Posttraumatic Stress in Medically Ill Patients

A trauma-focused approach targets the traumatic experience as the reason for the mental health symptoms. This is different from other psychiatric and psychotherapeutic approaches (such as medication treatment), some of which do not focus on the reason for the symptoms but on the alleviation of the symptoms regardless of their origin. A trauma-focused approach is also different from psychoanalytic psychotherapy because it focuses on the traumatic event rather than on experiences from the distant past as a focal point that can explain the development of the mental health symptoms.

During the evaluation, Rachel firmly stated that the start of her symptoms of distress and dysphoric mood was related to the time she had been hospitalized for the MI. She had been treated for a panic disorder when she was a teenager ("talk therapy"), but she is currently not receiving any mental health treatment. She repeatedly says that she is "not crazy" and that she wants a "short treatment" and does not want any prescribed medications because she "had enough of taking drugs for my other problems." A diagnosis is made of depressive disorder not otherwise specified accompanied by posttraumatic stress disorder (PTSD) related to the experience of having had an MI.

At this point, several treatment options are available. Both paroxetine(Drug information on paroxetine) and sertraline(Drug information on sertraline) are FDA-approved for the treatment of depression and PTSD in adults.^6,7 Sertraline (and quite possibly paroxetine) is safe in patients with cardiovascular illness.⁸ However, these agents have not been specifically evaluated for the treatment of PTSD in adults or children who are medically ill. Therefore, their use in this population, although reasonable, should be accompanied by a discussion of the limitations of current knowledge regarding the pharmacological treatment of PTSD in patients who are medically ill.

The use of pharmacological agents can be complicated by the fact that persons who are medically ill are frequently taking other medications, and the drug interaction profile between SSRIs and those medications may not always be known. Caution is recommended, especially when using other medications that are metabolized by the liver and have a narrow therapeutic window (such as valproic acid).

The blood levels of these medications can be affected by SSRIs. Therefore, if a patient is taking both preparations concomitantly, blood levels should be monitored regularly and frequently while the SSRI is being taken. Furthermore, insomnia or other somatic complaints may develop in patients who have PTSD, and it might be difficult to determine whether these complaints are related to PTSD or to the adverse effects of a medication.

When a somatic symptom develops in temporal relation to starting a pharmacological treatment for PTSD, the symptom should be assessed for severity and trauma-specific content (for example, nightmares about the traumatic event are more likely to be caused by PTSD, whereas insomnia without nightmares is more likely related to a medication side effect). Ultimately, it is up to the clinician and the patient to determine whether it is desirable to stop the medication or wait to see if the symptom subsides.

Some patients prefer medication treatment, whereas others prefer a nonpharmacological approach. Trauma- focused cognitive-behavioral therapy (CBT) with elements of relaxation and prolonged imaginary exposure is an example of the latter. Rachel was adamant about not using additional medication, but she agreed to participate in a once-a-week, 2-month-long course of trauma-focused CBT.

During this period, she was taught relaxation techniques and was asked to describe her traumatic experience (the first day of hospitalization) in detail, as though it were happening again. At first, she was unable to recall many details, but as she continued to talk about the experience over and over again, details emerged: it seems that she was aggressively treated to preserve the patency of her coronary arteries. During therapy, she was able to acknowledge that this approach led to quick recovery, but it was very confusing when she was in the emergency department and "everything happened at once." Through the act of repeatedly describing the experience, she became more comfortable with it and began speaking about her experiences and feelings to her friends. At the end of therapy, although she still did not like to think about the event, the nightmares had subsided, and her mood had improved.

Trauma-focused CBT that uses imaginary prolonged exposure is a highly effective treatment for PTSD in adults and children.^9,10 A recent randomized controlled trial of 284 female veterans⁹ showed that a protocol consisting of only 10 weekly sessions was effective in reducing PTSD symptoms to nondiagnosable levels in 41% of patients—an improvement that was significantly better than the 27% improvement experienced by the control group. Similarly, a randomized, controlled trial of 229 children who had posttraumatic stress as a consequence of child abuse found that a trauma-focused approach reduced not only symptoms of posttraumatic stress but also depression and behavioral problems.¹⁰ In addition, pilot data indicate that cognitive-behavioral approaches are safe and potentially useful in the specific treatment of PTSD in medically ill adults¹¹ and children.¹² As expected, trauma-focused CBT improves symptoms of depression in trauma survivors in general¹⁰ and in patients who are traumatized by their medical illness in particular.¹¹ Hence, it is appropriate to offer this treatment option to a traumatized patient with both depressive and PTSD symptoms.

In Rachel's case, this was an easy decision (she specifically requested a nonpharmacological approach). In other cases, when making the decision about which modality is preferable (pharmacotherapy or CBT), the following should be considered:

• Availability of a clinician who is familiar with trauma-focused CBT or with medication treatment for PTSD.
• The patient's motivation and ability to follow a structured CBT regimen (it is much easier to take a pill).
• The patient's age (trauma-focused CBT may not be appropriate for very young children; pharmacotherapy for PTSD is not approved for children of any age).
• Can the traumatic experience be characterized as a discrete event? (It would be hard to apply trauma- focused techniques to life circumstances that are distressing but are not specific events. For example, the experience of being debilitated may be very distressing but may not be associated with a specific traumatic event or occurrence. In such cases, the distress is probably better addressed using more general techniques, or medications.)

Combinations of several modalities of treatment have not been properly investigated. While they may ultimately prove to be the best way to treat PTSD, currently the combination of psychotherapy and psychopharmacotherapy in this setting should be considered experimental.

Is there anything that can be done to prevent the reemergence of posttraumatic symptoms in patients like Rachel before they actually need to go through another procedure that has previously proved traumatic? Although Rachel currently feels much better, it is possible that she will need recatheterization soon.

Medical illness-related traumas offer an opportunity that is rarely encountered in the general emotional trauma field, ie, the opportunity to engage in secondary and tertiary prevention. While it is not likely that a therapist will know in advance that a person is about to be raped (or injured), procedures such as scheduled cardiac catheterization or a transplant operation may be viewed as "scheduled traumas" that allow the treating physician to prepare the patient and parents or caregivers for the experience. What that preparation should entail is a matter of some debate.

Ongoing research is trying to elucidate what works and what does not seem to work in the medical emotional trauma-prevention model.¹³ There have been reports suggesting that propranolol(Drug information on propranolol), a ß-blocker, administered immediately after the trauma, may block the formation of traumatic memories¹⁴; however, it is currently premature to recommend this approach, except in the context of a clinical trial. The general recommendations in the Table might help reduce the traumatic impact of a procedure or a medical event.

With her consent, Rachel's cardiologist was informed about her symptoms and successful treatment. He promised to be aware of the importance of trying to prevent future traumatization by using the general approach delineated above and by being attuned to the importance of letting her play as integral a part as possible in determining the course of action in any further treatment decisions.