provides evidence Families are intricately involved in the lives of traumatized to consider antidepressants the pharmacologic treatment of first patients. Both families and patients may benefit from family choice for managing the disorder.12 Virtually every antide- counseling, as well as couples counseling, parenting classes, and pressant available has been used in some context to attempt to training in conflict resolution.10,11 Family members may also manage the clinical symptoms of PTSD.12 be able to provide relevant patient history (eg, emotionality, Selective Serotonin Reuptake Inhibitors: The medications in drug abuse, sleep habits, socialization) that the patients them- this class of antidepressants inhibit the reuptake of serotonin selves are unable or unwilling to report. by neurons, resulting in increased amounts of serotonin in Cognitive restructuring is designed to help patients synapses and improved functioning of serotonin in the central review and correct erroneous trauma-related beliefs by pro- nervous system.12,13 Serotonin has a regulatory effect on nore- viding education about the relationships between thoughts pinephrine activity through the locus ceruleus, helping to and emotions, by exploring common negative thoughts held modulate excessive external stimuli and reduce feelings of by traumatized patients, by identifying personal negative fear. Research and clinical practice have shown that selective beliefs, by developing alternative interpretations, and by serotonin reuptake inhibitors (SSRIs) are effective for man- practicing new ways of thinking.10,11 This treatment modality aging anxiety, depression, and panic attacks.12 also involves individual self-monitoring of thoughts and There are several reasons that SSRIs are the current med- the practice of learned techniques in real-life settings.10,11 ications of choice for managing PTSD.13 They ameliorate all Finally, cognitive restructuring may help veterans deal with three PTSD symptom categories. They are effective in man- 184 • JAOA • Vol 107 • No 5 • May 2007 Reeves • Clinical Practice CLINICAL PRACTICE aging the psychiatric disorders that often occur comorbidly Moclobemide, a reversible inhibitor of monoamine oxidase with PTSD (eg, depression, panic disorder, social phobia). type-A, is associated with less risk of hypertensive crisis and They may reduce such clinical symptoms as aggressive, impul- has been shown in clinical studies to reduce symptoms in all sive, and suicidal behaviors that often complicate manage- three PTSD symptom categories.20 However, moclobemide ment of PTSD, and they cause relatively few adverse effects.13 is not yet available in the United States. Open-label and double-blind trials have demonstrated Other Antidepressants: Several other antidepressants have that the SSRIs citalopram hydrobromide, fluoxetine, fluvox- been investigated for the treatment of patients with PTSD. amine maleate, paroxetine, and sertraline are all effective in the For example, nefazodone and trazodone hydrochloride are treatment of patients with PTSD.13 In addition, paroxetine potentially useful because they increase serotonin activity, and sertraline have been assessed in large multisite double- though not selectively. In six open-label trials reported by blind controlled trials, and, as previously mentioned, the FDA Hidalgo et al,21 nefazodone was found to reduce anxiety, has approved each of these medications for treatment of nightmares, and global ratings in patients with PTSD. In addi- patients with major symptom clusters of PTSD.14 tion, it was found to possibly help reduce PTSD-related sleep The adverse effects of paroxetine, sertraline, and other disturbance.21 As of 2001, however, the FDA has required SSRIs are generally more tolerable for patients than those of manufacturers and pharmacists to use a black box warning other categories of antidepressants.12 Escitalopram oxalate, a label on nefazodone because of potential risk for hepatotoxi- relatively new SSRI, may also eventually prove beneficial for city and liver failure.22 Trazodone has not been proven sig- patients with PTSD, but clinical experience using this drug to nificantly effective in management of the core symptoms of manage PTSD is limited at this time.15 PTSD.14 Furthermore, because it has a somewhat sedative Tricyclic Antidepressants: In addition to antidepressant effect, some clinicians prescribe it in low dosages to treat effects, tricyclic antidepressants (TCAs) have antipanic effects.16- patients with insomnia.14 18 Because of the resemblance between