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II. Formulation and Implementation of a Treatment Plan

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A. Initial Assessment

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1. Initial clinical approach to the patient

The timing and nature of initial assessments will be influenced by the type of the traumatic event (e.g., sexual assault versus natural disaster) and the scope of any destruction caused by the event. In large-scale catastrophes, the initial assessment may be the triage of individuals based on the presence of physical injury or psychological effects of the traumatic event, followed by the identification of individuals at greatest risk for psychiatric sequelae, including ASD or PTSD. Group interviews, consultation, or the administration of surveillance instruments may be part of this process. If local resources are overwhelmed by the catastrophe, psychiatric assessment will need to be prioritized so that the most severely affected individuals are seen first. Several self-rated and observer-based rating scales have been developed and validated to facilitate screening for possible PTSD; however, study of these scales in community-wide disasters with highly diverse populations has been limited. Such rating scales are most likely to be helpful after the acute event, when physical and cognitive functioning allow for a more complex assessment (16–18).

With individual traumas, the timing and nature of the first mental health contact may also vary. For individuals who have been sexually assaulted, for example, supportive psychological interventions may be initiated even before formal psychiatric assessment (e.g., use of educational materials on what to expect in the rape examination). In evaluations that occur shortly after exposure to the traumatic event, particularly in emergency settings, the initial clinical response consists of stabilizing and supportive medical care as well as supportive psychiatric care and assessment, including assessment of potential dangerousness to self or others. Addressing the individual's requirements for medical care, rest, nutrition, and control of injury-related pain is important for assuring the patient's physical health, enhancing the patient's experience of safety, and initiating the therapeutic relationship. Such interactions with trauma-exposed individuals will always entail sensitivity to the patient's wishes and to the changing symptoms, fears, and interpersonal needs that unfold after trauma exposure.

Whenever possible, care should be given within a safe environment. This may not be feasible after large-scale traumatic events in which there may be additional or ongoing exposures (e.g., earthquakes, war zones, ongoing gang warfare). With other types of traumatic events, further assurances of safety may be possible and necessary. For example, with traumatic events such as domestic violence, specific efforts or engagement of law enforcement or social service agencies may be needed to address the patient's safety and reduce the likelihood of repeat traumatization.

During the first 48–72 hours after a traumatic event, some individuals may be very aroused, anxious, or angry, whereas others may appear minimally affected or "numb" as a result of injury, pain, or dissociative phenomena (19). In triage or emergency department settings, an in-depth exploration of the traumatic event and the patient's experiences may increase distress but may be required for medical or safety reasons. For example, after physical or sexual assault, recounting events in response to the evaluator's questions or the mere gender of the evaluator may have a distressing effect in some individuals. Similarly, after an event involving death or injury to a family member, a clinician may need to obtain or disclose upsetting information, while gauging the patient's response as part of the evaluation. Insensitive or premature exploration of recent life-threatening events or losses can be counterproductive, leading the patient to avoid medical care, whereas other individuals may find in-depth exploration of recent events helpful. Therefore, evaluators must respond to the patient's needs and capabilities. After mass disasters, triage assessments in a group setting may be used effectively to identify those in need of intervention. However, discussion of distressing memories and events in heterogeneously exposed groups may adversely affect those with little or no exposure when they hear of the frightening and terrifying experiences of others.

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2. Assessing exposure to a traumatic event and establishing a diagnosis of ASD or PTSD

By definition, ASD and PTSD are psychiatric disorders consisting of physiological and psychological responses resulting from exposure to an event or events involving death, serious injury, or a threat to physical integrity. Events such as natural disasters, explosions, physical or sexual assaults, motor vehicle accidents, or involvement with naturally occurring or terrorist-related disease epidemics are examples of events that may elicit the physiological and psychological response required by the diagnostic criteria of ASD and PTSD. Thus, screening for acute or remote event exposure is a necessary first step in identifying persons with either ASD or PTSD.

Table 1 and Table 2 provide the full criteria for the diagnosis of ASD and PTSD, respectively. For both disorders, DSM-IV-TR defines criterion A as exposure to a traumatic event in which both of the following conditions are present:

  • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

  • The person's response involved intense fear, helplessness, or horror.

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Table Reference Number
Table 1. DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder (DSM-IV-TR code 308.3)a
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Table Reference Number
Table 2. DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder (DSM-IV-TR code 309.81)a

Thus, for both ASD and PTSD, establishing a diagnosis requires consideration of the individual's response to the event as well as the nature of the event itself. It is important to note that for some individuals, initial assessment may occur in a triage setting immediately after the trauma and before all symptoms related to the trauma exposure are manifest. In addition, the presence of dissociative symptoms may prevent patients from recalling feelings of fear, helplessness, or horror and may require that clinical judgment be used in determining whether criterion A for diagnosis has been satisfied (20–22).

Clinical evaluation for ASD or PTSD requires assessment of symptoms within each of three symptom clusters: reexperiencing, avoidance/numbing, and hyperarousal. In addition, to meet the diagnostic criteria for ASD, a patient must exhibit dissociative symptoms either during or immediately after the traumatic event. In PTSD, dissociative symptoms (e.g., inability to recall important aspects of the trauma) are not necessary to the diagnosis but are often observed.

By definition, ASD occurs within 4 weeks of the trauma and lasts for a minimum of 2 days. Consequently, it can be diagnosed within 2 days after the trauma exposure continuing to 4 weeks after the traumatic event. If symptoms are present 1 month after the trauma exposure, PTSD is diagnosed. Since diagnostic assessment may occur at any time following a traumatic event, the clinician must bear these essential distinctions in mind when evaluating the trauma-exposed individual.

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3. Additional features of the initial assessment

After it has been determined that the traumatically exposed individual is able to tolerate more extensive evaluation, it is important to obtain a detailed history of the exposure and the patient's early responses to the trauma as well as the responses of significant others. This history can provide important information for treatment and prognosis. Often, individuals provide negative responses to all-inclusive questions (e.g., "Have you ever been abused?"), and responses may also be affected by the timing and context of questioning. Consequently, it is helpful to ask more specific questions (e.g., "Have you ever been hit, beaten, or choked?") and attempt to elicit a history of trauma exposure at various points during the evaluation.

During the evaluation, the clinician obtains a longitudinal history of all traumatic experiences, including age at the time of exposure, duration of exposure (e.g., single episode, recurrent, or ongoing), type of trauma (e.g., motor vehicle accident, natural disaster, physical or sexual assault), relationship between the patient and the perpetrator (in cases of interpersonal violence), and the patient's perception of the effect of these experiences (on self and significant others). Other factors or interventions that may have intensified or mitigated the traumatic response should also be identified.

Clinical interviews may be combined with a variety of validated self-rated measures, including the PTSD Checklist (23), the Impact of Events Scale (24, 25) (available online at http://www.mardihorowitz.com), and the Davidson Trauma Scale (26), to assess the full range, frequency, and severity of posttraumatic symptoms and the related distress and impairment. Structured diagnostic interviews such as the Clinician-Administered PTSD Scale (27) and the Structured Interview for PTSD (28) have been used extensively in clinical research and are well validated instruments for the diagnosis of PTSD.

