Post Traumatic Stress Disorder - Essay Example

? The Effectiveness of Drug Treatments on PTSD compared to the Immediate Psychological Interventions Introduction There hasbeen an increase in the incidence of PTSD. Different therapists prefer different modalities of treatment. Some place emphasis on drug therapy, while others place emphasis on psychotherapy. This paper seeks to find out the effectiveness of drug therapy, when compared to immediate psychological interventions in the treatment of PTSD. Therefore, this paper seeks to answer the question whether drug treatment should be the first line management of PTSD when compared with immediate psychological interventions. NICE is an independent organization that was setup in 1999 1. NICE makes the decision with regards to drugs and treatment. The organization decides the availability of different treatment modalities that are available in England and Wales. Clinical guidelines can be termed as recommendations for good health practices. The recommendations in NICE are set up by representative groups of health workers. These groups analyse the available evidence on the best management or treatment modalities, and derive recommendations from this evidence. Guidelines are imperative in the medical field. Guidelines are protocols that are tailor made from research that has proven their efficacy1. They make the work of the health worker easier in management of diseases and complications. Post Traumatic Stress Disorder is classified as an anxiety disorder. Its development is preceded by an emotionally, incapacitating phenomenon. These can include highly unsafe, life threatening or frightening occurrence. Approximately 30% of those who have undergone a traumatic ordeal may proceed to development of PTSD2. It is estimated that PTSD may affect 8% of people at one point in their lives2. A patient with PTSD experiences lasting consequences of the frightening or traumatic ordeal. Families of affected victims, rescue workers and emergency personnel can develop PTSD. These patients frequently have reactions that include nervousness, anger, shock, fear, and guilt. It is worth noting that these are normal occurrences. The distinction in PTSD lies in the fact that these reactions are unrelenting. These reactions may increase in magnitude leading to incapacitation. Patients with PTSD have symptoms for greater than a month. Their level of functionality is decreased when compared to the pre-traumatic period. The symptoms of PTSD begin within 3 months after the traumatic ordeal3. However, there are those who can experience symptoms years after the ordeal. The duration and severity of the illness varies. The symptoms are classified into 3 main entities. These include avoiding, reliving and increased arousal. In avoiding, people avoid places, people, situations or thoughts that remind them of the traumatic ordeal. This frequently leads to isolation and feelings of detachment from friends and families. The patients also experience loss of experiences in previously enjoyed activities. In the second category of Reliving, patients frequently relive the traumatic ordeal through memories and thoughts. Henceforth, they experience nightmares, flashback and hallucinations. In the third category of increased arousal, patients exhibit excessive emotions3. They also have problematic relationship with others and sleep disturbances. The ICD-10 PTSD diagnosis criteria require the fulfilment of two conditions3. Firstly, the patient must have experienced a traumatic event. Secondly, the patient suffers from re-experiences and distressing symptoms. Five ICD-10 diagnostic criteria are then derived from these two conditions. The first criterion is that the patient must have had exposure to stressful ordeal of deleterious nature. The second criterion is that there must be persistent reliving of the traumatic ordeal in dreams, flashbacks or memories. Thirdly, the patient must exhibit avoidance of circumstances resembling or associated with the trauma. Fourthly, one of the following symptoms must be present: partial or complete inability to recall aspects of the traumatic period, anger, sleep disturbances, exaggerated startle response or hyper vigilance. Fifthly, the 2nd, 3rd, and 4th criterion must be met within six months of the traumatic ordeal3. There are various treatment modalities that are available for PTSD patients. Most revolve around psychological treatment4. Nonetheless, medications are also imperative for PTSD treatment. Treatment should be offered regardless of when the traumatic ordeal happened. The health care professional should issue the patient information that pertains to the disorder. The patient is then at liberty to choose a treatment modality that he/she is contented with. Psychological treatments include Eye Movement Desensitization & Reprocessing and Cognitive Behavioural Therapy focused on the trauma4-6. Trauma focused CBT targets the distressing cognitions (feeling and thoughts) and behaviour; therefore, leading to a positive change. The treatment focuses on thoughts, feelings and memories experienced by the patient. These can be done by listening to recordings of the patient’s account of the ordeal. CBT employs an array of therapeutic techniques that seek to change the distressing emotions by altering beliefs, thoughts and behaviour5. CBT modalities for PTSD can be classified into three programmes. These programmes