Post-traumatic stress disorder (PTSD) is a psychological condition precipitated by an extremely stressful event or series of events in which the individual experiences intense fear, horror, and/or a feeling of helplessness. Examples of such traumas include assaults, accidents, mass disasters, and combat. In PTSD, the stressful feelings are re-experienced in the presence of stimuli associated with the event(s), causing the individual to avoid such stimuli. It is distinguished from a normative stress reaction by its severity, high chronicity and comorbidity, and alterations in underlying neurochemical and neuroendocrine substrates.

PTSD is a significant public health problem, since exposure to at least one traumatic event is estimated to occur in 5% to 35% of the United States population annually. The lifetime prevalence of the disorder itself is believed to be about 8% and may range up to more than 50% in high-risk groups such as combat veterans. Onset of symptoms may be delayed months or even years after the traumatic event(s).

During a traumatic event, dissociative alterations of perception and cognition commonly occur. These alterations in thought process and perceptions remain in the person who develops PTSD. Research suggests that stress precipitates the corticolimbic release of glutamate and may have persistent effects on brain function and behavior, including dissociative symptoms. Electroencephalographic studies suggest sensory, cognitive, and affective processing abnormalities.

• Environment conducive to experiencing trauma, such as battle conditions or a high-crime neighborhood
• Employment in a high-risk occupation such as firefighting or law enforcement
• Psychiatric history preceding the traumatic experience
• Inadequate social support system
• Women exhibit PTSD at twice the prevalence rate of men.

• Intrusive thoughts recalling the traumatic event
• Nightmares
• Flashbacks
• Avoidance of trauma-related stimuli
• Dullness displayed in general responsiveness
• Lack of motivation
• Depression
• Feelings of guilt (e.g., about actions during combat or "survivor guilt" after a disaster)
• Startled reactions
• Irritability
• Poor concentration
• Hypervigilance
• Insomnia

• Normative stress reaction
• Generalized anxiety disorder
• Panic disorder
• Phobic disorders
• Obsessive-compulsive disorder

Psychometric assessment tools include:

• Impact of Event Scale (IES)
• Clinician Administered PTSD Symptom Scale (CAPS; PSS)
• Clinical Global Impression-Severity scale (CGI-S)
• Clinical Global Impression-Improvement scale (CGI-I)
• Davidson Trauma Scale (DTS)

Treatment for PTSD includes one or more of the following:

• Behavioral therapy—interventions include flooding and systematic desensitization; flooding consists of persistent exposure of the patient with PTSD to the aversive stimulus she is avoiding primarily through imagery which ultimately extinguishes the fear response; systematic desensitization refers to pairing a relaxation response with exposure to the aversive stimulus, resulting ultimately in inhibition of the fear response.
• Cognitive-behavioral therapy—leads to acquisition and maintenance of coping skills by changing the patient's dysfunctional thinking or cognitive appraisal about a traumatic event.
• Psychodynamic therapy—the patient learns to reconcile the occurrence of the traumatic event with her concepts of both the self and the world; this is achieved by reexperiencing the trauma in a supportive environment and gaining insight into the conscious and unconscious meaning of the symptoms.
• Pharmacotherapy may be considered.

• Either selective serotonin reuptake inhibitors (e.g., sertraline 25 mg/day for 1 week, followed by 50 to 200 mg/day thereafter depending on response and tolerance; alternatively, fluoxetine, fluvoxamine, or paroxetine) or monoamine oxidase inhibitors seem to be most effective.
• Anxiolytic drugs may be helpful but are generally not as effective for PTSD as they are in other anxiety disorders.

As discussed earlier, a conventional treatment that includes behavioral, cognitive and psychodynamic methods, is the predominant treatment approach for PTSD. The following modalities may also be considered:

• Eye Movement Desensitization and Reprocessing (EMDR)—value for PTSD suggested compared to no treatment; unclear if this confers any benefit compared to conventional treatment.
• Biofeedback—some merit suggested by a small scale randomized controlled clinical trial (RCT); more research is warranted.
• Hypnotherapy—case reports and RCT suggest the usefulness of this modality for PTSD.
• Acupuncture—case reports of its value; more research for use in PTSD is needed
• Kava kava—an herb that has anxiety-reducing properties and, therefore, may have therapeutic value for PTSD patients; although use for this specific disorder has not yet been tested or published.

EMDR Treatment

According to Cahill et al., EMDR was initially developed to treat symptoms associated with PTSD (Cahill et al. 1999). Similar to behavioral therapy described earlier, EMDR uses an "exposure-based" approach, requiring the client to confront an aversive stimulus (Sherman 1998). A main component of EMDR therapy involves guiding the patient to make several sets of deliberate lateral eye movements while recalling a traumatic incident. One of the earliest controlled studies evaluating EMDR, by Shapiro (1989), drew a favorable conclusion; however, that trial has been widely criticized for lack of methodological rigor (Cahill et al. 1999).