In addition, a complete psychiatric evaluation should be conducted in accordance with the general principles and components outlined in APA's Practice Guideline for Psychiatric Evaluation of Adults (29). These components include a history of the present illness and current symptoms; a psychiatric history, including a substance use history; medical history; review of systems and a review of prescribed and over-the-counter medications (including herbal products and supplements); personal history (e.g., psychological development, response to life transitions and major life events); social, occupational, and family history; history of prior treatments or interventions and their degree of success; mental status examination; physical examination; and diagnostic tests as indicated. Developmental and preexisting psychodynamic issues may make the patient especially vulnerable or reactive to a traumatic event. Old and dormant concerns may resurface and complicate or otherwise intensify the emotional response to a new trauma. Past exposure to traumatic events as well as previous patient and support network responses may affect the evaluation process and choice of and response to treatment. In the context of this complete psychiatric evaluation, certain areas of inquiry should receive additional attention and are described below. Table 3 summarizes the clinical domains relevant to the comprehensive assessment of ASD and PTSD.

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Table Reference Number
Table 3. Clinical Domains of Assessment for Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD)a
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a) Military and war-related traumatic event history

Evaluation of exposure to traumatic events during military service or in war-torn areas is an important and often difficult part of clinical assessment. Past exposure to war environments increases the probability of exposure to traumatic events. In addition, past exposures to traumatic events or past PTSD may increase the likelihood of current PTSD from a new exposure (31–34). Persons who come from nations with past or ongoing histories of war and war atrocities may have substantial exposure to traumatic events. Military support troops in rear areas as well as combat troops are vulnerable to attacks and other life-threatening experiences. Those serving in the military or involved in humanitarian assistance may have been massively exposed to death and the dead and can have high rates of ASD and PTSD. Military service members may also be involved in or witness training accidents, including motor vehicle accidents or aircraft crashes.

For those with military service, it is often helpful to begin the evaluation by exploring why the patient joined the military and what he or she hoped to do. Specific data to be gathered that can assist in the evaluation of traumatic event exposures include the length of service (and whether this length of time was broken or unbroken), the presence or absence of any disciplinary charges, and military awards received. The patient should also be asked if he or she was ever referred for alcohol or other substance use counseling, family violence counseling, or a psychiatric evaluation. If the patient had a family while in the service, it is important to explore the frequency and effects of family separation on the service member, the spouse, and the children. With service members or veterans who report having been in combat, a description of the location and the events should be obtained. It is often helpful to obtain copies of service records to verify combat exposures.

Witnessing atrocities, seeing the death of children, seeing friends killed and wounded, and feeling responsible for the death of a friend are especially disturbing elements of some combat and war environments for both military and civilian persons. As in all traumas, the recovery environment (that is, whether family, friends, and the nation are welcoming or ashamed) plays a large role in how the experience is recalled and managed. Some immigrants have previously lived in war zones or have served as members of military, paramilitary, or insurgent units before immigration. Some may also have been victims of torture, maltreatment, or rape as part of a war environment. Immigrants who may have served for regimes that espoused strong anti-American politics may fear repercussions from an unsympathetic country. These contextual issues require clear and supportive discussion in the evaluation and assessment in order to obtain necessary clinical information.

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b) Victims of crime and effects of legal system involvement

Individuals with ASD or PTSD may be involved in legal actions either because they are involved in a civil case (e.g., motor vehicle accident) related to their psychiatric condition or because they were a victim of a crime. Some individuals may express distress through a variety of symptoms that may abate after the conclusion of legal proceedings or payment of damages. This pattern may represent the effects of retraumatization resulting from exposure to a perpetrator or recollection of traumatic events during depositions, trial preparation, or testimony, followed by the (at times, only transient) sense of "closure" that these proceedings provide. If the perpetrator is incarcerated as a result of legal proceedings, symptoms may reoccur when the victim learns of the perpetrator's parole or release. Some persons may demonstrate waxing and waning symptoms regardless of the status of legal proceedings. Individuals may also fabricate or embellish symptoms. By raising the possibility that secondary gain, symptom exaggeration, or malingering may be part of the clinical picture, these factors can complicate assessment and treatment planning, as well as research (35). Confidentiality can also be compromised if the treating psychiatrist is in a dual role and is also required to communicate with members of the legal system. Some of the complexity of these cases can be managed by having the treatment and forensic evaluations performed by different psychiatrists, if possible (36, 37). As noted in DSM-IV-TR, the psychiatric assessment should address the possibility of malingering in situations in which financial remuneration or benefit eligibility is at issue or when forensic determinations play a role in establishing the diagnosis of PTSD. Determining the temporal course of symptoms relative to the timing of legal initiatives is helpful in this process (38).

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c) Identification of ASD and PTSD in the presence of common comorbid conditions

In patients who present for evaluation after a traumatic event, exacerbations or relapse of preexisting comorbid disorders may occur and require evaluation and treatment (see Section III.D, "Medical and Other Psychiatric Comorbidity") (39, 40). Exacerbations or relapse of preexisting PTSD may also occur with subsequent traumas or reminders of trauma.

For many individuals who have experienced a traumatic event but are presenting with other clinical needs, the diagnosis of ASD or PTSD may be missed entirely without a detailed evaluation. For example, individuals hospitalized on medical or surgical services after motor vehicle accidents, severe burns, or other major physical trauma have high rates of symptomatic distress, including ASD or PTSD, that often go unrecognized (34, 41–44). Patients with serious mental illness are exposed to high rates of physical assault and sexual abuse as well as other traumas (45–49). Mental health clinicians may fail to obtain this information unless they specifically inquire (50). Seriously mentally ill persons also have higher rates of PTSD (47–49, 51), compared to the general population (5). Individuals with psychotic disorders (48) and with borderline personality disorder (50, 52–54) are particularly likely to have experienced victimization in childhood and in adulthood. The associated PTSD often goes unrecognized. Histories of victimization and PTSD are also common among individuals with substance-related disorders (55–58) and eating disorders (59–61). In addition, family members—particularly spouses—who present with symptoms of bereavement after the traumatic loss of a family member should be assessed for PTSD (62).

High rates of comorbid psychiatric and other medical diagnoses are observed in those with ASD and PTSD. For a number of reasons, the medical and neurological effects of traumatic events may not be immediately apparent. Acute psychological responses to trauma such as dissociation may also diminish the initial experience of physical pain. In the presence of overwhelming anxiety and distress, individuals may not be able to describe their mental and physical state to medical professionals in an articulate fashion. Individuals exposed to traumatic events, particularly events that include interpersonal assault and violence, can find the motives of well-intentioned evaluators suspect. Without the establishment of trust, patients may be unwilling or unable to provide a complete medical or psychiatric history.

Patients with PTSD often have comorbid major depressive disorders, anxiety disorders, and substance use disorders (use of alcohol, tobacco, and other substances). Physical complaints, which may result from injury, may also represent comorbid somatization disorder or other somatoform disorders (12, 63). Similarly, patients with preexisting personality disorders or maladaptive character traits, as well as those with unresolved psychodynamic developmental concerns or histories of childhood traumatic events, may be at higher risk for an accentuated response to further traumatic events. In the presence of prominent depressive symptoms, social withdrawal and avoidance may be increased, and suicide risk may be heightened. Thus, identification and treatment of comorbid psychiatric and other medical illnesses is important to an integrated treatment plan that addresses all of the patient's needs and contributes to recovery from PTSD.

