• Anxiety Disorders
• Psychopharmacology
• Psychiatry

• Psychiatry & Psychology

Posttraumatic stress disorder (PTSD) was officially designated as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, said Charles C. Engel, MD, MPH, Senior Health Scientist, RAND Corporation, Arlington, Virginia, USA, in a review of the epidemiology and psychological trauma associated with PTSD. The criteria to diagnose PTSD have been further refined, most recently in DSM-5 in 2013 (Table 1).

PTSD comorbidities including depressive disorders, anxiety disorders (panic, generalized anxiety, phobias), substance abuse, somatic symptoms, mild traumatic brain injury, and fibromyalgia are common and affect an estimated 88% of men and 79% of women in their lifetime [Kessler RC et al. Arch Gen Psychiatry 2005].

Paula P. Schnurr, PhD, National Center for PTSD in the Department of Veterans Affairs and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA, provided an update on psychotherapy treatment for PTSD. Psychotherapy may be more effective than medication, according to a recent meta-analysis [Watts BV et al. J Clin Psychiatry 2013]. The delivery of treatment varies, and there are at least 7 clinical practice guidelines recommending treatment for PTSD. The Department of Veterans Affairs and Department of Defense Clinical Practice Guideline for Management of Posttraumatic Stress is used for veterans and military personnel. Using it as a framework, Dr. Schnurr recommended 5 principles to guide the choice of treatment (Table 2).

A recent randomized controlled trial with 121 patients provided evidence that an intensive 1-week regimen of cognitive therapy produced results equivalent to 12 weeks of cognitive therapy, and both were superior to 12 weeks of supportive therapy [Ehlers A et al. Am J Psych 2014]. A randomized, placebo-controlled trial of 67 patients with PTSD showed D-cycloserine (DCS) in addition to exposure therapy was effective only in a subgroup [de Kleine RA et al. Biol Psychiatry 2012]. Another randomized controlled trial (RCT) reported negative effects of DCS on exposure therapy; the authors suggested that in some cases, the compound may cause traumatic memories to be intensively reconsolidated to the detriment of the patient [Litz BT et al. J Psych Res 2012].

Dr. Schnurr stated that evidence-based psychotherapy works for most PTSD patients, including veterans, and the benefits can persist for years.

John H. Krystal, MD, Yale University School of Medicine, New Haven, Connecticut, USA, discussed the pharmacotherapy of PTSD. Anti-depressants have been the predominant class of drugs used in PTSD since the 1980s [Frank JB et al. Am J Psychiatry 1988].

Selective serotonin reuptake inhibitors (SSRIs) approved by the US Food and Drug Administration for treatment of PTSD are sertraline and paroxetine. The norepinephrine reuptake inhibitor desipramine provided benefits in a 12-week study [Petrakis IL et al. Neuropsychopharmacology 2012]. Norepinephrine targets adrenergic receptors, which are involved in the “fight or flight” response and learning. Antiadrenergic drugs including prazosin, clonidine, and propranolol have shown some evidence of benefit in PTSD studies, but definitive evidence of their efficacy is lacking. Other antidepressants block serotonin-2 receptors; trazodone has been the most commonly prescribed medication for PTSD in US veterans (despite the absence of placebo-controlled trials), and pilot studies of nefazodone have been positive.

Second-generation antipsychotics with prazosin-like and trazodone-like activity, as well as drugs that target the dopamine receptor D2 include risperidone, olanzepine, quetiapine, ziprasidone, clozapine, and aripiprazole. Benefits obtained with risperidone have not been compellingly different from placebo, and adverse effects including somnolence, weight gain, and decreased libido have been documented. Still, risperidone maybe beneficial for paranoia and psychosis and maybe warranted for those with less severe PTSD who are being treated with fewer medications. Quetiapine is the most commonly prescribed second-generation antipsychotic; preliminary data have been encouraging, with daytime sedation and weight gain being adverse concerns.

Benzodiazepines enhance the effects of the gamma-aminobutyric acid neurotransmitter. The resulting easing of depression-related symptoms made benzodiazepines a popular prescription for PTSD. However, use is declining because of concerns about its abuse and limited evidence-based efficacy [Hermos JA et al. J Trauma Stress 2007; Lund BC et al. J Clin Psychiatry 2012]. A GABA receptor-targeted drug that has shown more promise is S-zopiclone; a double-blind, placebo-controlled RCT demonstrated its effectiveness in improving sleep and lessening PTSD symptoms [Pollack MH et al. J Clin Psychiatry 2011]. Other GABA modulators being assessed for PTSD pharmacotherapy are tiagabine, valproate, and topriamate.

D-cycloserine may have potential in fear extinction through its targeted activity at the N-methyl-D-aspartate (NMDA) receptor, which is crucial in memory retention. Finally, the antidepressant action of ketamine was recently demonstrated [Berman RM et al. Biol Psychiatry 2000], and benefits appear to extend to PTSD treatment [Feder A et al. JAMA Psychiatry 2014].

David M. Benedek MD, Uniformed Services University, Bethesda, Maryland, USA, reviewed complimentary and alternatives approaches to treat PTSD. Complimentary approaches are used in conventional care. Alternative approaches are used in lieu of standard care, and can become complimentary as evidence for their efficacy accumulates. These approaches are currently the final step in a multistep hierarchy of treatment that begins with psychotherapy (cognitive-based therapy, relaxation techniques, imagery rehearsal therapy, hypnosis, group therapy, brief psychodynamic therapy) and, if necessary, progresses to include pharmacotherapy. The National Center of Complementary and Alternative Medicine (NCCAM) classification of complementary and alternative approaches are summarized in Table 3.

Complementary and alternative approaches, such as acupuncture, are reportedly used by about 40% of PTSD sufferers, mainly to improve mental health. The claimed benefits are currently more anecdotal than evidence-based; as of 2011, only 7 RCTs had been conducted (1 for body-oriented therapy and 6 for mind-body therapy). Evidence is relatively more solid for acupuncture, with its effect on the somatosensory cortex indicated. While relaxation therapy and yoga have health-related benefits, the evidence for their specific benefit in PTSD remains scant.

• © 2014 MD Conference Express®