panic attacks and severe Bupropion, duloxetine hydrochloride, mirtazapine, and PTSD arousal symptoms, TCAs may be helpful for managing venlafaxine hydrochloride are other antidepressants that are PTSD. Small controlled clinical trials have been conducted potentially useful for treating patients with PTSD.23 However, using the TCAs amitriptyline hydrochloride, imipramine, and none of these medications have been tested in clinical trials for desipramine.16-18 Amitriptyline, compared with placebo, in PTSD. Neither are they approved by the FDA for treatment of 46 veterans with PTSD resulted in better outcomes on the patients with PTSD. Hamilton Depression, Hamilton Anxiety, Clinical Global Mood-Stabilizing Agents—The sensitization and kindling Impression, and Impact of Event scales after 8 weeks of treat- of the limbic system has been hypothetically proposed as a ment.16 A study of 34 veterans with PTSD who were treated cause of physiologic changes in PTSD.24 In this model, repeated with imipramine, the monoamine oxidase inhibitor (MAOI) traumatic stress leads to sensitization and kindling, with a phenelzine, or placebo showed global assessment improvement spontaneous limbic discharge resulting from sensitization.24 in 75% of patients taking imipramine, 64% of patients taking Mood-stabilizing agents (ie, medications commonly used as phenelzine, and 27% of patients taking placebo.17 An investi- anticonvulsants) have the potential to prevent this sensitization gation of 18 veterans with PTSD who were treated with and kindling or to modulate these phenomena after they occur. desipramine showed improvement in symptoms of depression Therefore, they may ameliorate PTSD symptoms. but of no other symptoms related to PTSD.18 Investigations involving mood-stabilizing medications Tricyclic antidepressants carry the risk of cardiac con- for PTSD management have been limited primarily to open- duction disturbances, sedation, and overdose.16-18 Because label studies.14,25,26 Carbamazepine has strong antikindling SSRIs and other antidepressants that cause much fewer adverse properties and has been effective in PTSD management in effects than TCAs are now available, TCAs are no longer com- several small open-label clinical trials.23 Gabapentin, lamot- monly prescribed for depression or related mental distur- rigine, lithium carbonate, topiramate, and valproate sodium bances.12,13 have also shown effectiveness in PTSD management in at Monoamine Oxidase Inhibitors: Like TCAs, MAOIs pro- least one open-label study each.14,26 Thus, despite a strong duce antipanic effects. They have been used to treat patients theoretical basis, there has been only a small amount of sys- with mixed conditions of anxiety and depression.19 A quanti- tematic investigation to demonstrate the value of mood sta- tative analysis by Southwick et al,19 which included 15 mostly bilizers for the treatment of patients with PTSD. open-label clinical trials of TCAs and MAOIs, found that 82% Adrenergic Inhibitors—Autonomic dysregulation is thought of patients with PTSD who were treated with the MAOI to explain many of the physiologic changes seen in patients phenelzine reported a reduction in intrusive symptoms, com- with PTSD.27 Patients with the disorder have elevated levels pared with 45% of patients treated with a TCA. Unfortunately, of plasma norepinephrine at rest, substantial norepinephrine MAOIs must be used with caution because of the risk of hyper- increases when exposed to trauma-related stimuli, and down tensive crisis.19 Thus, they currently are rarely prescribed. regulation (ie, decrease in sensitivity) of norepinephrine recep- Reeves • Clinical Practice JAOA • Vol 107 • No 5 • May 2007 • 185 CLINICAL PRACTICE tors in platelets due to increased circulation of norepinephrine.27 antipsychotic medications.35 Most atypical antipsychotic drugs Sustained periods of increased norepinephrine levels are may also cause weight gain.35 thought to increase the risk of PTSD by contributing to over- The goal of the pharmaceutical management of PTSD is consolidation of memories of the traumatic event.28 symptom reduction and stabilization. Even if all symptoms do Medications that decrease adrenergic (ie, norepinephrine- not completely resolve, patients may still benefit from medi- mediated) activity may reduce anxious arousal in patients cations by getting a good night’s sleep and being less anxious with PTSD. Propranolol hydrochloride and other -adren- and irritable. Figure 3 summarizes some of the medications ergic blockers reduce the peripheral effects of