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Post-Traumatic Stress Disorder: Theory and Treatment Update

Article  in  The International Journal of Psychiatry in Medicine · August 2014

DOI: 10.2190/PM.47.4.h · Source: PubMed

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INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 47(4) 337-346, 2014

POST-TRAUMATIC STRESS DISORDER:

THEORY AND TREATMENT UPDATE*

HEATHER A. KIRKPATRICK, PHD, MSCP

GRANT M. HELLER, PHD

Michigan State University and Genesys Regional Medical Center

ABSTRACT

Post-traumatic stress disorder (PTSD) is one of the few mental disorders in

which the cause is readily identifiable. In this article, we review the new
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic
criteria, prevalence, and presentation of patients with PTSD in primary care.
The purpose of this article is to review current literature regarding theory,
etiology, and treatment effectiveness. Key findings in terms of neuro-
biological underpinnings with implications for future treatment are dis-
cussed. Recommendations regarding effective psychotherapy and pharmaco-
therapy, emerging treatment, and management issues in primary care settings
are offered.
(Int’l. J. Psychiatry in Medicine 2014;47:337-346)

Key Words: PTSD, trauma, post-traumatic stress disorder, primary care, trauma and
stress-related disorders

*Based on a presentation given at The 34th Forum for Behavioral Science in Family
Medicine, Chicago, IL, September 19-22, 2013.

337

Ó 2014, Baywood Publishing Co., Inc.

doi: http://dx.doi.org/10.2190/PM.47.4.h
http://baywood.com
338 / KIRKPATRICK AND HELLER

TOPIC: POST-TRAUMATIC STRESS DISORDER

Post-Traumatic Stress Disorder (PTSD) is a disorder in which a person who has
directly experienced a traumatic event develops a characteristic set of symptoms.
Recent revisions in the DSM-5 [1] categorize symptoms into four clusters:
intrusion/re-experiencing symptoms, avoidance symptoms, negative cognitions
and mood, and symptoms of hyper-arousal. Examples of how these symptoms
can present are listed in Table 1.

Epidemiology
The U.S. estimate of lifetime prevalence of PTSD in adults is 7.8%, with women
more at risk than men (20.4% vs. 8.2%) despite experiencing fewer traumas [2, 3].
Higher rates are also seen in African-Americans [4], Native Americans (14-16%)
[5], and in refugees from conflict-ridden areas of the world (9-60%) [6]. The types

Table 1. Key Symptoms of PTSD

Key symptoms of intrusion/re-experiencing the trauma (at least one required)

•recurrent and intrusive memories, images, thoughts
•distressing dreams
•dissociative reactions such as flashbacks
•strong emotional and physical reactions to cues that resemble or symbolize
an aspect of the trauma
Key symptoms of avoidance (at least one required)
•efforts to avoid thoughts, feelings, conversation or activities, places or
people connected to trauma
Key symptoms of negative cognitions and mood (at least one required)
•amnesia for important aspects of the trauma
•a persistent and distorted sense of blame of self or others
•persistent negative emotional state (e.g., fear, horror, guilt, shame)
•inability to experience positive emotions
•feelings of detachment or estrangement from others
•markedly diminished interest in activities
Key symptoms of hyper-arousal (at least one required)
•increased anxiety
•sleep difficulties
•poor concentration
•increased irritability
•outbursts of anger
•reckless or self-destructive behavior
•hypervigilence
•exaggerated startle response
 PTSD: THEORY AND TREATMENT UPDATE / 339

of events experienced as the initial trauma vary widely and include combat,
personal assault, natural disasters, motor-vehicle accidents, rape, childhood
physical and sexual abuse, loss of loved ones [7], and medical crises such as
burns, cancer, and myocardial infarction [8, 9]. Risk factors can be considered
in three areas: Pre-trauma, Peri-trauma, and Post-trauma [10]. See Table 2.
Symptoms can occur at any age, and generally present within 3 months of
the trauma, but may occur years later. In Acute Stress Disorder (ASD), symptoms
are present for more than 3 days, but less than 1 month, after the trauma. In
contrast, diagnosis of PTSD requires symptoms persisting more than 1 month.
Symptom duration varies widely, with over 50% resolving within 3 months,
while many have persisting symptoms for longer than 1 year [1]. Symptoms
are often intermittent and relapse can occur. PTSD can be strongly associated
with physical illness complaints, particularly musculoskeletal, nervous, sensory,
cardio-respiratory, gastro-intestinal, and vague symptom presentations [11].

