10 Factors to Consider When Assessing PTSD

Mr. B required systematic medication changes over 2 years, with a final regimen of 15 mg of prazosin and 30 mg of mirtazapine daily at bedtime plus 300 mg of sertraline and 50 µg of levothyroxine sodium daily (based on exacerbations of comorbid anergic depression correlated with high-normal thyroid-stimulating hormone levels of 3.5 to 4.5 mIU/L from a baseline of 1 to 2.4 mIU/L). With this regimen, nightmares stopped and he slept 7 to 8 hours for the first time in decades. The improvement in sleep and depression permitted in vivo exposure therapy that reduced first avoidance behavior and secondarily anger and hypervigilance. He has remained essentially well now for more than 3 years, even with current doses of 200 mg of sertraline, 15 mg of mirtazapine, and 5 mg of prazosin.

Ms. A’s treatment consisted of psychoeducation about the nature of PTSD followed by prolonged exposure, as well as extensive cognitive-processing therapy that addressed “survivor guilt.” After nearly 2 years, she came to accept her child’s death; recovered from her self-blame; and her depression, hypervigilance, and avoidance improved. Sleep improved with trazodone once her avoidance and hypervigilance responded to exposure. Venlafaxine, 225 mg daily, provided more benefit than SSRIs.

While (randomized controlled trials (RCTs) are generally 6-12 weeks long, continued improvement over 6 months may be seen with medication; over the long term, changes with medication may lead to changes in benefit from TF-CBT and vice versa.

Substance use disorders: treat PTSD concomitantly, especially sleep-related hyperarousal with prazosin and onset insomnia with trazodone or mirtazapine; mood disorders: may justify initiation of antidepressant or mood stabilizer before TF-CBT; medical conditions: may require ongoing collaboration with primary care providers, particularly when injuries resulted from the index trauma that also led to PTSD.

Consider work-up for primary sleep disorder: OSA, restless legs, RBD; monitor and address sleep complaints at initiation: prazosin for nightmares and sleep-related hyperarousal; trazodone, mirtazapine, or other non-benzodiazepine hypnotics for onset insomnia; CBT for insomnia, particularly for those with fear of sleep.

Make treatment decision based on cause of trauma: TF-CBT or medication, exposure, CPT, peer support group, antidepressant; some patients may prefer to adapt their lifestyles to the persisting effects of their trauma, including avoidance; some patients can translate the effects of their traumatic experience into actions to change public policy, protect others, etc.

Dissociation: unclear differential treatment implications; psychosis: atypical antipsychotic augmentation and antidepressant; complex PTSD: multimodal, staged treatment usually starting with practical and for some (eg, refugees), cultural adaptations.

The effect of increasing trauma severity on more severe symptoms and worsened functional outcome persisted over a 14-year period in one study of combat PTSD.

Fewer RCTs comprise combat veterans, but compared with civilian trauma, military sexual trauma does not reduce likelihood of treatment response; PTSD associated with childhood abuse has been least specifically studied in medication trials; patients with multiple traumas may require longer treatment with more nuanced interventions.

Address issues such as survivor guilt; disillusionment in combat veterans; mental “defeat” in relation to domestic violence.

For more information, see Treatment-Resistant PTSD, by Ralph J. Koek, MD, on which this slideshow is based.