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B. Principles of Psychiatric Management

Psychiatric management consists of a broad array of interventions and activities that may be instituted by psychiatrists for patients who have been exposed to extreme trauma. The specific components of psychiatric management that appear to mitigate the sequelae of trauma exposure and that are important to the treatment of patients with ASD or PTSD are described in more detail below.

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1. Evaluating the safety of the patient and others

As with all psychiatric patients, for patients exposed to trauma it is crucial to assess the risk for suicide and nonlethal self-injurious behavior as well as the risk for harm to others. Details of suicide assessment and estimation of suicide risk are described in APA's Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (64). Although many factors have been associated with an increased risk of suicide attempts and suicide in groups of individuals, it is not possible to predict suicide in a given individual at a given point in time. Nonetheless, a number of factors should be taken into consideration in evaluating and estimating the patient's potential for self-injury or suicide.

In assessing suicide risk, it is essential to determine whether the patient has had thoughts of death, self-harm, or suicide, and the degree to which the patient intends to act on any suicidal ideation, the extent of planning or preparation for suicide, and the relative lethality of any suicide methods that the patient has considered. The availability of the means for suicide, including firearms, should also be explored, and a judgment should be made concerning the lethality of those means.

Risk for suicide and for suicide attempts is also increased by the presence of previous suicide attempts, including aborted attempts. Thus, if a patient has a history of previous suicide attempts, the nature of those attempts should be determined. Individuals who experienced childhood abuse and who may have PTSD as a result of that experience sometimes exhibit self-harming behavior that is often repetitive but occurs in the absence of suicidal intent (65, 66). Such behavior may progress to more serious forms of nonlethal self-harm but also confers an increased risk of suicidal behaviors. Patients should also be asked about suicide in their family and recent exposure to suicide or suicide attempts by others.

Depression, substance use, panic attacks, and severe anxiety are commonly present in individuals with ASD or PTSD and are associated with increased risk for suicide and suicidal behaviors. Other factors that deserve specific attention in individuals with ASD or PTSD include the presence of dissociative symptoms; high levels of shame or stigma (e.g., after rape); loss of family, friends, or employment as a result of the traumatic event; specific neurovegetative symptoms, including insomnia or weight/appetite loss; social withdrawal; social or cultural isolation with relocation or immigration; and preexisting psychological issues, personality traits, or patterns of coping that may indicate a heightened response to a specific trauma. Individuals who feel trapped within an inescapable and abusive relationship (e.g., situations involving domestic violence, marital rape, or child abuse) or who anticipate continued, imminent exposure to traumatic experiences or stimuli may be more likely to act on suicidal ideas. An association has also been observed between the number of previous traumatic events and the likelihood that an individual will attempt suicide (67, 68). Thus, a complete assessment of suicidal risk should be individualized to the particular circumstances of the patient and should also include an evaluation of the patient's strengths, social support, and motivation to seek help (69–71).

Less is known about the risk factors for harm to others in the context of PTSD. Nonetheless, it is important to assess thoughts, plans, or intentions of harming others as part of the psychiatric evaluation. As with assessment of suicide risk, it is important to determine whether firearms or other lethal weapons are available that could be used for harming others. The presence of hallucinations, persecutory delusions about a particular individual or group, or the feeling of being trapped in a dangerous, abusive, and inescapable situation may augment risk of dangerousness to others.

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2. Determining a treatment setting

Treatment settings for patients with ASD or PTSD include the full continuum of levels of care. Treatment should be delivered in the setting that is least restrictive, yet most likely to prove safe and effective. In determining the appropriate treatment setting, multiple patient-specific factors are considered: symptom severity, comorbidity, suicidal ideation or behavior, homicidal ideation or behavior, level of functioning, and available support system. The determination of a treatment setting should also include consideration of the patient's personal safety, ability to adequately care for him- or herself, ability to provide reliable feedback to the psychiatrist, and willingness to participate in treatment. Here also, an important consideration is the patient's ability to trust clinicians and the treatment process; this ability may be limited as a consequence of traumatic events themselves, cultural barriers, or other factors. The choice of treatment setting and the patient's ability to benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment, as efficacy does not necessarily increase with increasing duration of treatment in a specific setting or level of care (72).

For the majority of individuals with ASD or PTSD, treatment on an outpatient basis is the most appropriate treatment setting. However, some patients, particularly those with comorbid psychiatric and other medical diagnoses, may require treatment on an inpatient basis. Patients who exhibit suicidal or homicidal ideation, plans, or intention require close assessment and monitoring. Hospitalization is generally indicated for patients who are considered to pose a serious threat of harm to themselves or others. If such patients refuse admission, they may be hospitalized involuntarily when their condition meets local jurisdictional criteria for emergency detention or involuntary hospitalization. Severely ill patients who lack adequate social support outside a hospital setting should also be considered for hospital admission, residential treatment, or participation in an intensive outpatient or day treatment program. For severely ill patients with repeated hospitalizations related to nonadherence, assertive community treatment may also be considered.

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3. Establishing and maintaining a therapeutic alliance

The therapeutic alliance is important and at times challenging to establish with patients who have experienced traumatic events.

Attention to the physician-patient interaction is important, even in settings such as emergency departments where the clinician may have only a single contact with the patient. Although more than 80% of victims of recent sexual or physical assault surveyed in an emergency department setting indicated interest in further mental health treatment (73), other studies have indicated that those with PTSD underuse or avoid mental health services (74). A positive experience may also make the patient more receptive to future evaluation or follow-up.

Evaluation and treatment should always be conducted with sensitivity and in a safe environment that facilitates the development of trust. The presence of ASD or PTSD may challenge the clinician's ability to ensure that the patient feels safe in the therapeutic relationship. Clinicians must acknowledge the patient's worst fears about reexposure to intolerable traumatic memories and recognize that treatment itself may be perceived as threatening or overly intrusive. The patient is often relieved when the therapist indicates that talking about traumatic life events can be distressing and that the patient will decide how deeply to explore the difficult events and feelings. This suggestion of flexibility helps the patient to maintain or restore a sense of control, which is often lost after exposure to traumatic events. In chronic PTSD, avoidant/numbing behaviors may have been present for many years or decades. Therefore, clinicians must be patient and ensure that therapy proceeds at a tolerable pace.

Many other components of the treatment of ASD and PTSD also require trust in the doctor-patient relationship as well as particular attention to the therapeutic alliance. Effective treatment of both of these disorders requires that patients understand educational or treatment plans and return for follow-up assessment and treatment. In addition, successful treatment may require patients to tolerate intense affect and/or disruptive or unpleasant medication side effects. To establish and maintain a therapeutic alliance, it is important for the psychiatrist to address the patient's concerns as well as treatment preferences. Developing a therapeutic alliance with a patient who has experienced significant traumatic events—particularly in childhood—may require considerable psychotherapeutic effort and require lengthening of treatment. Cultural factors may also impose barriers to developing a therapeutic relationship, since many non-Western cultures do not value traditional Western psychiatric interventions. Management of the therapeutic alliance also includes awareness of transference and countertransference issues, even if these issues are not directly addressed in treatment (75).