Etiology
PTSD is conceptualized as a failure of recovery caused in part by altered fear
learning; i.e., the failure to extinguish behavioral responses to stimuli associated
with the trauma. Following a trauma, the symptoms of PTSD are almost universal;
however, many people are able to eventually confront fearful stimuli such as
memories, reminders, or visual cues with a gradual decrease of fear. When this
decrease does not occur, people tend to develop cognitive and avoidance strategies
in an attempt to avoid distressing emotions. Subsequently, these strategies inter-
fere with the extinction of fear by limiting exposure to safe reminders. Alterations
in fear learning involve the hippocampus, amygdala, and prefrontal cortex. The
hippocampus appears to be involved in the ability to recall safe episodes when

Table 2. Risk Factors for PTSD

Pre-trauma factors Lower socioeconomic status

Parental neglect
Personal or family psychiatric disease
Female
Poor social support

Peri-trauma factors Severity, intensity, frequency, and duration of trauma

Initial severity of person’s reaction to trauma
Unpredictability and uncontrollability of the trauma

Post-trauma factors Lack of social support

Life stress
Failure for early identification and treatment
340 / KIRKPATRICK AND HELLER

faced with fearful stimuli. Research has shown that hippocampal volumes are
decreased in patients with PTSD, but this may be a risk factor rather than a sequella
[12]. There is also increasing attention to the role of the ventral medial prefrontal
cortex (VMPFC). Via its inhibitory control of the amygdala, the VMPFC may
allow the mind to “overwrite” the original fear, allowing safe episode memories
to become dominant [13]. There has also been extensive research regarding
aberrations in the hypothalamic-pituitary-adrenal axis function in patients with
PTSD; the dominant finding is that patients have increased levels of corticotrophin
releasing factor [14]. There is still little consensus in the literature regarding
the role of cortisol, with studies finding both higher and lower levels of cortisol
secretion in patients with PTSD [14]. Despite much investigation, there are no
reliable biological markers for at-risk patients [15]. Research continues in the
area of chemical prophylaxis (the prevention of PTSD pre- or immediately
post-trauma via interruption of fear learning), but controversy remains as study
findings are not consistent [16].

LITERATURE REVIEW

Assessment in Primary Care

The National Institute for Health and Clinical Excellence (NICE) 2005 guide-
lines caution against routine, crisis debriefings after a traumatic incident [17];
“watchful waiting” is recommended instead. There are a variety of screening
instruments available to providers, including the Primary Care PTSD Screen
(PC-PTSD) [18] and the PTSD Checklist (PCL) [19]. While the PCL can be used
to track symptoms throughout treatment; the PC-PTSD may be more useful for
initial screening in primary care. The PC-PTSD has four items, with a recom-
mended cutoff of three (although a cutoff of two can be used to increase sensi-
tivity.) A positive screen should prompt more in-depth discussion and assessment.
Providers may wish to refer such patients for further evaluation from behavioral
health providers, such as a psychologist, counselor, or clinical social worker.
See Figure 1 for the PC-PTSD.
PTSD may be recognized in primary care after a traumatic event, such as a
motor vehicle accident, work related injury, or assault. The patient may also
report history of prolonged or chronic exposure to trauma, such as repeated
childhood abuse or domestic violence. Frequent medical visits with unexplain-
able symptoms would warrant probing for possible trauma history. Providers
may also wish to inquire about specific symptoms of intrusion/re-experiencing,
avoidance, and hyperarousal.
Children and adolescents may present differently than adults and may not
express direct complaints of symptoms after a trauma. Traumatic experiences
may be repetitively reenacted through play. Constriction of play activities, social
withdrawal, sleep changes, as well as decreased display of affect or explosive
 PTSD: THEORY AND TREATMENT UPDATE / 341

