Core symptom clusters of PTSD may respond to many of the same medications that are effective in depression. Moreover, these same antidepressants treat common comorbid conditions such as mood and other anxiety disorders. SSRIs are considered first-line medication treatments for PTSD and they are well tolerated.40 Tricyclic antidepressants and monoamine oxidase inhibitors may also help, with a norepinephrine-serotonin reuptake inhibitor also of potential benefit.41 In addition, anticonvulsants, atypical antipsychotics, α2-adrenergic agonists, and ß-adrenergic blockers as monotherapy or adjunctive therapy may improve symptoms.40 Various forms of cognitive and behavioral psychotherapies can desensitize patients to trauma memories and environmental triggers, with demonstrated efficacy in treating PTSD.40 Empirically supported treatments include exposure therapy42 as well as cognitive therapy,43 interpersonal psychotherapy,44 and prolonged exposure therapy.45,46 Stress inoculation and trauma-focused group therapies may also be useful.40
Formal guidelines for treating somatization disorder are lacking, although successful treatment with cognitive- behavioral therapy (CBT) has been demonstrated.47,48 In a randomized controlled trial of CBT compared with standard medical care and psychiatric consultation, findings showed significant improvement with CBT in somatization disorder, self-reported functioning, and somatic symptoms, with reduced health care costs.48 Mai49 suggests that CBT sessions have realistic treatment goals; foster coping with symptoms and limitations; and promote recreation, relaxation, and a sense of control and autonomy. It is also important to develop a treatment strategy for individuals with trauma histories who have many somatic complaints but who do not meet full criteria for somatization disorder. Walker and associates50 discussed a model for treating patients with multiple medically unexplained symptoms. This model minimizes referral to specialists and encourages clinicians to remain self-aware and to process common feelings of anger and resentment.
Keeping in mind that patients who have been traumatized may somatize to express psychic pain and to elicit a nurturing response in caretakers may help modulate physicians' countertransference, which is often born of frustration. Comprehensive treatment includes patient education, use of psychiatric consultants, and treatment of psychiatric illness and primary medical problems. Just as with somatization disorder, the patient with medically unexplained symptoms should be encouraged to develop stress management skills, social supports, and healthy behaviors. Medications for comorbid anxiety and mood disorders are indicated as described above, while avoiding medications with potential for abuse or dependence.
The following case illustrates successful use of a combination of support, drug therapy, and psychotherapy for a trauma survivor, provided by a primary care physician in cooperation with a psychiatrist.
Edna H, a 35-year-old disabled woman, presented for psychiatric care in 1999, 4 years after suffering loss of hearing in one ear and soft tissue injuries in the Oklahoma City bombing. Edna had a history of childhood physical abuse and neglect and reported an episode of mild, untreated depression in her 20s. In addition to having avoided treatment for bombing-related PTSD, major depression, and panic disorder, Edna had not followed up regularly with her primary care physician for preexisting polycystic ovary syndrome, borderline diabetes mellitus, and hypertension, as well as new-onset nonmigraine headaches and unexplained musculoskeletal pain. She believed that her primary care physician did not care about her and he reminded her of her abusing parent. She was referred to an internist whose medical practice included many patients with mental disorders and lifetime histories of trauma. After a protracted time during which trust was repeatedly tested and finally established with her psychiatrist and internist, she began to comply with treatments prescribed by both.
Edna experienced gradual improvement in her PTSD and depression with an SSRI and multimodal psychotherapy. At first a supportive approach built trust and improved stress management skills and socialization. Eventually, therapy combined a psychodynamic approach (exploring past abuse and ensuing trust issues triggered by terrorism and troubled relationships) with a cognitive-behavioral paradigm (identifying and reshaping automatic negative expectations of repeated traumatization as more positive relationships and goals were attained.) Her primary care physician medically managed her diabetes, hypertension, and polycystic ovary syndrome, and encouraged a diet and exercise program designed by Edna to enhance her sense of personal control. Musculoskeletal pain was evaluated but not found to have a medical cause. Edna recognized that her pain was often linked to stress related to trauma reminders and life frustrations. The primary care physician scheduled visits at regular intervals to reinforce health-promoting behaviors and did not refer her to specialists for unsubstantiated physical complaints. Although she did not return to work, Edna reported satisfaction in joining several charitable organizations, making lasting friendships, and pursuing a new hobby of photography.
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