PTSD, Criteria for PTSD

Here are the criteria associated with PTSD. I hope people find them useful.

(1) An experience that is outside the range of usual human experience and that would be markedly distressing to almost anyone (e.g., serious threat to one’s life or physical integrity; serious threat or harm to one’s children, spouse, or other close relatives and friends; sudden destruction of one’s home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence).

(2) The traumatic event is persistently reexperienced in at least one of the follow-ing ways:

(a) recurrent and intrusive distressing recollections of the event,
(b) recurrent distressing dreams of the event,
© sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and disso-ciative [flashback] episodes, even those that occur upon awakening or when intoxicated), or
(d) intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma.

(3) Persistent avoidance of things associated with the trauma or numbing of general responsiveness
(not present before the trauma), as indicated by at least three of the following:
(a) efforts to avoid thoughts or feelings associated with the trauma,
(b) efforts to avoid activities or situations that arouse recollections of the trauma,
© inability to recall an important aspect of the trauma,
(d) markedly diminished interest in significant activities,
(e) feeling of detachment or estrangement from others,
(f) restricted range of affect (e.g., unable to have loving feelings), and/or
(g) sense of a foreshortened future (e.g., does not expect to have a career, marriage, or children, or a long life).

(4) Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
(a) difficulty falling or staying asleep,
(b) irritability or outbursts of anger,
© difficulty concentrating,
(d) hypervigilance (e.g., being too cautious or "too wound up"),
(e) exaggerated startle response (e.g., being too jumpy), and/or
(f) physiologic reactivity upon exposure to events that symbolize or resem-ble an aspect of the
traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator).

Here is information on treating PTSD that I compiled from a couple of different sources. It gets a little deep, but for those who are interested, the extent of information might be useful and informative. Adapted from an article by: Jennifer Travis Lange; Christopher L. Lange; and Rex B.G. Cabaltica, M.D. and Francine Shapiro, PhD.

Treatment
The diagnosis and treatment of PTSD are complicated. The wide range of symptoms and intricate psychobiologic features make therapy difficult. The three arms of treatment are: 1) patient education, 2) pharmacotherapy, and 3) psychotherapy. Nearly every patient can benefit from education, which is started at the time of diagnosis.

If symptoms are severe enough to prevent effective trauma-focused therapy, pharmacotherapy may be warranted. Pharmacotherapy and psychotherapy have been shown to alleviate the three clusters of PTSD symptoms, which are: re-experiencing, avoidance, and hypervigilance.

Here is some specific information about drugs that are used to treat PTSD.

Serotonergic Agents
Studies have consistently shown that serotonergic dysregulation can create avoidance, hypervigilance and other associated symptoms. Selective serotinin reuptake inhibitors (SSRIs) have the broadest range of effectiveness—being able to reduce all three clusters of PTSD symptoms. In addition, these agents treat many diseases that often coexist with PTSD. Patients taking sertraline (Zoloft) have reduced alcohol consumption, and those taking fluvoxamine (Luvox) have had a reduction in obsessional thoughts and the elimination of insomnia. Trazodone (Desyrel) at doses of 50 to 200 mg has SSRI properties and serotonin blockade action. It reverses the SSRI-induced insomnia; augments the antidepressant effects of SSRIs; promotes sleep through its sedative properties; and suppresses rapid eye movement sleep, thus reducing the nightmares associated with PTSD.

Tricyclic Antidepressants
The effectiveness of tricyclic antidepressants in relieving symptoms of PTSD has been mixed. In several studies, their use resulted in modest lessening of the symptoms of re-experiencing and minimal or no effect on avoidance or arousal symptoms. Patients treated with tricyclic antidepressants have not shown greater improvement than those treated with SSRIs, so the newer agents have replaced the antidepressants in pharmacotherapy for PTSD.

Monoamine Oxidase Inhibitors
Monoamine oxidase (MAO) inhibitors irreversibly inhibit monoamine oxidase, the enzyme responsible for the degradation of serotonin and related molecules. They have been used primarily as an effective antidepressant for depression, but their use has been curtailed because of dangerous side effects when combined with chemicals in certain foods. Patients with PTSD who have received phenelzine (Nardil) have shown moderate to good improvement in re-experiencing and avoidance symptoms, but the drug has had little effect on the symptoms of hyperarousal (i.e., too much arousal). Insomnia ceases to be a problem in these patients, and they have a modest reduction in the frequency of nightmares. However, there are substantial risks with the use of these agents because patients with PTSD frequently ingest alcohol and other contraindicated or illegal substances.

