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1. Goals of Treatment

  • Reduce the severity of ASD or PTSD symptoms.

    • Assist the patient to better tolerate and manage the immediate distress of the memories of the traumatic experience(s) and to decrease distress over time.

    • Help reduce intrusive reexperiencing and psychological and physiological reactivity to reminders.

    • Reduce trauma-related avoidant behaviors, nightmares, and sleep disturbance.

    • Diminish anxieties related to fears of recurrence.

    • Reduce behaviors that unduly restrict daily life, impair functioning, interfere with decision making, and contribute to engagement in high-risk behavior.

  • Prevent or treat trauma-related comorbid conditions that may be present or that may emerge.

  • Improve adaptive functioning and restore a psychological sense of safety and trust.

    • Foster resilience and assist the patient in adaptively coping with trauma-related stresses and adversities.

    • Help identify and develop strategies to restore and promote normal developmental progression.

    • Limit the generalization of the danger experienced as a result of the traumatic situation(s).

  • Protect against relapse.

    • Help the patient anticipate symptomatic exacerbation resulting from exposure to reminders of trauma or loss, additional life stresses or adversities, subsequent encounters with situations of danger or trauma, or discontinuation of psychotropic medication.

    • Assist the patient in developing skills such as problem solving, emotional regulation, and the appropriate use of interpersonal support and professional help.

  • Integrate the danger experienced as a result of the traumatic situation(s) into a constructive schema of risk, safety, prevention, and protection.

    • Assist the patient in addressing the meaning of the trauma in terms of his or her life experience.

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2. Choice of Initial Treatment Modality

  • Treatment for the symptoms of ASD or PTSD involves three approaches either alone or in combination: psychopharmacology, psychotherapy, and education and supportive measures.

  • Consider pharmacological intervention to relieve overwhelming physical or psychological pain, impairing insomnia, or extremes of agitation, rage, or dissociation, especially for patients whose degree of distress precludes new verbal learning or nonpharmacologic treatment strategies.

  • Once the patient's safety and medical stabilization have been addressed, supportive psychotherapy, psychoeducation, and assistance in obtaining resources such as food and shelter and in locating family and friends are useful.

  • Consider

    • the patient's age and gender;

    • presence of comorbid medical and psychiatric illnesses;

    • propensity for aggression or self-injurious behavior;

    • recency of the precipitating traumatic event;

    • severity and pattern of symptoms;

    • presence of particularly distressing target symptoms or symptom clusters;

    • development of interpersonal or family issues or occupational or work-related problems;

    • preexisting developmental or psychological vulnerabilities, including prior traumatic exposure; and

    • the patient's preferences.

  • Attempt to minimize the risk for additional trauma and development or prolongation of PTSD through direct and vigorous treatment of underlying depression with psychotherapy, antidepressant pharmacotherapy, or both.

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3. Approaches for Patients Who Do Not Respond to Initial Treatment

  • Systematically review factors that may contribute to treatment nonresponse, including

    • the specifics of the initial treatment plan, including its goals and rationale;

    • the patient's perceptions of the effects of treatment;

    • the patient's understanding of and adherence to the treatment plan;

    • the patient's reasons for nonadherence if nonadherence is a factor; and

    • the potential for other psychological disorders or underlying personality traits to interfere with treatment.

  • One strategy for nonresponse is to augment the initial treatment with another, for example, by adding pharmacotherapy to psychotherapy, psychotherapy to pharmacologic intervention, or couples therapy to individual psychotherapy.

  • Exhaust first the treatments for which there is the best evidence of efficacy before trying more novel treatments.

  • In some cases, the original treatment may need to be discontinued and a different modality selected, as in the case of a patient who is too overwhelmed by anxiety to tolerate exposure therapy.

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4. Ethnic and Cultural Factors

  • Understand the importance of social and cultural dynamics, to avoid alienating the patient from his or her family and community.

  • Consider the cultural meaning of symptoms or illness and the cultural values of the patient and the patient's family.

  • Recognize that cultural context and societal views may affect development of symptoms and treatment response.

  • Consider cultural values in the patient's decision making about taking medication and adhering to medication regimens and other treatment.

  • When determining a pharmacologic treatment plan, understand that genetic polymorphisms in hepatic cytochrome P450 enzymes occur at varying frequencies across ethnic groups.

References

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