entail exposure, cognitive therapy and stress management. In exposure, the therapist assists the PTSD patient in confronting their traumatic memories6. In the cognitive therapy programme, the health professional assists the patient in the identification and modification of the negative cognitions associated with the traumatic ordeal. In the stress management programme, the therapist teaches the patient on a range of skills geared towards stress reduction. These include breathing, relaxation, positive thinking and thought stopping technique. EMDR entails the health professional assisting the patient in looking at the trauma memories6. During EMDR, the patient is asked to focus on an image or a visual reconstruction of the traumatic event, while paying attention to the therapist’s fingers. Gradually, the patient is taught how to visualize the image while thinking positively. NICE guidelines recommend CBT for those who have developed PTSD within three months of a traumatic ordeal1. The course of CBT should be between 8 to 12 sessions. There is the recommendation that each session should last for 60 to 90 minutes1. If the symptoms are severe, then the treatment should be started within the first month after the traumatic ordeal. The CBT is provided on an outpatient basis. For patients with PTSD for greater than 3 months, trauma focused CBT or EMDR should be offered. The number and duration of sessions are the same as those with PTSD for less than 3 months. However, the sessions may be more than 12 depending on the outcome and the magnitude of trauma1. It is imperative to note that NICE endorses Trauma focused CBT and EMDR as first line treatment modalities for PTSD1. However, for adults with unremitting disease, medication may be prescribed. The medication can include paroxetine, mirtazipine, amitriptyline or phenelzine (are also antidepressants) 4. Regular monitoring of drug effects is mandatory. NICE does not recommend these drugs for those with suicidal ideation. Medication can be used together with psychotherapy. Another adjunct to treatment includes hypnotherapy 5-8. There are several factors that dictate the prognosis of the disease. Those who start treatment early have a good prognosis in terms of recovery. The level of family support is imperative in determining the overall prognosis. Aim This review places emphasis on the efficacy of various treatment modalities in PTSD. The treatment modalities in question are pharmacological and psychological PTSD treatment methods. In order to perform this, this paper will critically appraise trials that assert the efficacy of pharmacologic and psychological treatment methods. Methodology The topic that was assigned to me is the comparison of effectiveness of PTSD modalities of treatment. This provided me with the opportunity to decipher the best modality of treatment to commence as first line treatment for PTSD. I decided to major my research on treatment of PTSD secondary to burns. So as to gain background information on the subject matter, I employed search engines such as Google and yahoo. Initially, I began using broad terms like “Post traumatic stress disorder”, and “PTSD treatment”. I then went on to focus on the efficacy of PTSD treatment modalities. Therefore, I narrowed the search by using terms such as “Trauma focussed CBT”, “Pharmacologic PTSD therapy”, “EMDR in PTSD management”, “Efficacy of Trauma Focussed CBT”, “Efficacy of EMDR,” and “Efficacy of Pharmacologic therapy in PTSD”. I then went ahead to look for articles and trials that showed results of the different treatment modalities. These articles were randomized control trials and meta-analytic researches that elaborated on drug treatment and psychological therapy for PTSD. The databases that I utilised were PubMed, WebMD, Embase and from references of retrieved article reviews. No time period restrictions were imposed in any of the searches. However, the results were limited to English publications. These studies were eligible for inclusion if they detailed sufficient PTSD treatment data for analysis. Case studies were excluded. Results When searching the various databases using the aforementioned terms such as “PTSD treatment”, over 9,000 hits were obtained. The hits were then filtered. After further research, I decided to narrow the search to “After burns PTSD,” whereupon there were 60 hits. This necessitated further filtering, and I decided to limit the search to “After burns PTSD treatment efficacy comparison”. One of the articles found primarily focused on treatment of “after burns” PTSD. The remaining 3 articles encompassed a significant number of “after burns” PTSD and were warranted consideration. These four were then chosen for critical appraisal, so as elaborate on the most effective treatment modality. Their results are presented in this paper. The four articles entailed studies that analysed the efficacy of various PTSD treatment modalities. The participants of all these studies were patients of any age suffering from PTSD. The PTSD had to be due to bodily injury, specifically burns. The first research article chosen is one by Saxe et al9. This research studied the outcome of psychoactive medication therapy on PTSD in children with burns. The research further investigated the relationship between the dose of opiod administered to children, who were hospitalized for acute burn, and exhibited symptoms of PTSD. The research