Antiadrenergic Agents
Because autonomic hyperactivity may be a problem in patients with PTSD, antiadrenergic agents may be effective pharmacotherapy. Three agents in particular--Clonidine (Catapres), propanolol (Inderal) and guanfacine (Tenex), have successfully reduced nightmares, hypervigilance, startle reactions and outbursts of rage. Most patients respond to treatment with Clonidine, 0.2 mg three times a day, titrated from 0.1 mg at bedtime. Patients' blood pressures should be checked periodically when this agent is used for long-term therapy.

Benzodiazepines
Historically, benzodiazepines were the primary agent in PTSD treatment. Alprazolam (Xanax) and Clonazepam (Klonopin) have been used extensively, but the efficacy of benzodiazepines against the major PTSD symptoms has not been proven in controlled studies. These agents are effective against anxiety, insomnia and irritability, but they should be used with great caution because of the high frequency of simultaneous substance dependence in patients with PTSD. Patients should be fully informed of the risks and benefits of these medications, including the risks of dependency and of withdrawal after abrupt discontinuation.

Psychotherapy
Medications are used to relieve the most distressing symptoms, allowing the patient to concentrate on psychotherapy. Any medication regimen should be part of a psychotherapeutic process. Attention to a range of issues, including the effects on the family, education about the disease and treatment options, is paramount.

The goal of therapy is to break the pattern of self-defeat by reexamining the traumatic event and the patient's response to it. Education about the disease and recognition of cues or situations that trigger symptoms are invaluable. Improving the patient's coping mechanisms, such as relaxation techniques, can also foster the patient's relationships with others. PTSD can have devastating effects on the family, and family therapy may be warranted. Cognitive-behavioral therapy, group therapy, and stress-inoculation training (systematic desensitization) are helpful against re-experiencing and avoidance symptoms. Substance abuse programs, if needed, are vital before a patient engages in therapy. Formal psychotherapy is difficult in a brief office visit.

EMDR is another option for treating PTSD. EMDR stands for Eye Movement Desensitization and Reprocessing (EMDR) and integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies. EMDR is an information processing therapy and uses an eight-phase approach. During EMDR the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus. This sequence of dual attention and personal association is repeated many times in the session.

EMDR has been used successfully to treat: Sexual assault victims, victims of sexual dysfunction, clients at all stages of chemical dependency, pathological gamblers, and people with dissociative disorders, such as multiple personality disorder.

Initial Management
A prudent approach tailors each treatment plan to the needs of the patient. A good first-line treatment plan is thorough education about the disorder and enrollment of the patient into a local PTSD group. Any substance abuse issues should be addressed as an adjunct to therapy. Some PTSD symptoms are difficult for patients to tolerate, and rapid pharmacological treatment may be helpful. More than one class of medications may be needed to control the diverse symptoms. SSRIs are efficacious against the broadest range of symptoms, and the number of agents available helps to target patients' symptoms. Although a therapeutic response is usually evident in two to four weeks, any SSRI should be given a minimum of six to eight weeks at therapeutic dosages before it is declared a treatment failure. If insomnia continues to be a predominant complaint, Trazodone augmentation is a useful and safe alternative to sleep medications. Persistent insomnia accompanied by significant hyperarousal and re-experiencing symptoms should be treated with Clonidine. The major symptoms of PTSD can be alleviated with the combination of an SSRI, Trazodone, and Clonidine.

Prevention
Foa's brief prevention program has shown promise in reducing PTSD when started within 14 days of the trauma. Victims are educated about common responses to assault and taught breathing and muscle relaxation techniques. They are asked to confront their fear by reliving the assault, and their irrational beliefs about the trauma are challenged. Two months after the treatment, PTSD symptom severity in a treated group was one half that in a group whose symptoms were not treated. Ten percent of the treated subjects met criteria for PTSD, whereas 70 percent of untreated subjects still met the diagnostic criteria, demonstrating that early interventions substantially reduce symptoms of PTSD. Debriefing on the stress of the critical incident is a prevention method being used with more frequency for groups such as military personnel and victims of natural disasters. A group of participants discusses the important elements of a traumatic incident soon after it is over, verbalizing their emotions and examining their reactions to the witnessed events. Although long-term studies have not proven the efficacy of these stress debriefings in preventing PTSD, in the short term they have decreased anxiety and enhanced feelings of empowerment. Interventions should be undertaken as soon after the traumatic event as possible with empathic communication and confrontation of irrational beliefs, as needed. Because of the wide range of populations at risk and the many possible approaches to therapy, no one therapeutic approach has been proven the most effective for those who suffer from PTSD. Therefore, prevention and treatment must be tailored to the patient and the available community resources.

Hope people find this helpful.

Dr. Dave