Post Traumatic Tendencies
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PTSD intervention is complicated further by the fact that co-morbidities e. Particularly in situations where co-morbidity exists, a combined approached should be considered. Of interest due to the perilous state of the world i. According to experts, combat veterans with PTSD may be less responsive to treatment that other victims of other traumatic exposures 41 , Following is a list of possible reasons:.
Combat-caused PTSD is often associated with other psychiatric disorders, including depression, anxiety, mood disorders and substance abuse disorders It is usually believed that the most effective treatment results are obtained when both PTSD and the other disorder s are treated together rather than one after the other.
It is becoming increasingly critical to ascertain this position because the prevalence of PTSD and disorder of complex stress is bound to rise sharply in the next decade consequential to the present multinational state of alert and anxiety following ongoing tragic, wanton and widespread terrorism and particularly with respect to combat-related PTSD in present times. Some have more proven efficacy than others.
Some of these approaches may be appropriate to address the initial stages of trauma. Psychological debriefing is an intervention given shortly after the occurrence of a traumatic event. The goal is to prevent the subsequent development of negative psychological effects. In fact, psychological debriefing approaches to PTSD can be described as semi-structured interventions aimed at reducing initial psychological stress. Strategies include emotional processing via catharsis, normalization and preparation for future contingencies Gulf War veterans who underwent psychological debriefing showed no significant differences in their scores of two scales measuring PTSD when compared with the control group In general, there is little evidence of psychological debriefing approaches effectively acting to prevent psychopathology, although participants seem to be open to it, which may indicate its usefulness as a rapport builder or as a screening tool.
In general however, there is a lack of rigorously conducted research in this area. To this day there is paucity in the data to orient the treatment of combat-related PTSD for veterans The International Consensus Group on Depression and Anxiety supports that exposure psychotherapy is the most appropriate approach for this disorder 41 , although this approach does not show a significant influence on PTSD's negative symptomatology, such as avoidance, impaired relationships or anger control In terms of proven efficacy, cognitive behavior therapy and eye movement desensitization and reprocessing are effective approaches to deal with PTSD 50 — 54 , while other psychotherapeutic approaches e.
Cognitive-behavioral psychotherapy encompasses a myriad of approaches i.
What Causes PTSD?
Vietnam veterans receiving exposure therapy displayed improvement as evidenced in terms of reducing intrusive combat memories 55 , physiological responding, anxiety 56 , depression and feelings of alienation, while also promoting increased vigor and skills confidence Exposure therapy, combined with a standard treatment also showed effectiveness with other Vietnam veterans in terms of subject self-report symptoms related to the traumatic experiences, sleep and subjective anxiety responding to trauma stimuli In fact, typically, there is a combination of psychotherapy and medication treatments to treat chronic PTSD In general, the different co-morbidities associated with PTSD play a role in the kinds of pharmacotherapeutic treatments used for its treatment.
Antidepressants and other medications commonly used are tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, antianxiety and adrenergic agents and mood stabilizers Sertraline has been found effective to reduce PTSD symptomatology 61 , Sertraline and fluoxetine have produced clinical improvements among PTSD patients in randomized clinical trials Paroxetine, another selective serotonin reuptake inhibitor like sertraline, is also habitually used to treat chronic PTSD Mirtazapine was another successful agent when used in the treatment of PTSD afflicted Korean veterans In addition, Olanzapine and fluphenazine have been successfully used with combat-induced PTSD subjects from the Balkans.
Both medicines were successful in ameliorating both PTSD and psychotic symptomatology Rigorous, well-controlled methods are necessary for conducting studies on the efficacy of PTSD treatments. Well-controlled studies are characterized by the following characteristics:. Future clinical research in PTSD requires the stringent, rigorous and systematic approach provided by evidence-based medicine.
Evidence-based research in medicine goes beyond the routine narrative literature review. It systematically evaluates the strength of the available evidence and generates a consensus statement of the best available evidence in the form of a systematic review of the available research Fig. What are the interventions being looked at, e.
Are the interventions being compared or are predictions being drawn, i. What is the outcome of interest, e. The second step involves methodology, including the sampling of the research literature, and the tools for the critical analysis of the reports. The fourth step is concerned with the analysis of the data gathered in the evidence-based research process. This commonly entails meta-analytical and meta-regression techniques, as well as individual patient data analysis e.
Depending upon the tools utilized to evaluate the scientific literature, scores about the completeness and quality of research methodology, design and statistical handling of the findings are generated SESTA, systematic evaluation of the statistical analysis. These values are analyzed by acceptable sampling statistical protocols to establish whether or not the sample of research reports studied by means of the evidence-based process was statistically acceptable to produce reliable inferences. The last step is a cumulative synthesis, which summarizes the process and the findings.
