Update on Treating PTSD

WHILE MODERN understanding of post-traumatic stress disorder (PTSD) originally grew primarily out of attempts to treat affected combat veterans from World War I, World War II and, most pivotally, Vietnam, we now know that anyone who has endured a severe, traumatic event can be affected by its lingering symptoms that are debilitating and affect patients’ ability to function in everyday life due to flashbacks, avoidance, reactivity and/or mood imbalances.Today, it is not just military combat veterans who are diagnosed with PTSD, nor even just first-responders among civilians. Victims of violent crime and even witnesses to those crimes or to horrific accidents can develop PTSD. In fact, it is estimated approximately 7 percent to 8 percent of the U.S. population will suffer from PTSD at some point in life.¹

Ironically, it was PTSD skeptic Lt. Gen. George Patton who inadvertently helped bring public attention to the psychiatric conditions that exposure to intense or sustained traumatic stress can induce, which began the slow process of lowering prejudice toward PTSD and mental illness in general. During the Allied campaign in Sicily in August 1943, Patton angrily slapped two enlisted men under his command during a tour of field hospitals. During one visit, Patton encountered a patient who had been admitted despite not suffering any physical wounds. Pvt. Charles Kuhl had been sent to the hospital for what was then called battle fatigue or exhaustion. Seeing a soldier with no visible wounds in a hospital enraged Patton, who accused the man of cowardice while attacking him. A few days later, Patton again lost his temper at another military field hospital and slapped Pvt. Paul Bennet, whose superior officers had sent him to the hospital to recover from exhaustion and dehydration.²

Following these incidents, Patton initially issued orders that only those with physical wounds were to be sent to hospitals, and those suffering from combat fatigue must stay on the front lines. However, once theater commander Gen. Dwight Eisenhower got word of the incidents through the Medical Corps chain of command, he countermanded that directive and ordered Patton to apologize. (Later that year, when news of the two slapping incidents reached stateside newspapers, the political uproar was so great that Patton was relieved of his command. He would not return to combat duty until nearly a year later, following D-Day.)

Even if Patton was not yet aware of how “battle fatigue” or “exhaustion” was being diagnosed and treated, Army and Navy doctors certainly were. In the North African campaign that preceded the invasion of Sicily, Maj. Gen. Omar Bradley had, on the advisement of psychiatrist Frederick Hanson, issued orders that psychiatric casualties were to be treated at forward areas rather than being sent to the rear. Studies following World War I had shown that quick intervention near combat areas had been the most effective treatment for what was then called “shell shock,” a term for soldiers who exhibited a range of psychological symptoms after prolonged exposure to artillery fire or other high-stress combat. Field commanders had noted soldiers becoming unresponsive, even catatonic, slow to react or process orders, unable to communicate lucidly and wandering aimlessly around the battlefield. These men were obviously a danger both to themselves and to their comrades and, thus, had been removed from the front lines and handed over to medical staff for evaluation and treatment. Under Bradley’s order, more than half of all such patients were able to be successfully returned to their units after treatment.³

However, not all units or commands saw that same level of success. In the Pacific Theater, physicians and medics employed a similar treatment regimen at forward field hospitals. During the Battle of Biak off the north coast of New Guinea, Lt. Col. William Shaw, chief division surgeon, reported that only about one-third of battle fatigue casualties were able to return to combat duty with their units after a period of rest and restoration.⁴

It was the Vietnam War, however, that truly brought PTSD to the public’s attention, with nearly a quarter of all deployed military personnel requiring some form of psychological treatment either in theater or in the years following their return home.3 Rather than many combat veterans suffering the severe, disabling symptoms seen among combat commanders, they were suffering from a different manifestation: frequent nightmares, a heightened alertness, avoidance of anything that could remind them of the war and increased moodiness.

It was this public attention that brought to bear the resources and research leading to PTSD as a recognized diagnosis, as well as new and more-effective treatments. Today, along with an improved understanding of the causes and manifestations of PTSD, there are improved treatment options that provide clinicians with additional tools to help patients.

What Is PTSD?

PTSD was made an official diagnosis in 1980 with its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association. It is defined as a condition caused by “a dominating psychological experience that retains its power to evoke panic, terror, dread, grief or despair.”⁵

PTSD is marked by a constellation of symptoms:⁶

• Intrusive or re-experiencing symp-toms: flashbacks, nightmares, intrusive memories

• Avoidance of reminders of the trauma

• Hyperarousal: easily startled, sleep disturbances

• Negative emotions

• Significant distress or dysfunction

Key to a PTSD diagnosis is exposure to an extreme form of trauma. Initially, a traumatic event was defined as a catastrophic stressor that was outside the range of usual human experience. But today, there is an existing classification of “adjustment disorders” for those unable to cope with the sorts of normal challenges and disappointments of life, including divorce, unemployment, death of a loved one, etc.⁵

Diagnosing PTSD

The National Institute of Mental Health defines the criteria for a PTSD diagnosis as:⁷

• At least one re-experiencing or intrusive symptom

• At least one avoidance symptom

• At least two arousal and reactivity symptoms

• At least two cognition and mood symptoms

A diagnosis is typically made by a psychiatrist or psychologist, generally one with experience treating patients with PTSD.

Current Treatment Protocols

Two main interventions are available for treating PTSD: psychotherapy and medication.5 They may be used together, or one or the other may be used alone depending on specific symptoms, their severity and the overall health of the patient.

Many forms and models of psychotherapy can be employed depending on the severity and type of PTSD symptoms. These can be provided in group or private sessions or in a combination of the two.