In your life, have you ever had any experience that was so frightening,
horrible, or upsetting that, in the past month you:

1. Have had nightmares about it or thought about it when you did not
want to? YES NO

2. Tried hard not to think about it or went out of your way to avoid situations
that reminded you of it? YES NO

3. Were constantly on guard, watchful, or easily startled? YES NO

4. Felt numb or detached from others, activities, or your surroundings?

YES NO

Figure 1. The Primary Care PTSD (PC-PTSD) [18].

tantrums are potential indicators that would justify further exploration. Children
and adolescents may also present with a sense of a foreshortened future.
Symptoms may often present somatically through complaints of headaches,
stomach aches, or other maladies [17, 20]. Collateral information attained from
parents and/or caregivers about behavioral changes can be especially useful.
Assessment is also improved by asking children directly about their experiences.

Psychotherapeutic Treatment
There are many effective psychotherapeutic treatments for individuals experi-
encing PTSD. Although the trauma-related therapies are generally effective at
symptom remission, they require adequate levels of psychological stability to be
successful. Patients with poor psychological stability can benefit from supportive,
ego-strengthening, or motivational treatment before beginning trauma-related
therapies [21].
The best evidence for remission of symptoms is for the trauma related therapies:
exposure therapy and cognitive behavioral therapy (CBT). Exposure therapy
involves graded exposure to situations causing the fear response, allowing the
individual to become desensitized to fear cues (habituation). The Institute of
Medicine’s (IOM) most recent review found exposure therapy to be effective in
significantly improving PTSD symptoms [22]. The IOM examined 23 randomized
trials, seven of which were found to be very methodologically sound. All seven
found clinically significant improvement in PTSD symptoms. CBT engages
the patient in challenging dysfunctional beliefs about the world or themselves
while simultaneously engaging the patient in more healthy behaviors such as
342 / KIRKPATRICK AND HELLER

exercise, sleep management, social activation, and management of substance

abuse. Overall, the IOM found reasonably good evidence in favor of cognitive
therapy, although the authors acknowledged the superiority of evidence for
exposure therapy [22].
Other therapies that show good evidence for symptom treatment include
cognitive processing therapy (an information processing therapy that includes
education, exposure, and cognitive components that challenge dysfunctional
thoughts and modify beliefs related to the trauma experience) and motivational
interviewing (a set of techniques designed to reduce resistance to change)
[22]. For comorbid PTSD and substance abuse, Seeking Safety (a treatment
that teaches skills around emotional regulation and substance abstinence simul-
taneously) has been shown to improve outcomes [23].

Pharmacological Treatment

There are a wide variety of pharmacological treatments to consider. Medi-

cations are generally most effective in decreasing hyperarousal and improving
mood; they are less effective for symptoms of re-experiencing, numbing, and
avoidance. Sleep disturbance is especially difficult to manage and can easily
lead to polypharmacy.
First-line treatment is the utilization of antidepressants, particularly selective
serotonin reuptake inhibitors (SSRIs) [24, 25]. SSRIs available in the United
States include fluoxetine, sertraline, paroxetine, luvoxamine, citalopram, escitalo-
pram, and vortioxetine. Stein and colleagues conducted a meta-analysis of seven
randomized treatment trials utilizing SSRI medication and found a relative risk
ratio of 1.59 (with a 95% confidence interval of 1.39-1.82) for the effectiveness
of SSRIs in improving symptoms of PTSD, indicating strong effectiveness com-
pared to placebo (which would have a relative risk ratio of 1) [25]. Serotonin-
norepinephrine reuptake inhibitors (SNRIs) also can be effective for improve-
ment in PTSD symptoms. These medications include venlafaxine and duloxetine.
Patients receiving venlafaxine ER have had better symptom control (50.9%)
than those receiving placebo (37.5%) [26].
Adjunctive treatments include alpha-adrenergic receptor blockers, with
prazosin being the most studied. Prazosin has been shown to decrease nightmares
and improve sleep [27]. In addition, mirtazapine (a NaSSA antidepressant) has
been shown to be effective in managing insomnia symptoms associated with
PTSD, as well as in treating depressive symptoms [28].
Medications shown to be ineffective include older antidepressants such as
amitriptyline and nortriptyline, monoamine oxidase inhibitors, mood stabilizers,
gabapentin, pregabalin, and atypical antipsychotics [24]. Older antidepressants
are not considered first-line due to their safety and adverse effect profiles. Mood
stabilizers and atypical antipsychotics have had negative evidence in randomized
controlled trials and are not recommended [29, 30]. Particular caution is urged
 PTSD: THEORY AND TREATMENT UPDATE / 343