The process is applied to the performance of systematic reviews, which are all-encompassing of the available literature. Best case studies in evidence-based research entail a random performance of the process of evidence-based research with a random sample of the available literature. The future of clinical and translational research in PTSD lies in the systematic evaluation of the research evidence in treatment intervention for the patients. The collected evidence is then evaluated for research quality along certain standards [e.
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Timmer scale, Jadad scale and Wong scale The data from separate reports are pooled, when appropriate, for meta-analysis, meta-regression and individual patient data analyses. The data are analyzed from the perspective of Bayesian modeling in order to interpret data from research in the context of external evidence and judgments In the context of the treatment of patients with PTSD and co-morbidities, it is important and timely to generate a systematic review of the clinical research evidence for joint and simultaneous treatment of PTSD and the co-morbidities versus a staggered approach.
The summative evaluation of the outcome of such a systematic review will generate a consensus statement that will establish whether or not the problem was framed in a clinically relevant manner e. The statement must discuss the validity of the process of integration e. Was the search comprehensive and explicitly described?
Was the validity of the individual studies adequately assessed? Were the process of study selection, searching, assessing validity and data abstraction reliable? The statement also produces evidence about the rigor of the process by which information was integrated e.
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Are the summary findings representative of the largest and most rigorously performed studies? The quality, presentation and relevance of the findings must be discussed e. Are the key elements of each study clearly displayed? Is the magnitude of the findings statistically significant? Are the findings homogeneous or heterogeneous? Are sensitivity analyses presented and discussed? Do the findings suggest an overall net benefit for patients with PTSD?
This concerted, systematic and scientific-process driven mode of evaluating current treatment interventions for subjects with PTSD is timely and urgent to insure that the medical establishment will be prepared to handle the fast-approaching wave of PTSD cases in the next decade. This method-driven approach for the evaluation of clinical data has merit that its product, the consensus statement, must also generate a cost-effectiveness analysis i. The relevant findings in this cost-effectiveness analysis are usually expressed as the incremental cost-effectiveness between joint and simultaneous treatment of PTSD and its co-morbidities versus a staggered approach.
The incremental cost-effectiveness ratio, i. The consensus statement evaluates each competitive strategy, usually by means of the Markov model-based decision tree. This approach permits to model events that may occur in the future as a direct effect of treatment or as a side effect. The model produces a decision tree that cycles over fixed intervals in time and incorporates probabilities of occurrence. Even if the difference between the two treatment strategies appears quantitatively small, the Markov model outcome reflects the optimal clinical decision, because it is based on the best possible values for probabilities and utilities incorporated in the tree.
The outcome produced by the Markov decision analysis is generally obtained by means of the sensitivity analysis to test the stability over a range of probability estimates and thus reflects the most rational treatment choice Fig. The purpose of evidence-based research in medicine is to elucidate the best available evidence in response to a stated clinical problem e.
Following the scientific process of evidence-based research and the generation of the consensus statement Fig. Effectiveness and utilities data are estimated e. Markov model to aid the final clinical decision-making process The process of evidence-based research in medicine has begun its integration in the domain of PTSD. These findings confirmed earlier Cochrane-based systematic reviews 67 , In a separate line of study, systematic reviews established clear support of the research evidence for serotonin reuptake inhibitors as the preferred first line treatment for PTSD, whereas mood stabilizers, atypical neuroleptics, adrenergic agents and newer antidepressants were shown to show promise, but to require further controlled trials to establish their efficacy and efficaciousness 60 , The future of clinical and translational research in PTSD also lies in its judicious integration of complementary and alternative medicine CAM.
For instance, whereas PTSD symptoms are common in patients with breast cancer, this symptomatology is more effectively reduced by traditional psychosocial interventions compared with CAM-oriented intervention Research will determine whether this observation is true across all forms of PTSD-inducing stress and trauma and across all subjects.
In conclusion, it is timely to design similar evidence-based research studies to establish the strength of the evidence in support of complementary approaches for the treatment of PTSD. For example, use of complementary therapies e.
Post-Traumatic Stress Disorder: Evidence-Based Research for the Third Millennium
This trend appears to be particularly evident among native American veterans, who usually choose not to seek treatment at VAMC facilities, in part because of the preference they hold for alternative and complementary treatments, which are usually not available at those facilities This population of patients is therefore at serious risk of remaining underserved. Taken together, these developments should produce important novel information about the fundamental nature of PTSD from the perspective of allostasis and about its optimal treatment using the best available evidence obtained from systematic reviews.
This concerted approach will be particularly important as the prevalence of PTSD with its complex psychobiological co-morbidity rises and as alternative and complementary medical treatments for PTSD emerge and take hold. Such is, in our view, the future of research in PTSD, in order to establish a registry of regular critical evaluation updates of the available evidence for the immediate service of the clinical research community and the benefit of patients with PTSD, their families and society at large.