nore- that have proven effective or that are potentially effective for pinephrine.29,30 Propranolol has been shown to improve PTSD the clinical management of PTSD. Acute PTSD responds better symptoms in one small clinical trial,29 but it was not helpful in to pharmaceutical management than does chronic PTSD, and, another small trial.30 Because 2-adrenergic receptor agonists generally, the earlier treatment begins, the better.10,12,33 (eg, clonidine, guanfacine hydrochloride) act at noradrenergic Pharmacotherapy should be initiated with SSRIs in view autoreceptors to inhibit the firing of cells in the locus ceruleus, of the extensive data available to document their effective- they may also be responsible for reducing the release of nore- ness for PTSD and their relatively few adverse effects.12,13 If pinephrine in the brain.31 In small open-label clinical trials, patients cannot tolerate SSRIs, or if they show no improvement clonidine showed promise in reducing symptoms among in symptoms with SSRI treatment, second-line medications patients with PTSD.31 The use of prazosin hydrochloride, an should be considered. Augmentation should be considered 1-adrenergic receptor antagonist, resulted in robust improve- for patients who exhibit a partial response to SSRIs. Patients ment of several PTSD symptoms, particularly sleep quality with excessive hyperactivity or feelings of arousal or dissoci- and reduction of nightmares, in a double-blind crossover pro- ation might be helped by use of an adrenergic inhibitor.27,32 tocol by Raskind et al.32 Patients with aggressiveness, impulsiveness, or lability as Antianxiety Agents—Benzodiapines and buspirone prominent symptoms of PTSD might benefit from treatment hydrochloride are among the medications that are not cur- with a mood-stabilizing anticonvulsant.22 Patients exhibiting rently recommended for treating patients with PTSD. hypervigilance, paranoia, or psychotic behaviors might benefit Benzodiazepines: Frequently prescribed to reduce anxiety from atypical antipsychotic medications.35 and promote sleep in patients.33 However, their efficacy in In all cases, physicians need to be aware of potential managing the specific symptoms of PTSD has not been estab- adverse effects associated with the medications prescribed. lished. In fact, they may worsen the disorder by virtue of their Appropriate patient monitoring is also essential. Pharma- dissociative and disinhibitory properties.33 In addition, their cotherapy should be used in combination with psychosocial potential for abuse through addiction remains a major area of treatment modalities as well as other treatment options to concern.33 Therefore, benzodiazepines cannot be recommended ensure a comprehensive approach to patient care. for patients with PTSD. Buspirone: A nonaddictive medication widely used to Osteopathic Manipulative Treatment and PTSD treat patients with anxiety.34 However, like benzodiazepines, To date, there have been no studies investigating the effec- the effectiveness of buspirone for managing the core symptoms tiveness of osteopathic manipulative treatment (OMT) in of PTSD remains to be established. patients with PTSD. Nevertheless, it seems logical that OMT Antipsychotic Medications—Although psychotic symp- could benefit these patients. One might hypothesize that toms are not included in the diagnostic criteria for PTSD, some patients with posttraumatic stress are likely to have increased patients with PTSD may experience brief psychotic episodes sympathetic nervous system activity and associated somatic and also have psychotic symptoms as part of a comorbid dis- dysfunction, particularly in the thoracolumbar region. Uncom- order.4 Use of older, “conventional” antipsychotic medica- fortable paravertebral muscle spasm may accompany these tions (eg, haloperidol) is not recommended because of the dysfunctions. Thus, in my view, addressing these dysfunc- risk of adverse effects and the availability of more suitable tions with appropriate osteopathic manipulative techniques alternatives.35 Preliminary results suggest that the newer, atyp- could aid in the healing process—as well as help improve ical antipsychotic drugs (eg, olanzapine, quetiapine fumarate, patient-physician rapport and patient compliance with sup- risperidone) may be useful for patients with PTSD and psy- plemental therapeutic modalities. chotic symptoms to augment treatments with first- or second- line medications.35 Such patients include those experiencing agi- Other War-Related Mental Disorders tation, dissociation, hypervigilance, intense