in using benzodiazepine medications as they have been shown to be ineffective,

and the risk of abuse and dependence are high [31, 32]. Practitioners are strongly
encouraged to weigh the risks and benefits of using benzodiazepines beyond
a short-term course early in the trauma recovery process.

KNOWLEDGE GAPS AND NEW FRONTIERS

Despite being the most common approach, there is a paucity of studies
examining combined pharmacologic and psychological treatment [33]. With
a lack of these studies, it is best to rely upon expert opinion recommending
SSRIs and CBT that includes exposure [33-35]. In addition, common real-world
presentations of PTSD often include other conditions, including pain, somatiza-
tion, substance abuse, mild traumatic brain injury (TBI), and suicide, while
relatively little evidence indicates appropriate treatment for comorbid illnesses.
Dialectical Behavior Therapy strategies to improve distress tolerance skills
would appear to be theoretically helpful but have not been fully examined for
effectiveness in the PTSD realm [35, 36]. Similarly, Acceptance and Commitment
Therapy shows promise in helping therapists and patients accept and improve
the willingness to explore painful private experiences and to realign one’s life
in accordance with one’s values, but it has not yet amassed good evidence to be
recommended beyond adjunctive therapy [37].
Without clear etiology for why some individuals develop or maintain PTSD
symptoms after trauma while others do not, more work is needed to determine
recommended treatments for prevention or symptom reduction. There are many
promising neurobiological treatments under examination to alter memory
consolidation (glucocorticoids, corticoptropin-releasing factor, norepinephrine
signaling modulators) or alter fear extinction (glucocorticoid receptor modu-
lators, glutamate receptor modulators, and D-cycloserine, a glycine receptor
agonist) [16]. There is limited research examining the role of the use of
empathomimetics such as 3,4-methylenedioxymethamphetamine (MDMA, also
known as “ecstasy”) to facilitate rapid rapport and improve the efficacy of
trauma-based psychotherapies [38].

SUMMARY
In summary, PTSD is best characterized as a disorder of failed recovery.
It represents one of the few mental disorders in which the inciting event or
cause is generally known. Practitioners should recognize that avoidance is often
the “glue” that causes the disorder to endure, and treatments should be targeted
toward reduction of avoidance and titration of exposure to facilitate habituation.
Practitioners of primary care can educate patients that there are many effective
treatments for PTSD, and remission is very possible for many patients. We
are fortunate to be practicing during a time of explosive research on effective
344 / KIRKPATRICK AND HELLER

treatments of PTSD, many of which show good results. Psychotherapy is

considered the first-line treatment, with many medications offering assistance in
the management of some symptoms. Practitioners should be mindful and cautious
in prescribing sedatives, hypnotics, and anxiolytics, as these medications carry
a high risk of dependence and can also maintain avoidance, which compromises
psychotherapeutic effectiveness.
Key therapeutic messages for patients include hope for recovery through
many effective treatments: asking for support from those who listen; communi-
cating their experiences; identification of self as a survivor; engaging in healthy
behaviors such as adequate sleep, good nutrition, and the avoidance of substance
use; and establishing or re-establishing the routine activities of daily living.

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Direct reprint requests to:

Heather A Kirkpatrick, Ph.D.
Genesys Downtown Health Center
420 S. Saginaw St.
Flint, MI 48502
e-mail: hkirkpat@genesys.org

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