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4. Coordinating the treatment effort

Providing optimal treatment for patients with ASD and PTSD may require a team approach involving the coordinated effort of several clinicians. Patients may have a wide variety of comorbid psychiatric and/or physical disorders that need to be addressed. Family intervention or coordination of support services is often needed. One team member must assume the primary overall responsibility for the patient's treatment. This individual serves as the coordinator of the treatment plan, advocates for the appropriate level of care, oversees the family involvement, makes decisions regarding which potential treatment modalities are useful and which should be discontinued, helps assess the effects of medications, and monitors the patient's safety. Because of the diversity and depth of medical knowledge and expertise required for this oversight function, a psychiatrist may be optimal for this role, although this staffing pattern may not be possible in some health care settings. Ongoing coordination of the overall treatment plan is enhanced by clear role definitions, plans for the management of crises, and regular communication among the clinicians who are involved in the treatment. If team members work collaboratively with each other, with the patient, and with the patient's family and other social supports, the treatment has a better chance of helping the patient distinguish safe from dangerous and potentially retraumatizing situations, develop self-monitoring skills and coping strategies for anxiety states related to reminders of his or her trauma, avoid abusive relationships, minimize alcohol and other drug misuse, and control impulsive, aggressive, or self-destructive behaviors.

Those who have experienced an acute traumatic injury or assault often require ongoing medical attention. Collaborating with physicians who are providing additional medical treatment to the patient is an important part of psychiatric treatment. Individuals with PTSD also often have high rates of somatic and somatoform (i.e., medically unexplained) symptoms that are not directly related to the traumatic event but that prompt visits to primary care physicians (76–79). In such settings, collaboration between the psychiatrist and the primary caregiver may facilitate appropriate medical assessment and management.

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5. Monitoring treatment response

During treatment, different features and symptoms of the patient's illness may emerge or subside. Monitoring the patient's status for the emergence of changes in destructive impulses toward self or others is especially crucial. For patients whose risk of such behaviors is found to be increased, additional measures such as hospitalization or more intensive treatment should be considered. Emergence of new symptoms, significant deterioration in functional status, or significant periods without response to treatment may suggest a need for diagnostic reevaluation. The psychiatrist should be particularly vigilant for comorbid medical conditions or substance-related disorders, for the emergence of symptoms such as interpersonal withdrawal or avoidance, and for the development or progression of symptoms of other disorders, including anxiety disorders or major depression.

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6. Providing education

For persons who seek care after traumatic events, it is helpful to provide education concerning the natural course of and interventions for ASD and PTSD as well as for the broad range of normal stress-related reactions. The APA Disaster Psychiatry web site (http://www.psych.org/disasterpsych/) provides educational materials and links to other online resources. Education should also be given to involved family members or significant members of the patient's support network. It is important to help patients understand that their symptoms may be exacerbated by reexposure to traumatic stimuli, perceiving themselves to be in unsafe situations, or remaining in abusive relationships and that they can learn methods for better managing their feelings when they are reminded of the traumatic event. Emphasizing that ASD and PTSD are conditions for which effective treatments are available may be crucial in educating patients who attribute their illness to a moral defect or in educating family members who are convinced that nothing is wrong with the patient. Education regarding available treatment options can also help patients (and family members) make informed decisions, anticipate side effects, and adhere to treatment regimens.

For individuals or groups whose occupation entails likely exposure to traumatic events (e.g., military personnel, police, firefighters, emergency medical personnel, journalists), ongoing educational efforts may decrease exposure to trauma (by reducing risk behaviors) or improve the likelihood that an individual in need will seek care. Awareness of the predictable initial psychological and physiological responses to traumatic events may also be reassuring when these responses occur and may vitiate new fears or expectations of disability. Such education can also aid in the accurate identification and support of colleagues who develop symptoms of ASD or PTSD (80, 81).

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7. Enhancing adherence to treatment

For patients who develop chronic PTSD, a long or indefinite duration of treatment may be needed. During acute exacerbations, patients with chronic PTSD may be easily discouraged and unduly pessimistic about their chances of recovery. In addition, the side effects or requirements of treatments may lead to nonadherence. Patients with PTSD who appear to have achieved a stable and positive clinical response and those who appear to have recovered from ASD may exhibit sudden relapse when new events reactivate traumatic concerns and fears about the safety of their families or themselves. For patients involved in ongoing litigation related to the traumatic event and subsequent impairment, legal proceedings may similarly reactivate concerns or emotions surrounding the event and its aftermath. The patient's motivation for participating in PTSD treatment may also be altered by ongoing legal actions. Psychiatrists should recognize these possibilities, address them in therapy, and encourage the patient to discuss any concerns regarding adherence, personal safety, or reexposure to traumatic reminders.

Medication adherence may be improved by emphasizing to the patient 1) when and how often to take the medicine, 2) the expected time interval before beneficial effects of treatment may be noticed, 3) the necessity to take medication even after feeling better, 4) the need to consult with the physician before discontinuing medication, and 5) steps to take if problems or questions arise (82). Some patients, particularly those who are elderly, have achieved improved adherence when both the complexity of the medication regimen and the cost of treatments are minimized. Severe or persistent problems of nonadherence may represent psychological concerns, psychopathology, or disruptions in the doctor-patient relationship, for which additional psychotherapy should be considered. Family members who are supportive of medication and/or other treatment can also play an important role in improving adherence. Although models of care such as assertive community treatment have not been specifically studied in individuals with PTSD, they have demonstrated efficacy in decreasing symptom severity, reducing length of hospitalization, and improving living conditions in individuals with serious and persistent mental illness (83–86). Consequently, such approaches may be useful in improving adherence in individuals with PTSD who have repeated hospitalizations related to nonadherence, particularly in the presence of significant psychiatric comorbidity.

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8. Increasing understanding of and adaptation to the psychosocial effects of the disorder

While trauma itself often results in detrimental social, familial, academic, occupational, and financial phenomena, further effects may also stem from the symptoms of ASD or PTSD and may perpetuate these illnesses. For example, if one loses employment as a result of a disaster or because of missed work secondary to symptoms of ASD, the additional stressor of unemployment may increase the risk of developing PTSD (87). Consequently, the psychiatrist should assist the patient in addressing issues that may arise in various life domains, including family and social relationships, living conditions, general health, and academic and occupational performance, and help the patient to consider options that may be available to address such problems (e.g., consideration of alternative school or work schedules, other vocational options, financial or social supports). Working in collaboration with patients to set realistic and achievable short- and long-term goals can be useful. Patients can increase their sense of self-worth through achieving these goals, thereby reducing the demoralization that exacerbates or perpetuates illness. It may also be important to help the patient with ASD or PTSD obtain clinical assistance for family problems or for family members who may themselves require clinical intervention. Patients who have children may need help in assessing and meeting their children's needs, both during and in the wake of acute episodes.