paranoia, or brief Posttraumatic stress disorder is the primary war-related mental psychotic reactions associated with PTSD. Atypical antipsy- disorder seen in veterans who returned from the 1991 Per- chotic medications may cause serious adverse effects, including sian Gulf War.5 However, other mental disorders may occur tardive dyskinesia and neuroleptic malignant syndrome, in the context of combat and should be given appropriate con- though these effects are less likely than with conventional sideration. With PTSD, comorbidity is the rule, not the excep- 186 • JAOA • Vol 107 • No 5 • May 2007 Reeves • Clinical Practice CLINICAL PRACTICE Medications For Managing Posttraumatic Stress Disorder Class and Drug Adult Dosage (mg/d) Adverse Effects and Risks Antidepressants ▫ SSRIs – Citalopram hydrobromide 20-60 Nausea, drowsiness, dry mouth, sexual dysfunction – Paroxetine* 20-60 Nausea, drowsiness, dry mouth, sexual dysfunction – Sertraline hydrochloride* 50-200 Nausea, insomnia, loose stools, sexual dysfunction ▫ TCAs – Amitriptyline hydrochloride 50-300 Drowsiness, weakness, cardiac conduction disturbances Mood-stabilizing Agents (Anticonvulsants) ▫ Carbamazepine 400-1000 Nausea, sedation – risk of anemia and agranulocytosis ▫ Gabapentin 300-2400 Drowsiness, dizziness, ataxia, fatigue ▫ Lamotrigine 25-400 Sedation, ataxia, headache – risk of serious skin rash ▫ Topiramate 50-400 Drowsiness, dizziness, ataxia, confusion ▫ Valproate sodium 250-2000 Nausea, weight gain – risk of hepatic failure and pancreatitis Adrenergic Inhibitors ▫ Clonidine 0.2-0.6 Dry mouth, dizziness, sedation, weakness ▫ Prazosin hydrochloride 2-10 Dizziness, headache, sedation – risk of syncope ▫ Propranolol hydrochloride 40-160 Bradycardia, hypotension, fatigue, insomnia Antianxiety Agents ▫ Alprazolam† 0.25-6 Drowsiness, short half-life – high risk of dependency ▫ Buspirone hydrochloride 15-60 Nausea, dizziness, headache ▫ Clonazepam† 0.5-4 Drowsiness – risk of dependency Atypical Antipsychotic Medications ▫ Olanzapine 5-20 Extrapyramidal symptoms, sedation, weight gain – risk of diabetes mellitus ▫ Quetiapine fumarate 25-300 Sedation, dizziness, postural hypotension – risk of cataracts ▫ Risperidone 0.5-8 Extrapyramidal symptoms, agitation, anxiety, insomnia, rhinitis Figure 3. Medications with proven or potential effectiveness in the promise in small open-label or controlled trials. The effectiveness of management of posttraumatic stress disorder (PTSD).12 The effec- antianxiety agents has not yet been established in clinical trials. Pre- tiveness of selective serotonin reuptake inhibitors (SSRIs) has been liminary results indicate that atypical antipsychotic medications may proven in large clinical trails. Tricyclic antidepressants (TCAs) have be useful to augment treatment with other medications. *This med- produced moderate improvement in symptoms in small controlled clin- ication is approved by the US Food and Drug Administration for the ical trails. The effectiveness of mood stabilizers has been suggested in management of PTSD. †This medication is not recommended for small open-label clinical trails. Adrenergic inhibitors have shown treating patients with PTSD because of risk of dependency. tion.8 Prior to a conclusive diagnosis of PTSD, patients should ulcers—are common among patients with PTSD.37 In many receive a thorough psychiatric and medical examination to cases, the comorbid conditions likely prompt initial requests rule out other possible problems. As previously noted, a for treatment, especially in the primary care setting. These number of psychiatric disorders may occur in the postcombat complaints should be properly assessed and never assumed to setting, including anxiety and mood disorders, personality be exclusively psychogenic in origin. disorders, psychosis, and substance abuse.2,5-8,36 In addition, A number of mental disorders, including depression, general medical conditions—including anemia, arthritis, mania, panic disorder, and schizophrenia, commonly have asthma, back pain, diabetes, kidney disease, lung disease, and an age of onset between the late teens and early 30s—the same Reeves • Clinical Practice JAOA • Vol 107 • No 5 • May 2007 • 187 CLINICAL PRACTICE to encourage these patients to avoid social isolation and with- Physicians’ Resources drawal. Veterans often report that the opportunity to connect ▫ American Psychiatric Association Practice Guidelines— with and be supported by other veterans is a valued experi- http://www.psych.org/psych_pract/treatg/pg/PTSD-PG -PartsA-B-C-New.pdf