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Post-traumatic Stress Disorder (PDQ®)

Treatment

The chronic and sometimes devastating psychologic and interpersonal sequelae of post-traumatic stress disorder (PTSD) necessitates timely and effective treatment of people with this syndrome.[1,2] The avoidant responses associated with PTSD often delay or prevent these individuals from seeking professional assistance. While no specific therapies for PTSD in the cancer setting have been developed, treatment modalities used with other people with PTSD can help alleviate distress in cancer patients and survivors.[3,4]

Most clinicians recommend using a multimodal approach, choosing components to meet the specific needs of each patient and taking into account any concurrent psychiatric disorders such as depression or substance abuse. Multiple modalities are frequently considered in a crisis intervention approach to facilitating adjustment of cancer patients.

The crisis intervention model comprises a broad range of therapies that can be helpful in the treatment of PTSD. The goals of this model are to reduce symptoms and restore patients to their usual levels of functioning. In this model, the therapist often takes an active, directive stance with the patient, focusing on resolving concrete problems, teaching specific coping skills, and providing a safe and supportive environment.[5][Level of evidence: II]

Cognitive-behavioral techniques have proven especially helpful within the crisis intervention setting. Some of these methods include helping the patient to understand symptoms, teaching effective coping strategies and stress management techniques (such as relaxation training), restructuring cognitions, and providing exposure to opportunities for systematic desensitization of symptoms.[6] In a single case study, a 10-session cognitive-behavioral intervention for a male cancer patient 3 years post–bone marrow transplant with PTSD was found to be effective. This study used a combination of cognitive coping strategies, relaxation procedures, relapse prevention, and generalization techniques; benefits were found to be maintained at a 6-month follow-up.[7][Level of evidence: III] Behaviorally oriented approaches to sexual therapy may also be useful when the avoidance manifested by patients is decreased sexual activity and avoidance of intimate situations.

Support groups also appear to benefit people who experience post-traumatic symptoms. In the group setting, such patients can receive emotional support and encounter others with similar experiences and symptoms, thereby validating their own experiences and learning a variety of coping and management strategies.

For patients with particularly distressing or severe symptoms, psychopharmacology may provide an additional means of treatment. Several classes of medications have been used in the treatment of individuals with PTSD.[8,9] (See the table below for a list of pharmacological treatments for PTSD.) For example, tricyclic and monoamine oxidase-inhibitor antidepressants are commonly used, particularly when the symptoms of PTSD are accompanied by depression. Selective serotonin reuptake inhibitors such as fluoxetine are effective in reducing the hyperarousal and intrusive symptoms of PTSD.[1] Antianxiety medications may help reduce overall arousal and anxiety symptoms. Infrequently, antipsychotic medications may reduce severe intrusive flashbacks.

Evidence Base for Pharmacological Treatments for PTSD in Noncancer Patientsa,b
MedicationDosing (mg/day)Target SymptomscEvidence Basis
RCT = randomized controlled trial.
aAdapted from Berger et al.[10] and Asnis et al.[11]
bAll studies conducted in noncancer patients only. No studies conducted in patients with cancer.
cPTSD symptom clusters are as follows: cluster B, re-experiencing; cluster C, avoidance/numbing; cluster D, hyperarousal.
dConsidered first-line treatments for PTSD.
eFDA approved for the treatment of PTSD.
fUsed mainly as augmentation to SSRIs or serotonin-potentiating non-SSRIs.
Selective Serotonin Reuptake Inhibitors (SSRIs)d
Sertralinee50–200All symptom clustersSeveral RCTs
Paroxetinee20–50All symptom clustersSeveral RCTs
Fluoxetine20–60All symptom clustersSeveral RCTs
Fluvoxamine50–300All symptom clustersOpen label
Citalopram20–60All symptom clustersOpen label
Serotonin-potentiating Non-SSRIs
Venlafaxine37.5–225All symptom clustersOpen label
Trazodone50–300Insomnia, possibly other clustersOpen label
Mirtazapine15–45Insomnia, possibly other clustersOpen label
Other Antidepressants
Imipramine50–225Possibly all clustersOne RCT
Other Agents Used as Augmentation Therapy Onlyf
Atypical antipsychotics
Risperidone1–6Clusters B and D, possibly cluster CSeveral RCTs
Olanzapine5–20Possibly all clustersOne RCT
Anticonvulsants
Lamotrigine50–400Clusters B and COne RCT
Adrenergic-inhibiting agents
Prazosin2–6All symptom clusters (primary target symptom: nightmares)Several RCTs

References

  1. Davidson JR, Foa EB: Diagnostic issues in posttraumatic stress disorder: considerations for the DSM-IV. J Abnorm Psychol 100 (3): 346-55, 1991. [PUBMED Abstract]
  2. Alter CL, Pelcovitz D, Axelrod A, et al.: Identification of PTSD in cancer survivors. Psychosomatics 37 (2): 137-43, 1996 Mar-Apr. [PUBMED Abstract]
  3. Foa EB: Psychosocial treatment of posttraumatic stress disorder. J Clin Psychiatry 61 (Suppl 5): 43-8; discussion 49-51, 2000. [PUBMED Abstract]
  4. Adshead G: Psychological therapies for post-traumatic stress disorder. Br J Psychiatry 177: 144-8, 2000. [PUBMED Abstract]
  5. Perry S, Difede J, Musngi G, et al.: Predictors of posttraumatic stress disorder after burn injury. Am J Psychiatry 149 (7): 931-5, 1992. [PUBMED Abstract]
  6. Mikulincer M, Solomon Z: Attributional style and combat-related posttraumatic stress disorder. J Abnorm Psychol 97 (3): 308-13, 1988. [PUBMED Abstract]
  7. DuHamel KN, Ostroff JS, Bovbjerg DH, et al.: Trauma-focused intervention after bone marrow transplantation: A case study. Behav Ther 31 (1): 175-86, 2000.
  8. Marmar CR, Neylan TC, Schoenfeld FB: New directions in the pharmacotherapy of posttraumatic stress disorder. Psychiatr Q 73 (4): 259-70, 2002 Winter. [PUBMED Abstract]
  9. Davidson JR: Pharmacotherapy of posttraumatic stress disorder: treatment options, long-term follow-up, and predictors of outcome. J Clin Psychiatry 61 (Suppl 5): 52-6; discussion 57-9, 2000. [PUBMED Abstract]
  10. Berger W, Mendlowicz MV, Marques-Portella C, et al.: Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review. Prog Neuropsychopharmacol Biol Psychiatry 33 (2): 169-80, 2009. [PUBMED Abstract]
  11. Asnis GM, Kohn SR, Henderson M, et al.: SSRIs versus non-SSRIs in post-traumatic stress disorder: an update with recommendations. Drugs 64 (4): 383-404, 2004. [PUBMED Abstract]
  • Updated: September 3, 2014