Resilience has been alternately defined (by various researchers) as an individual trait or quality, an outcome, or a process. The concept of resilience may also encompass the ability to negotiate psychosocial and emotional changes after trauma exposure and in this way increase recovery possibilities. However, studies to date have identified no universal resilience factor or outcome (88, 89). Barnes and Bell (90) suggested that factors involved in resilience include 1) biological factors (intellectual and physical ability, toughness), 2) psychological factors (adaptive mechanisms such as ego resilience, motivation, humor, hardiness, and perceptions of self; emotional attributes such as emotional well-being, hope, life satisfaction, optimism, happiness, and trust; cognitive attributes such as cognitive styles, causal attribution such as an internal locus of control and blame, world view or philosophy of life, and wisdom), 3) spiritual attributes, 4) attributes of posttraumatic growth, 5) social attributes (interpersonal skills, interpersonal relationships, connectedness, and social support), and 6) environmental factors such as positive life events and socioeconomic status. Some studies show that optimism can buffer the effects of life stress (91–97) and enable some individuals to mobilize protective factors such as adaptive coping skills, increased self-efficacy, ways of reinterpreting adverse experiences in a positive manner, and strategies for seeking social support (98–101). Although no published studies have assessed the effect of optimism training on the development or outcome of ASD or PTSD, a school-based community-wide screening followed by psychosocial intervention was able to effectively identify and reduce disaster-related trauma symptoms and facilitate psychological recovery in children (102). Thus, efforts to improve psychosocial functioning and resilience may help to minimize symptoms and enhance recovery and remission.

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9. Evaluating and managing physical health and functional impairments

Because ASD and PTSD are often the result of physically traumatic events, they are frequently associated with physical health problems and with functional impairments. Other mechanisms (e.g., hyperarousal, hypothalamic-pituitary-adrenal [HPA] axis dysregulation, poor self-care) may contribute to this association (103). In those who have experienced a trauma, medical problems may affect many aspects of health. Consequently, the presence, type(s), and severity of medical symptoms should be monitored continuously. Medical symptoms, symptoms of ASD or PTSD, and psychosocial or interpersonal relationship problems are each associated with impairments in a patient's ability to function. For such impairments to be addressed, level of functioning should also be assessed on an ongoing basis. For example, some patients may require assistance in scheduling absences from work or other responsibilities, whereas others may require encouragement to avoid major life changes during intensification of symptoms.

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C. Principles of Treatment Selection

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1. Goals of treatment

The goals of treatment for individuals who have experienced a traumatic event and have received a diagnosis of ASD or PTSD include the following:

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a) Reduce the severity of ASD or PTSD symptoms

Treatment aims include reducing the patient's overall level of emotional distress as well as reducing specific target symptoms that may impair social or occupational function. In general, the clinician attempts to 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. In addition, the clinician works to enhance the patient's ability to discriminate trauma cues and reminders from the original traumatic experience(s) by promoting adaptive coping with reexperiencing states and instilling the belief that the current response to triggers results from recall of a past danger that is no longer present. Thus, the aim of treatment is to prevent, ameliorate, and promote recovery from the presumed neurobiological alterations associated with ASD and PTSD. Symptom-specific goals include helping the patient reduce intrusive reexperiencing, psychological and physiological reactivity to reminders, trauma-related avoidant behaviors, nightmares and sleep disturbance, and anxieties related to fears of recurrence. Other targeted goals include reducing behaviors that unduly restrict daily life, impair functioning, interfere with decision making, and contribute to engagement in high-risk behavior.

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b) Prevent or reduce trauma-related comorbid conditions

Little is known about the effects of comorbid disorders on the course of ASD. Depression, substance abuse, and other conditions can impede recovery in PTSD and carry additional risks for psychiatric morbidity and functional impairment (4, 104). Medical disorders and somatic complaints are also common in war veterans (79, 105, 106) and persons with a history of sexual abuse (107–114). Thus, a major goal of treatment is to prevent secondary disorders and to appropriately diagnose and treat other concurrent conditions when present.

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c) Improve adaptive functioning and restore or promote normal developmental progression

ASD and particularly PTSD are associated with a range of functional impairments in various areas of daily life (10, 12, 115–122). In addition to interventions that may be needed to address such impairments, related goals are to foster resilience and assist patients in adaptively coping with trauma-related stresses and adversities.

Traumatic experiences at any stage in the life cycle may impede the normal developmental progression. Posttraumatic stress symptoms can curtail current developmental achievements (for example, in dating, friendship, marriage, parenthood, educational achievement, occupational advancement, and retirement). Fears of event or symptom recurrence, avoidant behaviors, and restrictions on interpersonal life can also lead to lost developmental opportunities. As patients recover from PTSD, a therapeutic goal is to help identify and develop strategies to restore and promote normal developmental progression.

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d) Protect against relapse

The course of acute and posttraumatic stress reactions can vary with symptomatic exacerbation relating to reminders of trauma or loss, additional life stresses or adversities, subsequent encounters with situations of danger or trauma, or discontinuation of psychotropic medication (123). Relapse prevention assists patients in anticipating such situations and in developing skills such as problem solving, emotional regulation, and the appropriate use of interpersonal support and professional help.

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

The danger or consequences associated with the original traumatic experience can skew personal beliefs, expectations, and constructs about the future, the risks of life, and safety. In addition, patients often search for the meaning of their life experience. The treatment of PTSD may include strategies to assist patients to constructively address these issues. As PTSD often evolves into a chronic illness, the meaning of the precipitating trauma in terms of its connections to past experience and its effects on subsequent perceptions of self-worth and interpersonal relationships may need to be addressed. Psychodynamic approaches and other psychotherapies may facilitate this integration (124–127).

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2. Choice of initial treatment modality

Patients assessed within hours or days after an acute trauma may present with overwhelming posttraumatic physiological and emotional symptoms that would appear to prevent or severely limit psychotherapeutic interchanges. Such presentations do not necessarily indicate impending development of ASD or PTSD. However, pharmacological intervention to relieve overwhelming physical or psychological pain, impairing insomnia, or extremes of agitation, rage, or dissociation may restore baseline function or may be a useful temporizing measure as the clinician monitors for the development of additional symptoms and considers additional psychotherapeutic intervention and/or medication treatment.

Treatment of ASD or PTSD symptoms includes three broad categories of intervention: pharmacological treatment, psychotherapeutic intervention, and education and supportive measures. While cognitive and behavior therapies and pharmacological intervention (particularly with SSRIs) have reasonable clinical evidence to support their efficacy in treating the core symptoms of PTSD (see Section II.D, "Specific Treatment Strategies"), few direct comparisons of specific interventions or studies of combinations of support/education, pharmacological intervention, and psychotherapies are available. Nonetheless, consensus suggests that several factors, including the presence of specific target symptoms and individual patient characteristics, may guide decisions regarding initial treatment; these factors are reviewed in Section II.D, "Specific Treatment Strategies".

For patients with ASD as well as for those without overt symptoms, single-session individual debriefing does not prevent PTSD and may impede recovery (128, 129). In ASD, early after a trauma, once the patient's safety and medical stabilization have been addressed, supportive psychotherapy, case management, and assistance in obtaining resources such as food or shelter are useful (130, 131). Furthermore, in contrast to the findings for debriefing, there is no evidence to suggest that early supportive care is harmful (131–134). Preliminary evidence also suggests that ASD patients may be helped by cognitive behavior psychotherapy that incorporates exposure (135–137). Although there are few studies of pharmacological interventions in patients with ASD, treatment with SSRIs and possibly other antidepressants may represent reasonable initial clinical interventions.