used twenty four children admitted to the hospital for trauma related to acute burns. They were assessed twice while in the hospital, and six months after discharge. The change in PTSD symptoms was derived in each PTSD assessment. The assessment was conducted using a PTSD reaction index and the coloured analogue pain scale. Children with PTSD have high scores in the PTSD reaction index and coloured analogue pain scale. Over the six month period of monitoring, the PTSD reaction index decreased for all children. The drug therapy entailed opiate medication during the hospitalization period. The opiod employed in this research was morphine. Increased doses of morphine were associated with reduction in PTSD symptoms. Pain perception was found to decrease with increased opiod dose. This significant relationship was independent of the research variables. The research also determined the influence and efficacy of other psycho-tropic medications (especially benzodiazepines) 19, 20. 10 of the 24 children were treated with benzodiazepines (Lorazepam). Benzodiazepines were found out to have minimal impact on the changes in PTSD symptoms over the six months of assessment19. Other medications that were analyzed were Sertraline, paroxetine, carbamazepine and Guanfacine. The administration of the opiods and benzodiazepines precluded the correlation analysis of these drugs on the impact in PTSD changes9. The second research10 selected is a meta-analysis on the efficacy of various treatment modalities in the early intervention of PTSD by Brett et al. The majority of the PTSD patients were derived from burns and combat related trauma. In this research, single session-debriefing therapeutic interventions were considered. In his meta-analysis, Brett pointed out that randomized control trials done by Pynoos et al.11, did not justify the use of debriefing intervention in PTSD patients. The research11 showed that psychological therapy was relatively ineffective if conducted for one, two and three sessions. However, greater than 4 sessions of CBT had significant efficacy in the early intervention of PTSD secondary to burns and trauma. 12 or more sessions were associated with increased efficacy11. The research went ahead to analyse the efficacy of pharmacologic modality in the management of PTSD in a research by Ballenger et al12. Benzodiazepines were found to have decreased efficacy in the overall management of PTSD. This was attributed to the side effects profile of these drugs. Increased dosages of benzodiazepine medication lacked a demonstration of efficacy in PTSD treatment. Contrary, patients administered with benzodiazepines had increased rates of PTSD at 6 months of follow up when compared to a control group. The nonbenzodiazepine sedative-Hypnotic Trazodone was found to be effective in decreasing some symptoms of PTSD. Trazodone decreased acute sleep difficulties associated with PTSD in a majority of the patients who used the drug12. Brett et al demonstrated that Propanolol may have properties that serve to protect from PTSD. However, the research noted that the use of the drug in the management of PTSD is highly experimental. Brett pointed out a study13 which showed the probability of Propanolol being successful in decreasing the symptoms of PTSD. Brett analyzed a research14 done to demonstrate the efficacy of SSRI. The research employed Fluoxetine in acutely injured trauma survivors, including burns victims. Flouxetine was shown to be effective in PTSD management. Tricyclic antidepressants were ruled out in the study, owing to their adverse effects, which negate their benefit. The third research is by Van Etten and Taylor18. The research aimed to demonstrate the efficacy of psychological therapies in treatment of patients with PTSD attributed to injurious stimuli including burns. Patients were subjected to EMDR and CBT. Large mean effect sizes were found for the EMDR. The research provided a meta-analysis of different trials that had utilized CBT and EMDR in the management of PTSD. Most of the trials had a large effect size of the psychological modalities. EMDR was highly effective. The efficacy of this treatment modality was noted after several sessions. There was little, or no efficacy noted within the first three sessions of EMDR. Van Etten & Taylor noted that there was only one trial which demonstrated lack of efficacy of EMDR in PTSD management. However, Van Etten and Taylor attributed this to serious methodological quality in the study. The research also sought to compare the efficacy of CBT and EMDR. It was found that the two have equal efficacy. An increased duration for the psychological treatment was required for significant efficacy. The research purports that psychological modes of treatment are more effective than pharmacologic18. The fourth research analysed was one done by Stewart and Wrobel5. This research5 evaluated the efficacy of psychotherapy and pharmacotherapy in the treatment of burns and injury related post-traumatic stress disorder. The pharmacotherapy therapy included tricyclic antidepressants, SSRI and monoamine oxidase inhibitors. The treatment duration was between 4 and 12 weeks. The treatment duration for psychotherapy was between 6 and 52 weeks. Patients that were put on drugs demonstrated statistically significant reduction in PTSD symptoms when compared with psychotherapy. Discussion The first study9 indicates that pharmacotherapy