Posttraumatic Stress Disorder: Neurobiology, Psychology, and Public Health

By Robert J. Ursano, MD, David M. Benedek, MD, and Carol S. Fullerton, PhD | March 1, 2008

Dr Ursano is professor and chair, department of psychiatry, and director, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Md. Dr Benedek is associate professor of psychiatry and assistant chair of the department and senior scientist, Center for the Study of Traumatic Stress. Dr Fullerton is professor (research) of psychiatry, assistant chair of the department, and senior scientist and scientific director, Center for the Study of Traumatic Stress.

Often, health care planners and providers underestimate the duration of the impact of a terrorist event or disaster on a community, focusing primarily on the acute impact rather than on the recovery stage. Such overemphasis of the impact stage neglects the important elements of recovery that include the stress of relocation and new life events involving altered economics, social settings, stigma, and job loss that occur in communities hit by disaster. These postdisaster events and secondary adversities have substantial impact on the psychological distress and health of individuals and communities and are risk factors for PTSD.^34,35 In addition, the recovery of those with PTSD, whether from war or disaster, requires making resources available for care and addressing the barriers to care and adherence with health care recommendations. Only 32% of those in whom a mental health disorder developed following Katrina had accessed care 8 months later.³⁶

Looking at the future

So, what is on the horizon? First, PTSD will be the first mental disorder to be preventable. It already is. Studies by Bryant³² have shown that cognitive-behavioral therapy given at about 3 weeks to those with acute stress disorder can lower the rates of PTSD. Similarly, we know that using seat belts—a protective behavior—prevents injury and injury is one of the strongest predictors of PTSD resulting from motor vehicle accidents.

Current research also offers promise of early pharmacological intervention to prevent PTSD, perhaps targeted to those with risk genes. In addition, studies of PTSD biomarkers suggest that we will have both biochemical (eg, blood) and brain imaging biomarkers to predict the risk of PTSD as well as for stages of the disease process.

Second, present studies on the importance of integrating PTSD detection and treatment into primary care (and as part of screening for those who are injured) suggest that collaboration with our primary care colleagues can provide the best public health approach to PTSD, particularly in disaster populations. Easily administered screenings and algorithms for primary care treatment and referral for specialty care are needed.

Third, we can hope that the current experience with PTSD may lead to the development of postdisaster, real-time mental health and risk-behavior surveillance—just as is done for other injuries and disorders that may impair communities, such as surveillance for infectious diseases. Such changes can decrease the stigma of mental illness as the public better understands psychiatric illness as being similar to other disorders. Finally, as we better recognize PTSD as a disorder of forgetting, we may well learn a great deal about when forgetting is important to assist health and when it may impair health, a fundamental issue for all psychotherapies. The Table lists some of the aspects of potential treatment and care for PTSD in the future.


TABLE Future of PTSD: prevention and treatment


	Pharmacological interventions to prevent PTSD (the first mental disorder to be prevented)
	Biomarkers for risk, disease onset, and treatment of PTSD
	Primary care detection and early treatment of PTSD in disaster populations and in trauma centers
	Postdisaster mental health surveillance as with other postdisaster disease/injury
	Understanding PTSD as a disorder of forgetting will contribute to psychotherapy treatment across other disorders

Opportunities and challenges are before us for the understanding of human responses to traumatic events and for the care of trauma and disaster victims—from psychopharmacology to psychotherapy and system interventions. The knowledge base needs to be fostered and new models need to be tested. Those who are trauma victims deserve our best health care and services.

Pages: 1 2

Hobfoll SE, Watson P, Bell CC, et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry. 2007;70: 283-315.
Institute of Medicine. Diagnosis of PTSD. Washington, DC: National Academies Press; 2006.

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Posttraumatic Stress Disorder: Neurobiology, Psychology, and Public Health

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