Post-Traumatic Stress Disorder (PTSD)

After a severe trauma, people often experience a range of reactions: fear, disbelief, sadness, disgust, horror, anger, a sense of emotional numbing. They may find it difficult to fall asleep or stay asleep. They may find that they are always watchful, "on edge" and unable to relax. They may find that the experience has changed the way they view themself, or the way they view the world around them. Despite efforts to forget, the experience intrudes on their mind in the form of nightmares, images, intense re-experiencing ("flashbacks"), or intrusive thoughts. They may find themself avoiding certain people, places or activities that remind them of the trauma, and experiencing physical and psychological distress when they are reminded of the trauma.

Over the first month or so, these symptoms improve significantly for some victims of trauma. For others, however, the symptoms persist and even intensify. Untreated, the symptoms can sometimes persist long-term. Often, a diagnosis of Post-Traumatic Stress Disorder is the best fit to describe the experience.

Post-Traumatic Stress Disorder is a relatively new diagnostic term, having been introduced in the third edition of the Diagnostic and Statistical Manual (DSM) in 1980. The experience of PTSD, however, has been described across cultures and across millenia. In the United States, various terms such as combat neurosis, battle fatigue, or shell shock were described before the current definition of PTSD was introduced. While many of these terms evoke combat experiences, we now know that PTSD can be caused by a wide range of traumatic exposures that are unrelated to military combat as well.

As our understanding of PTSD has evolved, the options for treatment have improved as well.

Psychotherapy

Psychotherapy is a treatment of choice for Post-Traumatic Stress Disorder, with the American Psychological Association identifying several psychotherapeutic approaches as "strongly recommended" in published national guidelines. These approaches include Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT), Cognitive Therapy, and Prolonged Exposure (PE).

I typically recommend a course of Cognitive Processing Therapy (CPT) for individuals who meet criteria for PTSD and who have not yet engaged in trauma-focused psychotherapy. Cognitive Processing Therapy is a time-limited treatment that typically takes around 12 sessions, most often completed by weekly meetings.

In Cognitive Processing Therapy individuals with Post-Traumatic Stress Disorder examine the impact their traumatic experience has had on them. For many people who have experienced trauma, their beliefs change significantly as a consequence. Ideas such as "it was my fault," "no one can be trusted," or "the world is a terrible place" can start to "run in the background" so to speak, changing the way the individual sees and navigates the world. Frequently, these beliefs occur automatically, without any deliberate choice to adopt them.

In CPT, we start by identifying the often multiple ways one's beliefs and assumptions have been shaken by the traumatic experience. We examine patterns of distortion in thinking that frequently occur in the wake of trauma, and assess the accuracy of many trauma-related beliefs. As beliefs change, emotions and behaviors frequently change as well.

An approach like CPT can initially be painful because it deliberately exposes affected individuals to difficult trauma-related thoughts, memories, and emotions. For many people, however, the improvements seen by the end of treatment can be substantial and are regularly maintained long after therapy ends. For this reason, approaches like CPT or other related psychotherapies are an excellent starting point for PTSD. For some individuals with PTSD, after completing a course of CPT they find that no further treatment is needed.

Medications

Medications have also been shown to be effective at reducing the symptoms of Post-Traumatic Stress Disorder. First-line options include selective serotonin reuptake inhibitor antidepressants (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (see APA and VA/DOD recommendations). Medications can be used along with psychotherapy, which for some patients can produce a more robust response. When preferred, or when psychotherapy has not been helpful or well-tolerated, medications can also be a primary treatment for Post-Traumatic Stress Disorder.

My approach to medication for Post-Traumatic Stress Disorder involves using the lowest effective doses of medication needed to achieve the desired response. The choice of medication can be based on a range of factors, including the particular symptoms that are most troubling to you and the presence of any other mental health conditions that require treatment. While first-line treatments such as venlafaxine, fluoxetine, paroxetine, and sertraline are often the best first choice, in some cases other co-occuring conditions can make a range of other medication options a better first choice.

Working with an expert psychopharmacologist can be helpful in the treatment of Post-Traumatic Stress Disorder, especially if you are dealing with several concurrent mental health issues or if the usual first-line options have not proven sufficient. I work closely with patients especially toward the start of medication-based treatment, and strongly encourage other changes (such as sleep hygiene practices, maintaining a healthy diet and activity level, and remaining active in personally meaningful activities) that can improve the response to medications.