In individuals with PTSD, evidence from randomized, controlled trials supports both psychotherapeutic and medication-based approaches to initial treatment. SSRIs are recommended as first-line medication treatment for PTSD, and other antidepressants may also be beneficial. In terms of psychotherapies, cognitive behavior therapy is an effective treatment for core symptoms of acute and chronic PTSD. EMDR is also effective. Stress inoculation, imagery rehearsal, and prolonged exposure techniques may also be employed in treating PTSD as well as associated symptoms such as anxiety and avoidance. The use of psychodynamic psychotherapy in treating PTSD is supported by a considerable number of descriptive studies and process-to-outcome analyses as well as substantial clinical experience. It may be useful in addressing developmental, interpersonal, or intrapersonal issues that may be of particular importance to social, occupational, and interpersonal functioning. It also appears to be useful in addressing the patient's changes in beliefs, world expectations, generalization of threat experiences to other life events, and attempts to find meaning in her or his experience. Interpersonal issues that develop as a result of ASD or PTSD, including changes in interpersonal relationships, fears, avoidance, loss of trust, anger and aggression, and increasing generalization of fears and threat, should also be addressed psychotherapeutically.

The presence of a comorbid psychiatric disorder may also guide initial intervention. For example, substance misuse is a common concomitant of ASD or PTSD and signals a need for specific treatment for substance use disorder. In addition, individuals who are depressed may be at greater risk for further exposures to trauma. For example, when domestic partner violence is ongoing, low self-esteem or decreased energy accompanying depression may produce increased violence in the abusive partner or inadequate self-protective efforts in the patient. Thus, direct and vigorous treatment of underlying depression with psychotherapy and/or specific antidepressant pharmacotherapy may minimize the risk for additional trauma and development or prolongation of PTSD.

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3. Approaches for patients who do not respond to initial treatment

Because of the paucity of high-quality evidence-based studies of interventions for patients with treatment-resistant PTSD, treatment nonresponse cannot be addressed algorithmically. However, a systematic review of the factors that may be contributing to treatment nonresponse is possible. Since the initial treatment plan will have detailed each selected treatment, the rationale for its use, and the goals for treatment outcome, a review of this initial plan of care should help determine the extent to which therapeutic goals have been met. If interventions have been introduced sequentially, it will be easier to discern their individual effects. In reviewing the original plan, the clinician should explore with the patient which (if any) symptoms have improved, worsened, or remained the same. It is also important to determine whether the patient understands the plan and is adhering to it and, if nonadherence is present, the reasons for nonadherence. For example, has the patient failed to do homework assignments or discontinued medications or skipped doses because of side effects or financial difficulties? The potential of other psychological disorders or underlying personality traits to interfere with the treatment should be reconsidered and addressed as needed. The therapist should inquire about any new psychosocial or other environmental factors that may be hindering therapy, such as a conflict at work or with family members.

If it appears that the therapist-patient relationship is not at issue and that the patient is adhering to the treatment, the therapist should explore other options. One strategy for nonresponse is to augment the initial treatment with another—for example, adding pharmacotherapy to psychotherapy, psychotherapy to a pharmacological intervention, or couples therapy to an individual psychotherapy. Generally, the therapist should first exhaust 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. Because most therapies used for the treatment of PTSD or ASD are also indicated for other psychiatric conditions, a review of the literature on strategies for improving response in those situations may also be helpful. However, there are limited data to guide the clinician in the treatment of patients with treatment-resistant PTSD and ASD, and, at present, clinical judgment must prompt the selection of one path rather than another.

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D. Specific Treatment Strategies

Since patients with a diagnosis of ASD or PTSD experience a broad and complex range of symptoms, caring for patients with these disorders involves an array of approaches and should include consideration of the biopsychosocial diversity of the patient's clinical presentation. When choosing a specific strategy to treat ASD or PTSD, it is important to consider the weight of scientific evidence supporting each treatment option as well as the limitations of the current evidence base. There have been relatively few double-blind, randomized, controlled trials of treatments for patients with PTSD and even fewer such trials for patients with ASD. Many promising results still require replication, and some interventions that are commonly used, based on extensive clinical experience and consensus, have yet to be examined in more methodologically rigorous studies. In the studies that are available, treatment and follow-up durations are typically short, sample sizes are frequently small, and the possibility of a placebo response is often inadequately addressed (138). Furthermore, measured outcomes have often concentrated on more readily quantifiable changes in specific symptoms rather than focusing on the diagnosis of ASD and PTSD per se or on important short- and long-term outcomes such as social, occupational, and interpersonal functioning.

It is also likely that responses to specific treatments may differ depending on the type of trauma experienced (e.g., acute versus ongoing or cumulative, natural disaster versus interpersonal violence, community-wide versus individual traumatic event, presence versus absence of simultaneous physical injury) and the timing of treatment relative to the occurrence of the traumatic event. Since ASD, by definition, occurs in the 4 weeks immediately after a traumatic event, studies of treatment interventions during this period should be considered as treatment of ASD and potentially as preventive strategies for PTSD. Treatment strategies for symptoms occurring between 1 and 3 months after trauma exposure (acute PTSD) may be different than those for symptoms occurring (or reoccurring) more than 3 months after the traumatic event(s) (chronic PTSD), although the differential efficacies of specific strategies for treating acute versus chronic PTSD have not been well studied. Throughout the first 3 months after a traumatic event, recovery is the general rule (139), and this natural recovery period may extend up to 6 months (34, 140). Here, the clinician is guided by the expectation of recovery, the relief of suffering, and the use of interventions to speed recovery and to prevent additional exposure to the traumatic event, chronicity of symptoms, and relapse.

In choosing a specific treatment strategy, consideration should also be given to the patient's age, gender, and previous history (e.g., developmental history, past traumatic experiences, substance use disorders, other psychiatric diagnoses), current comorbid medical and psychiatric illnesses, propensity for aggression or self-injurious behavior (see Section III, "Specific Clinical Features Influencing the Treatment Plan"), or other factors that may vary widely across individuals. Although systematic study of these factors is rare, clinical experience suggests that these factors may also necessitate modification of the individual treatment plan. Specific treatment strategies should be selected to target the symptoms or symptom clusters (i.e., reexperiencing, avoidance/numbing, or hyperarousal) that are most disruptive for the patient and to take into account the time interval between trauma exposure and symptom development. Personality style and family interactions may affect symptom expression, persistence, or exacerbation.