ence.10 Such an experience may be difficult to accomplish out- ▫ Current Concepts in Pharmacotherapy— side a VA facility or other setting devoted to the needs of http://ps.psychiatryonline.org/cgi/content/full/55/5/519 returning veterans. ▫ Iraq War Clinician Guide—http://www.ncptsd.va.gov A number of helpful online resources on PTSD are avail- /ncmain/ncdocs/manuals/iraq_clinician_guide_ch_1.pdf able for both physicians and veterans. A list of these resources ▫ National Center for Posttraumatic Stress Disorder— is presented in Figure 4. http://www.ncptsd.org/index.html Conclusions Veterans’ Resources Primary care physicians who see patients that have returned ▫ Homecoming After Deployment: Dealing with Changes to the United States after military service in Afghanistan and and Expectations—http://www.ncptsd.va.gov/ncmain Iraq should consider the possibility that active-duty stressors /ncdocs/fact_shts/homecoming.html have contributed to patient symptoms. With these events in ▫ War-Zone–Related Stress Reactions: What Veterans Need mind, physicians should make respectful and gentle inquiries to Know—http://www.ncptsd.va.gov/ncmain/ncdocs /fact_shts/war_veteran.html?opm=1&rr=rr126&srt=d as to patient history so that appropriate treatment can be ini- &echorr=true tiated and necessary referrals provided quickly. ▫ MedlinePlus: Post-Traumatic Stress Disorder— The principles discussed in the current article are pre- http://www.nlm.nih.gov/medlineplus/posttraumaticstress sented primarily in the context of combat-related PTSD. How- disorder.html ever, the same principles can apply to the treatment of all patients with PTSD—regardless of the nature of the trauma. Some examples of noncombat-related causes of PTSD include Figure 4. Internet resources on posttraumatic stress disorder for physical assault, exposure to natural disasters, and terrorist physicians and veterans. attacks. Patients who have experienced such trauma may ben- efit from the same types of interventions provided to military veterans with PTSD. age range of many individuals engaged in the nation’s current military conflicts.2,5-8 In a person who is susceptible to a par- References ticular disorder, that disorder could be precipitated by the 1. Magruder KM, Frueh BC, Knapp RG, Davis L, Hamner MB, Martin RH, et al. Prevalence of posttraumatic stress disorder in Veterans Affairs primary stresses of combat situations. In addition, mental disorders care clinics. Gen Hosp Psychiatry. 2005;27:169-179. already present, but in latent or controlled states, could worsen 2. Litz B, Orsillo SM. The returning veteran of the Iraq War: background as a result of the impact of such trauma.2,5-8 Thus, it is impor- issues and assessment guidelines. In: Iraq War Clinician Guide. 2nd ed. White tant for primary care physicians to consider the full range of River Station, Vt: National Center for Post-Traumatic Stress Disorder, Depart- ment of Veterans Affairs; 2004:21-32. Available at: http://www.ncptsd.va.gov possible psychiatric disorders before making a diagnosis. /ncmain/ncdocs/manuals/iraq_clinician_guide_ch_3.pdf. Accessed April 13, The comorbidity of PTSD and substance abuse is high, so 2007. it is important to regularly assess these patients for substance 3. Montagne R, Hammes T. Italian’s death and rules of engagement in Iraq abuse and related disorders.8 Substance abuse may begin or [interview]. Morning Edition. Washington DC: National Public Radio. March worsen for soldiers in the Middle East combat theater. Opium 9, 2005. Available at: http://www.npr.org/templates/story/story.php?sto- ryId=4527852. Accessed May 30, 2007. poppies and marijuana remain the two largest cash crops in 4. Echevarria AJ II. Globalization and the Nature of War. Carlisle, Pa: Strategic Afghanistan. Further, clinicians in Iraq report that alcohol is War Studies Institute, US Army War College; 2003. Available at: easily accessible and black-market diazepam is inexpensive and http://www.strategicstudiesinstitute.army.mil/pdffiles/PUB215.pdf. Accessed readily available.38 May 30, 2007. 5. Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic Ongoing Support for Patients With PTSD stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol. Combat veterans with PTSD may present a unique challenge 2003;157:141-148. Available at: http://aje.oxfordjournals.org/cgi/content to primary care physicians, with psychiatric consultation usu- /full/157/2/141. Accessed April 13, 2007. ally being necessary. Referral to a Veterans Affairs (VA) med- 6. 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