is associated with a significant impact on PTSD symptoms over a 6 month period. Administration of morphine was found to decrease symptoms of PTSD. Benzodiazepines are less effective than morphine. Morphine is a drug that acts to decrease pain perception. Pain is a psychobiological experience, which is relevant to PTSD. Decreased pain has been associated with decreased PTSD symptoms. However, this is not the only mechanism by which morphine serves to decrease the symptoms of PTSD. Morphine has been found to enhance memory consolidation and fear conditioning in PTSD patients. After a traumatic ordeal, there is an increase of adrenergic levels in the brain. Increased adrenergic output has been linked to the pathogenesis of Post Traumatic Stress Disorder. By decreasing adrenergic levels in the brain, morphine retards the pathogenesis of PTSD. This implies that increased doses of morphine are associated with the reduction in PTSD symptoms. Acutely stressed persons have been found to have elevated levels of endogenous opiods. The stress-induced release of opiates in the body may serve as a protective function against Post Traumatic Stress Disorder15-17. Another significant point to be noted from the research is that morphine can serve as a protective factor from PTSD in patients who are exposed to a traumatic ordeal. With this respect, opiods may serve to retard the chronicity of PTSD. Another drug which may have significant efficacy is Propanolol13. As noted earlier, PTSD is associated with increased adrenergic discharge levels. Propanolol is a beta blocker, serving to decrease the sympathetic response. This implies that the drug decreases the adrenergic levels in the brain. This serves to ameliorate the cause of PTSD; therefore, decrease the symptoms of PTSD. Trazodone is another drug that has proven to be effective in the management of PTSD12. This drug can be used as an adjunct in the treatment of PTSD. It serves to treat the sleep difficulties associated with the disorder. Over the years, benzodiazepines have been used in the management of stress disorders. However, from the above findings, this group of drugs has not demonstrated significant efficacy in altering the course of PTSD. Treatment with benzodiazepines was associated with deleterious effects in a subset of patients12. Another subset of drugs with proven efficacy is the Selective Serotonin Reuptake Inhibitors (Such as Flouxetine) 14. Cognitive behavioural therapy has an imperative role in the management of PTSD. However, the number of sessions is important in determining the overall efficacy of this treatment modality. Sessions fewer than 4 are not associated with proven efficacy. Sessions that are more than four have some level of efficacy. 12 or more sessions are needed for maximal efficacy of this psychological intervention. EMDR is effective in the management of PTSD. Its efficacy is comparable to that of CBT as proven above. EMDR requires increased sessions for efficacy in managing PTSD. Repeated sessions are the key to success of psychological treatment modality. The duration of the psychological treatment modality is imperative in determining the outcome of the therapy. When comparing pharmacological and psychological treatment modalities for the management of PTSD, several factors should be considered. To begin with, there is a large rift in the cost of the two modalities. Psychological treatment demands a significant amount of money. The cost required to complete a whole programme may be unattainable to some. Pharmacologic therapy is affordable for most people. Drugs such as morphine, Propanolol and flouxetine, are inexpensive21, 22. Additional costs are incurred in terms of transport cost (for appointments with the psychological therapist). This is not the case with pharmacologic therapy. In terms of cost benefit analysis, pharmacologic therapy outweighs psychological therapy. The duration of the psychological session is also demanding. As noted above, CBT and EMDR may need months of sessions so as to realize progress. Drug therapy only takes days so as to realize progress. Patients are likely to tire from attending such sessions. Pharmacologic therapy usually entails a shorter duration. Administration of psychological treatment requires highly trained personnel. Contrary, pharmacologic therapy does not require highly trained personnel so as to administer. Some of the pharmacologic therapies are associated with deleterious effects. Drugs such as Flouxetine have significant side effect profile. Some of the antidepressants used in PTSD treatment are toxic when consumed in high doses. PTSD patients with suicidal ideations can easily overdose the drugs with deleterious consequences. Psychological therapy has no proven adverse reactions. In light of this, drug treatment is limited by the side effect profile. Both of these two treatment modalities are associated with nearly similar efficacy. Another factor to note is that PTSD may recur in those who are treated with drugs as a monotherapy. Psychotherapy is associated with low recurrence rates23-27. Presented with the above facts, there is a need to consider drug treatment as a first line in the management of PTSD. Psychological treatment can be used as an adjunct, so as to improve the outcome of PTSD and prevent recurrence. Combination therapy of both pharmacologic and psychological therapies may have additive factors22, 29. This