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Can Posttraumatic Stress Disorder Be Prevented?

Can Posttraumatic Stress Disorder Be Prevented?

Posttraumatic stress disorder (PTSD) is an anxiety disorder
that may develop following severe psychological
trauma. The person's immediate response to the event
must involve intense fear, helplessness, or horror (or
in children, disorganized or agitated behavior).1 Three symptom
clusters that characterize the emergence of PTSD are reexperiencing,
avoidance and numbing, and hyperarousal. Specific
symptoms include flashbacks, nightmares, and feeling detached
or estranged following exposure to an extremely traumatic stressful
event. These symptoms usually appear within the first 3
months after the trauma, although there may be a delay of
months or even years.

Terrorist attacks, such as those
occurring on September 11, 2001, and
combat experiences in Afghanistan
and Iraq, have put many Americans at
risk for long-term psychological consequences
and the development of PTSD.
Instead of a gradual recovery from
preoccupation with whatever serious
life-threatening event a person has
experienced, persons with PTSD have
traumatic memories with daytime
recollections, recurrent nightmares,
repetitive flashbacks to the original
stressor, and maladaptive avoidance
patterns. PTSD will develop in about
25% of persons exposed to extreme
trauma, but the likelihood that symptoms
will develop in an individual
depends on the intensity and kind
of traumatic exposure as well as on
“individual resilience.”2 In community
studies, the reported lifetime prevalence
rate is about 8% for PTSD.3

Ways to prevent PTSD include
keeping civilian and military populations
out of harm's way and completely
eliminating emotional traumas associated
with rape, violent crime, or severe
accidents. Unfortunately, neither goal
is possible to achieve. Therefore, we
need to focus on better therapies for
sufferers of acute trauma so that longstanding
PTSD will develop in fewer
of these individuals.

It also turns out that certain persons
run a higher risk of PTSD than others.
Women have twice as high a risk as
men,4 and sexual and physical abuse
during childhood may sensitize the
nervous system, which then overreacts
and perseverates when exposed to traumatic
events in adulthood.5 In a 2004
literature review and discussion article,
Charney6 identified 11 possible
neurochemical, neuropeptide, and hormonal
mediators of the psychobiologic
response to extreme stress and
related them to either resilience or
vulnerability. The list includes cortisol,
dehydroepiandrosterone, corticotropin-
releasing hormone, the locus
caeruleus-norepinephrine system, estrogen,
neuropeptide Y, dopamine,
serotonin, benzodiazepine receptors,
and several other systems.

How little we actually know about
preventing PTSD after exposure to a traumatic emotional event is illustrated
by recent research that found that critical
incident stress debriefing (CISD),
the major intervention following 9/11,
was relatively ineffective. It may even
turn out that CISD, which involves a
single 1-hour to 3-hour individual or
group session soon after the event,
allowing people to vent their emotions
and relive the traumatic experience, may
be more harmful than helpful. A 2003
interdisciplinary task force assembled
by the American College of Neuropsychopharmacology
concluded that “it
is possible that reliving and rehearsing
raw emotion leads to consolidation of
traumatic memories.”7

That conclusion is supported by a
2002 meta-analysis of 7 controlled
trials measuring clinical outcomes
after various interventions within 1
month of various kinds of psychological
trauma. This analysis found no
benefit from CISD and suggested a
detrimental effect when it was compared
with no intervention or minimal
help (30-minute counseling, education, and historical group debriefing).8 A just-updated Cochrane Review concluded: "There is no evidence that single session individual psychological debriefing is a useful treatment for the prevention of posttraumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease. A more appropriate response could involve a 'screen and treat' model."9

In contrast to (but theoretically
consistent with) the disappointing
findings from CISD, findings from a
pilot study show that early intervention
with an adrenergic blocking agent
within a few hours after a catastrophic
event is helpful.10 The logic behind
this approach is based on previous
research showing that epinephrine,
either exogenously administered or
endogenously released, strengthens
memory consolidation and fear conditioning.
Therefore, Pitman and
colleagues10 decided to try a placebo-controlled trial of the β-blocker propranolol
administered in an emergency
department setting just after a traumatic
event. They gave 40 mg orally within
6 hours of the event and then had
patients continue taking 40 mg qid
for the next 10 days. At 1 month, the
rate of PTSD among those who took
placebo was 6 (30%) of 20 compared
with 2 (18%) of 11 among those who
took propranolol.


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