Treatment for the symptoms of ASD or PTSD involves three approaches either alone or in combination: psychopharmacology, psychotherapy, and education and supportive measures. To date, no psychotropic medications have been developed specifically for use in ASD or PTSD. Therefore, in clinical practice and in pharmacotherapy research, medications have been used in doses similar to those recommended or approved for other psychiatric illnesses. While the clinical evidence to date for each of these interventions is limited, the efficacy of combinations of education/support, psychotherapy, and psychopharmacology has been even less well characterized. Clinical practice and consensus support combinations of these approaches based on several factors, such as specifically identified target symptoms, psychiatric and other medical comorbidity, and the patient's preferences. Medication therapy may also be initiated to address symptoms (e.g., physical pain, agitation, severe insomnia, or psychosis) that might otherwise limit the efficacy of psychotherapy. The sections that follow summarize specific psychopharmacological, psychotherapeutic, and educational and supportive approaches to the treatment of ASD and PTSD. Where efficacy has been established to a greater degree with regard to particular symptoms or clinical features or at particular time intervals after the trauma exposure, these findings are highlighted.

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1. Psychopharmacology
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a) SSRIs

Evidence from several large randomized, double-blind controlled trials suggests that SSRIs are first-line medication treatment for both men and women with PTSD (123, 141–147). There are four reasons that SSRIs are the current medications of choice for PTSD: 1) they ameliorate all three PTSD symptom clusters (i.e., reexperiencing, avoidance/numbing, and hyperarousal), 2) they are effective treatments for psychiatric disorders that are frequently comorbid with PTSD (e.g., depression, panic disorder, social phobia, and obsessive-compulsive disorder), 3) they may reduce clinical symptoms (such as suicidal, impulsive, and aggressive behaviors) that often complicate management of PTSD, and 4) they have relatively few side effects.

Reductions in the severity of core PTSD symptoms have been shown with fluoxetine, sertraline, and paroxetine in studies that were of relatively short duration (8–12 weeks) and included predominantly women with chronic PTSD resulting from rape or assault (123, 141–146, 148). While symptom reduction was generally observed within 2–4 weeks of treatment, symptoms of anger and irritability were reduced within the first week (149). In studies of fluoxetine, improvement in arousal, numbing, and avoidance (but not reexperiencing) and overall response were greater in women than in men. Other studies have demonstrated efficacy for these agents in intrusive, avoidance/numbing, and arousal symptoms. Smaller open-label studies of fluvoxamine have shown efficacy in sleep-related symptoms (including nightmares) in combat veterans (147, 150). Head-to-head comparisons between any of the SSRIs for ASD or PTSD symptoms have not been published; however, clinical consensus holds that these agents differ primarily in their pharmacokinetics, metabolic effects on other medications, and side effects rather than in their efficacy in treating ASD or PTSD.

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b) Tricyclic antidepressants and MAOIs

Studies of tricyclic antidepressants demonstrated efficacy for amitriptyline and imipramine (151, 152) but not desipramine (153). With the MAOIs, limited data suggest the efficacy of phenelzine and brofaromine (an MAOI available in Europe) (154, 155). In all of the trials, subjects were primarily male combat veterans, which limits the generalizability of findings. There do not appear to be studies of the effects of either MAOIs or tricyclic antidepressants specifically in women with PTSD or ASD.

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c) Benzodiazepines

While benzodiazepines can reduce anxiety and improve sleep, their efficacy in preventing PTSD or treating the core symptoms of PTSD has been neither established nor adequately evaluated (156, 157). Concerns about addictive potential in individuals with comorbid substance use disorders may prompt additional caution regarding the use of benzodiazepines. Worsening of symptoms with benzodiazepine discontinuation has also been reported (158). However, in a naturalistic study of more than 300 veterans with PTSD and comorbid substance abuse, treatment with benzodiazepines was not associated with adverse effects on outcome (159).

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d) Anticonvulsants

Open-label studies of divalproex, carbamazepine, and topiramate have demonstrated mixed or limited efficacy with regard to specific symptom clusters of PTSD (160–162), but these studies, as well as a single controlled trial of lamotrigine (163), have indicated benefit with regard to the reexperiencing symptoms.

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e) Antipsychotics

Psychotic symptoms are not included in the diagnostic criteria for either ASD or PTSD. Nonetheless, patients with these illnesses may also experience psychotic symptoms as part of a comorbid disorder. Before initiating antipsychotic treatment, careful diagnostic evaluation is required to appropriately address the potential contributions of delirium, dementia, primary thought disorders, brief psychotic reactions, delusional disorder, substance abuse, closed head injury, or other comorbid general medical conditions. Preliminary studies of the second-generation antipsychotic agents olanzapine (164–166), quetiapine (167), and risperidone (168) in patients with PTSD suggest a potential role for these medications in pharmacological treatment, particularly when concomitant psychotic symptoms are present or when first-line approaches have been ineffective in controlling symptoms.

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f) Adrenergic inhibitors

The α2-adrenergic agonists decrease central adrenergic activity and have been proposed for the treatment of PTSD. Preliminary evidence from small open-label studies has shown possible benefits with prazosin (169) and with clonidine in combination with imipramine (170). However, there have been no published controlled studies of these agents to date.

While β-adrenergic blockers are at times prescribed for PTSD (171) and have been used in the treatment of performance anxiety, there have been no controlled studies of these agents for PTSD. Preliminary results suggest that acute administration of propranolol after trauma may reduce some later symptoms of PTSD (137, 172). Further controlled studies are necessary to evaluate this practice before it can be considered a part of the therapeutic armamentarium.

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2. Psychotherapeutic interventions
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a) Cognitive and behavior therapies

Cognitive behavior therapy in ASD or PTSD targets the distorted threat appraisal process (in some instances through repeated exposure and in others through techniques focusing on information processing without repeated exposure) in an effort to desensitize the patient to trauma-related triggers. Distinctions may be drawn between psychotherapies that focus principally on aspects of cognitive processing and those that emphasize behavioral techniques. However, aspects of both are frequently combined, and studies that identify the effective components of these therapies or that distinguish one from another are not available. A course of cognitive behavior therapy generally begins with education about the symptoms of the disorder, as well as a rationale for asking the patient to recall painful experiences and relaxation training. After the therapist assesses the patient's ability to tolerate within-session anxiety and temporary exacerbations of symptoms, the patient is led through a series of sessions in which the traumatic event and its aftermath are imagined and described, and the patient is asked to focus on the negative affect and arousal until they subside. Reassurance and relaxation exercises aid the patient in progressing through these sessions, and homework assignments allow the patient to practice outside the sessions or while confronting triggers of anxiety (specific places or activities) in vivo (125, 173, 174). A limited number of well-designed studies demonstrate some success not only in speeding recovery but also in preventing PTSD when cognitive behavior therapy is given over a few sessions beginning 2–3 weeks after trauma exposure (135, 173, 175–178). Both stress inoculation and prolonged exposure techniques have demonstrated efficacy in women with PTSD resulting from assault or rape (179–181). Prolonged exposure (through imaginal and in vivo exposure to avoided situations associated with previous trauma) has been shown to be effective, particularly in the PTSD-associated symptoms of anxiety and avoidance (179, 182). However, several studies have noted that exposure may increase rather than decrease symptoms in some individuals (178, 183). Stress inoculation training involving breathing exercises, relaxation training, thought stopping, role playing, and cognitive restructuring has also proven effective alone and in combination with prolonged exposure in reducing PTSD symptoms (179). Survivors of rape, crime victims, and combat veterans have demonstrated improvement in overall PTSD symptoms and nightmares in response to imagery rehearsal (i.e., imaginal prolonged exposure) (184, 185). Clinical improvement (but not recovery) was also demonstrated in a group of PTSD patients with diverse trauma exposures who received either imaginal exposure or cognitive behavior therapy (186, 187). In group settings, cognitive processing therapy designed to correct distortions related to threat appraisal and safety through a facilitated study of the patient's written narrative of his or her traumatic experience has shown promise (188). Most of these trials have been short-term, and the extent to which improvement is maintained over time has not been assessed through follow-up study.