will serve to speed up the recovery process. Conclusion PTSD incidence has been on the increase. Various treatment modalities have been described for the disorder. NICE recommends trauma focused CBT and EMDR as first line for PTSD. This is despite the fact that psychological treatments are costly, hence, inaccessibility. Psychological treatment also requires repeated and demanding sessions. On the other hand, pharmacologic management of PTSD is cheap and easily accessible. With this respect, there is the suggestion that drug therapy should be PTSD first line. Psychological therapies should then be instituted as adjuncts; therefore, work synergistically with drugs. Drugs have been shown to have high efficacy when it comes to different aspects of PTSD. Morphine and Propanolol serve to decrease adrenergic output in the brain. Trazodone treats sleep problems in PTSD. More research is needed in the area, so as to generate more data that will assist in the development of newer guidelines. Reference List 1. National Institute for Health and Clinical Excellence (2005) [Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care]. [CG26]. London: National Institute for Health and Clinical Excellence 2. Yu BH, Dimsdale JE. Posttraumatic stress disorder in patients with burn injuries. J Burn Care Rehabilitation. 1999; 20(5):426–433. 3. American Psychiatric Association. DSM-IV Sourcebook. Washington (DC): The Association; 1991. 4. Shalev AY, Bonne O. Treatment of posttraumatic stress disorder: a review. Psychosomatic Med 1996; 58: 65–182. 5. Stewart C, Wrobel T. Evaluation of the efficacy of pharmacotherapy and psychotherapy in treatment of injury related Post-traumatic stress disorder. Military Medicine 2009; 174(5): 460-469. 6. Ehde DM, Patterson DR, Wiechman SA, Wilson LG. Post-traumatic stress symptoms and distress following acute burn injury. Burns 1999; 25(7):587–592.  7. Bryant RA, Harvey AG. Acute stress disorder: a critical review of diagnostic issues. Clinical Psychology Review 1997; 17: 757–73 8. Difede J, Ptacek JT, Roberts J, et al. Acute stress disorder after burn injury: a predictor of posttraumatic stress disorder? Psychosomatic Medicine. 2002; 64(5):826–834. 9. Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, et al. Relationship between acute morphine and the course of PTSD in children with burns. Child Adolescent Psychiatry 2001; 40 (8): 915-920. 10. Brett T, Fauerbach J, McCann U. stress disorder following a traumatic ordeal: treatment considerations. Psychiatry weekly, 2010; 87 (5): 11. Pynoos RS, Frederick C, Nader K et al. Life threat and posttraumatic stress in school age children. Arch Gen Psychiatry 1987; 44: 1057–1063 12. Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement update on posttraumatic stress disorder from the international consensus group on depression and anxiety. Journal of Clinical Psychiatry 2004; 65(1):55-62. 13. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry 2002; 51(2):189-192. 14. Zatzick D, Roy-Byrne P. Psychopharmacologic approaches to the management of posttraumatic stress disorders in the acute care medical sector. Semin Clinical Neuropsychiatry 2003; 8(3):168-174. 15. Hamner MB, Hitri A. Plasma beta-endorphin levels in post-traumatic stress disorder: a preliminary report on response to exercise-induced stress. J Neuropsychiatry Clinical Neuroscience 1992; 4: 59–63 16. Pitman RK. Post-traumatic stress disorder, hormones, and memory (editorial). Biological Psychiatry 1989; 26: 221–223 17. Van der Kolk BA, Greenberg MS, Orr SP, Pitman RK. Endogenous opiods, stress induced analgesia, and posttraumatic stress disorder. Psychopharmacologic Bulletin 1989; 25: 417–421. 18. Van Etten M, Taylor S. Comparative efficacy of treatments for post-traumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy 1998; 5(3): 126-144. 19. Gelpin E, Bonne O, Peri T, Brandes D, Shalev AY. Treatment of recent trauma survivors with benzodiazepines: a prospective study. Journal of Clinical Psychiatry 1996; 57: 390–394 20. Davis M. Pharmacological and anatomical analysis of fear conditioning. NIDA Res Monogr 1990; 97:126–162. 21. Southwick SM, Krystal JH, Morgan A, et al. Abnormal noradrenergic function in posttraumatic stress disorder. Arch Gen Psychiatry 1993; 50: 266–274 22. Vaiva G, Ducrocq F, Jezequel K, et al. Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma. Biol Psychiatry 2003; 54(9):947-949. 23.  Blanchard EB, Hickling EJ, Malta LS, et al. One- and two-year prospective follow-up of cognitive behavior therapy or supportive psychotherapy. Behavioral Res Therapy 2004; 42(7):745-759. 24. Zatzick D, Roy-Byrne P, Russo J, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry 2004; 61(5):498-506. 25. Cobb S, Lindemann E. Symposium on the management of Cocoanut Grove Burns at Massachusetts General Hospital: neuropsychiatric observations. Ann Surgery 1943; 117: 814–24. 26. Bryant A, Harvey A, Dang S, Sackville T, Basten C. Treatment of acute stress disorder: a comparison of cognitive behavior therapy and supportive counseling. J Consult Clinical Psychologist 1998; 66: 862–6. 27. Herndon D. Total Burn Care. London, UK: WB Saunders; 2008. 28. Foa E, Hearst-Ikeda, Perry K. Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. J Consult Clinical Psychologist 1995; 63: 948–55. 29. Folstein M, Folstein S, McHugh P. Mini-Mental State. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Res 1975; 12: 189–98. Read More