The American Psychological Association (APA) lists four therapies as “strongly recommended” for treating PTSD:

• Cognitive behavioral therapy (CBT)

• Cognitive processing therapy

• Cognitive therapy

• Prolonged exposure

CBT is a form of psychotherapy that focuses on modifying dysfunctional emotions, behaviors and thoughts. Considered a “solutions-oriented” form of talk therapy, CBT rests on the idea that by changing how patients consciously think about an event, improvements can be made in how they react to it.⁸ In addition to sessions with a therapist, additional work is completed by patients on their own.

Cognitive processing therapy is a subset of CBT that provides patients with tools to allow them to review their emotions and thoughts regarding the trauma they experienced in an effort to assist them in returning to a nonimpaired day-to-day life.⁹

Cognitive therapy is another subset of CBT that focuses on changing pessimistic interpretations of a trauma to allow for a resumption of normal daily activities.⁸

Prolonged exposure involves both revisiting previously avoided memories of a trauma, as well as engaging in activities that have been avoided due to their association with that trauma. The goal is to help patients realize that the memories themselves are not dangerous, and that normal activities can be resumed.¹⁰

In addition, three other therapies are “conditionally recommended” by APA that have proved effective, but are not as well-proven as the four strongly recommended therapies:

• Brief eclectic psychotherapy

• Eye movement desensitization and reprocessing therapy

• Narrative exposure therapy

Brief eclectic psychotherapy blends CBT with other therapies with the goal of helping patients confront and then discard their feelings of shame and guilt arising from the trauma.⁸

With eye movement desensitization and reprocessing therapy, patients recall the traumatic memory while following an object with their eyes, which allows their brains to remap the memory without triggering the normal stressful response.¹¹

In narrative exposure therapy, a therapist leads patients through a process of recounting their entire life story, including the traumatic event. Patients tell the story in great detail to allow them to take control of their own life history.¹²

In addition to therapy, specific medications may be prescribed by a physician to assist patients’ recovery — either in concert with therapy or as a stand-alone treatment.¹³

Certain antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), have been shown to help relieve many PTSD symptoms. Two SSRIs approved by FDA to treat PTSD are sertraline (Zoloft) and paroxetine (Paxil).¹⁴ Venlafaxine (Effexor) is an SNRI that has shown promise in treating PTSD symptoms.¹⁵ And, prazosin (Minipress), which is often used to treat symptoms of an enlarged prostate, has shown some potential for preventing nightmares associated with PTSD.¹⁴

Lastly, anti-anxiety medications may be used to treat some PTSD symptoms, although these generally have significant side effects and are typically only prescribed for a set duration.

Ongoing Research

Clinicaltrials.gov lists more than 1,500 ongoing, recent or pending studies of PTSD treatment.

One study being conducted at the Minneapolis VA Health Care System is investigating the use of the drug ketamine in concert with prolonged exposure therapy. A similar study at the Depression and Anxiety Center at the Icahn School of Medicine in Mount Sinai, N.Y., is looking at adding trauma-focused psychotherapy to ketamine treatment. Researchers at Tel Aviv University are studying whether attention control treatment can treat symptoms of PTSD, while a team at the New York State Psychiatric Institute is looking at interpersonal psychotherapy for adolescents who suffer from PTSD. And, the Stress, Trauma, and Anxiety Research Clinic at Wayne State University in Detroit has been utilizing dance therapy and yoga with some promising results, although more study is needed to quantify any benefit.⁶

On the pharmacological side, the Connecticut VA is studying whether intranasal insulin might help calm hyperactivity in the amygdala region of the brain. And, other studies are investigating whether already approved drugs, including oxytocin, the antipsychotic brexpiprazole (Rexulti), the blood pressure medication clonidine (Catapres) and the epilepsy-treating pregabalin (Lyrica), can be used to treat PTSD.

There are also a handful of new drugs in the clinical trials pipeline. A new allosteric modulator of NMDA receptor, NYX-783, is in recruitment stage for clinical trials. And, the Danish company H. Lundbeck A/S is conducting trials on a proposed monoacylglycerol lipase inhibitor, Lu AG06466, for its effectiveness in relieving PTSD. It is also being tested for efficacy in treating multiple sclerosis and epilepsy.¹⁶

Finally, medical devices are being proposed to treat PTSD. Butler Hospital in Providence, R.I., is studying the use of transcranial direct current stimulation. The Eastern Colorado Health Care System is testing Apollo Neuro, a stress relief wearable device that fits on the wrist or ankle, to see if its use of vibration can help ease PTSD symptoms. And, the U.S. Army and the University of Arizona are collaborating on a study using bright light therapy to attempt to improve sleep among PTSD patients.

Looking Ahead

While the United States recently withdrew its military forces from Afghanistan, military veterans from that and earlier conflicts will be dealing with PTSD for decades to come. And as seen in Ukraine, warfare seems quite far from extinction; with reports of widespread attacks on civilians, survivors of that conflict will also be dealing with PTSD for the foreseeable future.

In the United States, rising murder and assault rates in many urban areas have erased decades of progress in lowering the incidence of violent crime, leaving traumatized victims in their wake. And modern industrial society continues to cause horrific trauma unimaginable to our ancestors, maiming and killing victims in traffic and workplace accidents as powerful machines inadvertently meet very vulnerable human flesh.

With these realities, physicians and therapists will have no shortage of patients needing PTSD treatment in this lifetime. But, thankfully, ongoing research seems likely to yield more effective treatments to allow those affected to resume lives as normal as possible.