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b) Eye movement desensitization and reprocessing (EMDR)

EMDR is a form of psychotherapy that includes an exposure-based therapy (with multiple brief, interrupted exposures to traumatic material), eye movement, and recall and verbalization of traumatic memories of an event or events. It therefore combines multiple theoretical perspectives and techniques, including cognitive behavior therapy. Some point to the use of directed eye movements as a feature markedly distinguishing this form of therapy from other cognitive behavior approaches. Others point to the fact that traumatic material need not be verbalized; instead, patients are directed to think about their traumatic experiences without having to discuss them. Like many of the studies of other cognitive behavior and exposure therapies, most of the well-designed EMDR studies have been small, but several meta-analyses have demonstrated efficacy similar to that of other forms of cognitive and behavior therapy (189–192). Studies also suggest that the eye movements are neither necessary nor sufficient to the outcome (193–195), but these findings remain controversial (196, 197). Although it appears that efficacy may be related to the components of the technique common to other exposure-based cognitive therapies, as in the previously described cognitive behavior therapies, further study is necessary to clearly identify the effective subcomponents of combined techniques. Follow-up studies are also needed to determine whether observed improvements are maintained over time.

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c) Psychodynamic psychotherapy

Psychodynamic therapy has, from its beginnings, been concerned with responses to traumatic events (198–200). There is an extensive body of research that includes descriptive designs, process-to-outcome correlational studies, and case studies. However, randomized, controlled research on psychodynamic psychotherapy in patients with ASD or PTSD is extremely limited. One controlled trial of psychodynamic therapy versus hypnotherapy or desensitization versus no therapy showed all interventions were superior to the control condition (no treatment) in decreasing avoidance and intrusive symptoms (201). Other controlled trials of hypnotherapy for ASD or PTSD have not been published, but descriptive studies and clinical consensus support its use—by appropriately trained individuals—in reducing symptoms of anxiety associated with acute distress and traumatic event cues and as a nonpharmacological adjunctive approach to anxiety reduction (202). A meta-analysis of controlled psychotherapy trials (including the study by Brom et al. [201]) also suggested the efficacy of hypnosis—particularly at the end of therapy (203).

The clinical research and narrative-based literatures on psychodynamic psychotherapy outline two major approaches to the treatment of traumatic stress disorders. The first views an individual's defenses and coping skills as a product of his or her biopsychosocial development and focuses on the meaning of the trauma for the individual in terms of prior psychological conflicts and developmental experience and relationships, as well as the particular developmental time of the traumatic occurrence(s). This approach examines the person's overall capacity to cope with memories of traumatic event(s) and their triggers and the coping style he or she uses to manage these memories (204, 205). The second approach focuses on the effect of traumatic experience on the individual's prior self-object experiences, overwhelmed self-esteem, altered experience of safety, and loss of self-cohesiveness and self-observing functions and helps the person identify and maintain a functional sense of self in the face of trauma (206, 207). Both approaches appear to be useful in addressing the subjective and interpersonal sustaining factors of the illness (e.g., shattered assumptions about attachments, issues of trust), as well as the changes in beliefs and world view and the widely altered threat perceptions often seen in chronic PTSD (21, 208, 209). Psychodynamic psychotherapists employ a mixture of supportive and insight-oriented interventions based on an assessment of the individual patient's symptoms, developmental history, personality, and available social supports as well as an ongoing assessment of the patient's ability to tolerate exploration of the trauma (210, 211). In chronic PTSD, issues of transference are often explored to help the patient understand conscious and unconscious concerns surrounding the meaning of recent and more remote traumatic events in his or her life as they appear in the treatment (212). Awareness of countertransference is a central component of treatment of traumatic experience in psychodynamic psychotherapy and in other therapies. The therapist's emotional response on hearing the patient describe the traumatic events can either facilitate or disrupt the therapeutic alliance, making ongoing attention to countertransference of particular importance in treating patients with ASD and PTSD.

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d) Psychological debriefing

Psychological debriefing was developed as an intervention aimed at preventing the development of the negative emotional sequelae of traumatic events, including ASD and PTSD. This staged, semistructured group (or, as often administered, individual) interview and educational process includes education about trauma experiences in general and about the chronological facts of the recently experienced traumatic event and exploration of the emotions associated with the event. Since debriefing has received considerable publicity, it may be expected (or specifically requested) by leaders or managers when a group confronts disaster. In the military, for example, group debriefings have been used as a means for describing normative responses to trauma exposures and educating individuals about pursuing further assistance if symptoms persist or cause significant dysfunction or distress. However, well-controlled studies of debriefing that have used single-session, individual, and group debriefing have not demonstrated efficacy (128, 129, 213–216). Although some trauma survivors have reported that they experienced such debriefings as helpful, there is no evidence at present that establishes psychological debriefing as effective in preventing PTSD or improving social and occupational functioning. In some settings, it has been shown to increase symptoms (217–219). Its use may be most problematic with groups of unknown individuals who have widely varying trauma exposures or when it is administered early after trauma exposure, before safety and decreased arousal are established. Immediately after exposure, persons may not be able to listen attentively, absorb new information, or appreciate the nuances of the demands ahead in a manner that promotes recovery (220, 221). Also, in heterogeneous groups, some individuals will be increasing their exposure through group participation and obtain no added support after the group session, thereby potentially increasing their likelihood of later distress (19).

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3. Psychoeducation and support

Supportive interventions are often used as the control intervention in studies of more specific treatments. However, clinical experience indicates that both support and psychoeducation appear to be helpful as early interventions to reduce the psychological sequelae of exposure to mass violence or disaster. When access to expert care is limited by environmental conditions or reduced availability of medical resources, rapid dissemination of educational materials may help many persons to deal effectively with subsyndromal manifestations of trauma exposure. Such educational materials often focus on 1) the expected physiological and emotional response to traumatic events, 2) strategies for decreasing secondary or continuous exposure to the traumatic event, 3) stress-reduction techniques such as breathing exercises and physical exercise, 4) the importance of remaining mentally active, 5) the need to concentrate on self-care tasks in the aftermath of trauma, and 6) recommendations for early referral if symptoms persist. Encouraging persons who are acutely traumatized to first rely on their inherent strengths, their existing support networks, and their own judgment may reduce the need for further intervention. Although the efficacy of these measures alone in prevention of ASD or PTSD is unproven, emphasis on self-reliance and self-care should augment other strategies when and if they become necessary.

Table Reference Number
Table 1. DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder (DSM-IV-TR code 308.3)a
Table Reference Number
Table 2. DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder (DSM-IV-TR code 309.81)a
Table Reference Number
Table 3. Clinical Domains of Assessment for Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD)a

References

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