Posttraumatic Stress Disorder and 9-11 (cont.)

In addition, stress inoculation training, a variant of exposure therapy, can be used for the management of anxiety. This therapy includes relaxation. It also involves carefully monitoring the patient's thoughts that follow from thinking about the traumatic event. Then, when thoughts of the trauma do occur, the patient uses a script that was created in therapy to attempt to change their thoughts that follow thinking about the trauma. At first, the patients may even need to imagine themselves as someone else (role playing) to bring about this change in their thought pattern. But then, the role-playing gradually becomes the reality.

Other types of therapy that are useful for anxiety are visualization techniques and confidence builders, such as positive self-talk and social skills training. In visualization techniques, patients train themselves to recall and visualize a particularly peaceful or pleasant place or situation whenever thoughts of the trauma occur.

Other avoidance symptoms, referred to as numbing, include emotional unresponsiveness, detachment from others, and loss of interest in life's pleasures. For the treatment of numbing, most experts recommend the cognitive therapies, psychodynamic psychotherapy, and peer group support. In fact, numbing symptoms are among the most difficult symptoms to treat. For these symptoms, peer group support is extremely important.

The medications

In terms of medications, all types of PTSD symptoms, except sleep disturbance, will respond to the selective serotonin reuptake inhibitors (SSRIs) and other related drugs. The only drug with an approved (by the Food and Drug Administration, FDA) indication for posttraumatic stress disorder at this time is the SSRI, sertraline (Zoloft). If the patient also suffers from bipolar disorder (manic depressive), a mood stabilizer, such as lithium or divalproex sodium (Depakote), should be added. For sleep disturbance, trazodone (Desyrel), zolpidem (Ambien), or nefazodone (Serzone) are often recommended.

The results of treatment and the follow-up

Most people suffering from a posttraumatic syndrome should expect a good response to treatment within 3 months, as long as they do not have another severe psychiatric illness, substance abuse, depressive disorder, bipolar disorder (manic depressive), or other maladaptive personality disorders, such as antisocial personality disorder.

After the initial 3 months of treatment, acute PTSD can be treated with group or individual psychotherapy booster sessions every 2 to 4 weeks. Chronic PTSD patients should be seen regularly for at least six months with booster sessions. However, a small percentage of patients with PTSD, especially those with another associated psychiatric disorder, remain quite symptomatic for longer periods of time. For acute PTSD, the duration for continuing medication before considering tapering is 6 to 12 months. For chronic PTSD with a good response, we can consider tapering medication at 1 to 2 years. However, patients with chronic PTSD with residual symptoms need to continue treatment for at least 2 years.

Summary and conclusions

There are events that occur to us as children or adults that are so overwhelming and inherently frightening that they cause transient (temporary), and in some cases, permanent changes in our physical and psychological responses to stress. Thankfully, most of us have a relatively non-traumatic childhood and do not suffer many traumas as adults. However, when there is a significant traumatic event, everyone can expect to be temporarily overwhelmed and develop at least some of the symptoms of posttraumatic stress disorder.

Others, however, may be more biologically (inherently or genetically) vulnerable, have a history of more trauma, or are more directly and/or deeply affected by the trauma. Still, these people usually will have transient (temporary) symptoms of posttraumatic stress syndrome that can be managed and treated effectively. In fact, in many cases, PTSD can be cured. The treatment includes early management (intervention), supportive critical incident stress debriefing, group and peer rapport, targeted psychotherapy (for most patients, exposure therapy, anxiety reduction, and cognitive therapy), and medications, especially SSRI's, such as sertraline.

Nevertheless, there is another small percentage of people who develop a more chronic (long duration) PTSD. Some of them may also develop other associated psychiatric disturbances that complicate the clinical picture of PTSD and make their full recovery more challenging. Finally, it is somewhat comforting to know that the various methods of treatment are highly effective and that there are trained clinicians experienced at handling the difficult problems of posttraumatic stress. But, of course, we hope that we will never have to experience a repeat of the traumatic tragedy of September 11th.

Medical Author: Peter J. Panzarino, Jr. M.D. F.A.P.A.
Medical Editor: Leslie J. Schoenfield, MD, PhD
Last Editorial Review: 4/3/2002



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