Treatment and prevention strategy of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a clinical phenomenon associated with severe stressors such as natural disasters, military operations, and terrorism.

The article “Posttraumatic stress disorder: from diagnosis to prevention” (Xue-Rong Miao et al, 2018) published an analysis based on more than 3000 sources from PubMed devoted to posttraumatic stress disorder.

As a rule, PTSD is diagnosed based on clusters of symptoms. The pathogenesis of the disorder is multifactorial and includes activation of the hypothalamic–pituitary–adrenal axis (HPA axis), immune responses, and genetic characteristics. The mechanisms leading to PTSD have not been fully elucidated. It is assumed that, in response to a stressor, the hypothalamic–pituitary–adrenal axis is activated, resulting in abnormal release of glucocorticoids and catecholamines. This subsequently causes immunosuppression with suppression of metabolic processes. Treatment and prevention methods are relatively heterogeneous and range from psychological interventions to pharmacological therapy.

Current approaches to PTSD treatment and prevention encompass multiple psychological and pharmacological methods, which can be divided into three groups:

• Primary prevention – before the traumatic event, including prevention of the event itself
• Secondary prevention – between the traumatic event and the development of posttraumatic stress disorder
• Tertiary prevention – after the first symptoms of posttraumatic stress disorder appear

While secondary and tertiary prevention offer numerous approaches, including pharmacological correction, primary prevention remains at an early stage of development.

Thus, primary prevention is mainly applicable to groups at risk of developing PTSD, such as military personnel, firefighters, rescue workers, and police officers. The basis of primary prevention is psychoeducation, which includes:

• Skills for responding to stress
• Methods for reducing anxiety
• Relaxation
• Coping strategies
• Identification of destructive thoughts and emotions
• Reduction of bodily tension
• Selection of an appropriate course of action
• Attention control
• Control of emotional regulation

More relevant information is available via Diagnosis and prevalence of posttraumatic stress disorder

The potential of pharmacological treatment is directed at addressing the consequences of stress, including memory formation after a stressful event. The following groups of medications are used:

• Drugs acting on the hypothalamic–pituitary–adrenal axis
• Drugs acting on the autonomic nervous system, particularly the sympathetic division: sympatholytic drugs such as alpha-blockers and beta-blockers
• Opiates
• Antidepressants – serotonin and norepinephrine reuptake inhibitors; monoamine oxidase inhibitors (MAO inhibitors)
• Antipsychotics
• Anticonvulsants
• Benzodiazepines

Among medications with a clinically demonstrated effect in reducing PTSD symptoms (Jonas DE et al, 2013), the following are used:

• Fluoxetine
• Paroxetine
• Sertraline
• Topiramate
• Risperidone
• Venlafaxine

Clinical trial data report that pharmacological treatment is most effective when initiated soon after exposure to the traumatic factor.

However, it should be noted that research in this field remains limited because of strict and complex ethical requirements.

Most guidelines on psychological interventions for PTSD recommend:

• Cognitive behavioral therapy
• Cognitive therapy
• Cognitive processing therapy
• Cognitive restructuring
• Coping skills therapy, including stress inoculation therapy
• Exposure-based therapies
• Eye movement desensitization and reprocessing (EMDR)
• Hypnosis and hypnotherapy
• Brief eclectic psychotherapy

Additional relevant facts are available via Psychedelic-assisted therapy for PTSD

Psychological methods may be applied individually with a patient as well as in groups or families of affected individuals. Thirty-two randomized controlled trials involving 2935 patients, with follow-up lasting up to 6 months (Kline AC et al, 2018), demonstrated a positive therapeutic effect of psychological methods compared with other treatment approaches. Comparative data on psychological and pharmacological treatments for PTSD are insufficiently convincing regarding the superiority of either method. In addition, data on adverse PTSD outcomes such as mortality, suicidal behaviors, self-harmful behaviors, and treatment discontinuation were relatively rare.

The diagnostic criteria for posttraumatic stress disorder remain complex and ambiguous, which is related to the still insufficiently understood phenomenon of PTSD. The principal mechanisms of PTSD reflect changes at different levels involving both psychological and organ-level modulation. From the treatment perspective, psychological and pharmacological methods offer substantial potential for a positive disease course, but require development of a systematic approach and improvement of symptomatic therapy. PTSD causes not only individual suffering for the patient but also disrupts family functioning and poses risks to society. Future research should focus on PTSD prevention, which could reduce the prevalence of the disorder and prevent the impact of PTSD consequences on families and society.

References

Miao XR, Chen QB, Wei K, Tao KM, Lu ZJ. Posttraumatic stress disorder: from diagnosis to prevention. Mil Med Res. 2018;5(1):32. Published 2018 Sep 28. doi:10.1186/s40779-018-0179-0

Author: Olena Vyrva, MD

Questions & Answers

Q1. What are the three levels of PTSD prevention described in the article?
Primary prevention takes place before a traumatic event, secondary prevention occurs between the event and development of PTSD, and tertiary prevention begins after the first PTSD symptoms appear.

Q2. What evidence for psychological interventions is described?
The article cites 32 randomized controlled trials involving 2935 patients with follow-up of up to 6 months that demonstrated a positive therapeutic effect of psychological methods compared with other treatment approaches. The available comparative evidence was insufficient to establish superiority of psychological versus pharmacological treatment.