National Center for Biotechnology Information , U. Evid Based Complement Alternat Med. Negoita Neagos 2 Psychoneuroimmunology Group, Inc. Author information Article notes Copyright and License information Disclaimer. Received Jun 10; Accepted Sep Published by Oxford University Press. This article has been cited by other articles in PMC. Abstract The stress that results from traumatic events precipitates a spectrum of psycho-emotional and physiopathological outcomes. Allostasis and PTSD Allostasis and the Response to Stress Allostasis refers to the psychobiological regulatory process that brings about stability through change of state consequential to stress.
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In addition, there are other considerations affecting the treatment appropriateness: Well-controlled studies are characterized by the following characteristics: Vojdani A, Thrasher JD. Cellular and humoral immune abnormalities in Gulf War veterans. Case-control study of genotypes in multiple chemical sensitivity: Am J Med Sci. On the Etiology and Prevalence of Diseases of the Heart among.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Press; Assessment of a new self-rating scale for post-traumatic stress disorder. Validation of a brief measure of posttraumatic stress disorder: The Impact of Event Scale-Revised. Wilson J, Keane TM, editors. Psychometric review of the trauma symptom checklist Measurement of Stress, Trauma, and Adaptation. The validation of a self-report measure of posttraumatic stress disorder: The Los Angeles symptom checklist: A clinician rating scale for assessing current and lifetime PTSD: Neural correlates of the classic color and emotional Stroop in women-related posttraumatic stress disorder.
Gender differences in cognitive and neural correlates of remembrance of emotional words. An fMRI study of anterior cingulate function in posttraumatic stress disorder. Mississippi scale for combat-related posttraumatic stress disorder: J Consult Clin Psychol. Trauma and the Vietnam war generation: Report of findings from the National Veterans Readjustment Study. Clinical evaluation of a measure to assess combat exposure.
The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: Low-dose risperidone as adjunctive therapy for irritable aggression in posttraumatic stress disorder.
Posttraumatic stress disorder and self-reported physical health status among US Military personnel serving during the Gulf War period: Clinical presentations in combat veterans diagnosed with posttraumatic stress disorder. An ethnocultural study of posttraumatic stress disorder in African-American and white American Vietnam War veterans. Minnesota multiphasic personality inventory profiles of Vietnam combat veterans with posttraumatic stress disorder and their children.
Engdahl B, Eberly R. Assessing PTSD among veterans exposed to war trauma 40—50 years ago. Consciousness, emotional self-regulation, and the psychosomatic network: John Benjamins Publishing Company; a. Clinical, experimental and translational psychoneuroimmunology research models in oral biology and medicine.
Chiappelli F, Cajulis OS. Sterling P, Eyer J. Fisher S, Reason J, editors. Handbook of Life Stress, Cognition, and Health. The concept of allostasis in biology and biomedicine. The Guilford Press; A multidimensional meta-analysis of psychotherapy for PTSD. Olanzapine versus fluphenacine in an open trial in patients with psychotic combat-related post-traumatic stress disorder.
Posttraumatic stress disorder and depression in soldiers with combat experience. Assessment of posttraumatic stress disorder and comorbidity. Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder. Foa E, et al. Psychological sequelae following the Gulf war: Intrusive reawakening of emotional memories stemming from childhood losses — i. Feelings of emotional detachment, i. Conversely, difficulty letting go of an ex, difficulty letting go fof feelings of rejection, longing, and regret.
Difficulty letting go period like a dog with a bone over a conflict with another, a disappointment, etc. Episodes of self-neglectful or self-destructive behavior. Difficulty withstanding and overreacting to the customary emotional ups and downs within intimate relationships. Reaching impasses — trouble working through the conflict with others.
Extreme sensitivity to perceived rejections, exclusions or criticisms. Emotional pendulum swings between fear of engulfment and fear of abandonment: Tendency to feel hopelessly hooked on a partner who is emotionally unavailable. Emotional anorexia or emotional bulimia: Difficulty naming your feelings or sorting through an emotional fog. Abando phobism — a tendency to avoid close relationships altogether to avoid risk of abandonment.
Conversely, a tendency to rush into relationships and clamp on too quickly. Difficulty letting go because you have attached with emotional epoxy, even when you know the person is not good for you. Conversely, a tendency to create chaos by avoiding responsibility, procrastinating, giving up control to others, making messes, and feeling out of control. People-pleasing — excessive need for acceptance or approval, setting yourself up for a lack of reciprocity within your relationships.
Tendency to act impulsively without being able to put the brakes on, even when you are aware of the negative consequences. Tendency toward unpredictable outbursts of anger, sometimes burning bridges to important social connections. Negative narcissism — preoccupied with self-criticism and worry over how you are perceived by others. Intrusive feelings of insecurity — a major source of self-sabotage in primary relationships and in goal-achievement.