A recent critical review of the scientific literature considers several different questions including: "does EMDR work" and, if so, "compared to what?" According to the authors, conclusions about efficacy vary by study design (Cahill et al. 1999):

• Compared to no treatment, EMDR showed benefit in reducing indices of distress with relatively enduring positive effects (up to 15 months). The studies that demonstrate the most benefit evaluate patients experiencing a specific trauma (e.g. rape victims) as opposed to all causes of PTSD; this approach leads to greater similarities in the subjects at baseline and, perhaps, reduction of confounding variables.
• In comparison to three nonvalidated treatments for PTSD (including active listening, relaxation training with or without biofeedback, and image habituation training (IHT) in which the patient listens to a taped recording of the traumatic event for one hour each day as a form of exposure therapy), EMDR appeared to be more effective than the treatments mentioned.
• Despite the encouraging findings compared to no or nonvalidated treatments, EMDR has not yet been compared favorably to independently validated approaches such as cognitive behavioral therapy. In one randomized controlled clinical trial, PTSD patients receiving EMDR did significantly worse than those receiving Trauma Treatment Protocol (TTP) (a variant of cognitive behavioral therapy). In addition, post-treatment follow-up at 3 months showed that the TTP group maintained or increased symptomatic improvement while the effectiveness of EMDR decreased over that time course (Devilly and Spence 1999). There may be other ongoing research to try to more fully address this question (Cahill et al. 1999).

Biofeedback-assisted Desensitization Treatment

A randomized controlled study of 16 PTSD patients (all Vietnam combat veterans with a seven-year history of PTSD) showed that electromyographic biofeedback-induced desensitization (EMG-D) could be effective in relieving:

• Anxiety
• Muscle tension
• Recurring nightmares
• Flashbacks

The treatment group continued to show less anxiety, fewer nightmares and flashbacks, and enhanced coping with remaining flashbacks after two years. During the same time period, hospital readmissions were less frequent among the treatment group (Novey 2000).

In a randomized, uncontrolled study, thermal biofeedback and deep breathing were not shown to be superior to simple relaxation in 90 Vietnam veterans with PTSD. The three treatments groups were:

• Relaxation only
• Relaxation and deep breathing
• Relaxation, deep breathing, and thermal biofeedback

While relaxation instruction demonstrated modest therapeutic benefits, adjunctive thermal biofeedback training and/or deep breathing did not increase improvement (Watson et al. 1997).

Hypnosis 

Hypnotic techniques have long been used for treatment of war-related post-traumatic conditions, although more recent applications include cases of sexual assault (including rape), anesthesia failure, Holocaust survivors, and car accidents (Cardena 2000). Because hypnosis induces a state of deep relaxation, applications for PTSD seem possible including:

• Behavioral modification
• Reduction of anxiety
• Reframing traumatic events

A randomized, controlled study of 112 patients, for example, demonstrated positive benefits from hypnotherapy compared to systematic desensitization and psychodynamic therapy. Although only about 60% of patients showed clinically significant improvements from any therapy, hypnosis and systematic desensitization were both useful for decreasing intrusive thoughts (Brom et al. 1989). A case report further suggests that hypnosis may be useful in the treatment of PTSD for the following (Winsor 1993):

• Increase feelings of safety and control
• Achieve distance from the traumatic event

Music Enhanced Hypnosis

According to a psychotherapist reporting on the use of music as a trigger for hypnotic suggestion with four patients, music-enhanced hypnosis reduced situational anxiety and enabled patients to maintain gains and insights from the particular therapeutic approach (Kelly 1993). It is unclear whether the use of music enhancement offers significant improvement over hypnosis alone.

• Inositol may be helpful in reducing anxiety associated with PTSD. According to a double-blind, placebo-controlled crossover study, 21 patients who had panic disorder were given 12 g/day of inositol (the myoisomer of inositol, a member of the vitamin B complex, is found in vegetables, citrus fruits, cereal grains, and meats). The number and severity of panic attacks decreased while taking the supplement (Benjamin et al. 1995). The specific application to PTSD is not known; research may be elucidating.

Although there is no documented evidence of the benefit, some general nutritional guidelines to consider for patients with PTSD include:

• Avoiding stimulants such as caffeine from chocolate, coffee, black tea, and cola
• Avoiding depressants like alcohol
• Maintaining a balanced blood sugar to help stabilize mood; this can be accomplished by eating small, frequent meals with a small amount of protein included at each meal. Avoid processed, refined, simple sugars; teach the patient to eat a whole-foods diet, including whole grains, fresh fruits and vegetables, and protein from vegetables and fish.

• Kava kava (Piper methysticum) is thought to reduce stress-related anxiety and to be an effective and safe possible alternative to benzodiazepines and tricyclics without the associated risk of side effects (Scherer 1998; Volz and Kieser 1997). Use specifically for PTSD is unknown.

Other herbs that may be useful for the symptoms of restlessness, nervousness, and anxiety that can be associated with PTSD include (Blumenthal et al. 2000):

• Passionflower (Passiflora incarnata) 
• Valerian (Valeriana officinalis) 

While homeopathy may be useful in mitigating symptoms of PTSD it has not yet been subjected to clinical trials in the treatment of this disorder. An experienced clinician, however, might consider one of the following remedies:

• Aconitum napellus—for recurring panic following trauma including heart palpitations and shortness of breath, which produce a tremendous fear of death (Jonas and Jacobs 1996). 
• Arnica—for chronic conditions after trauma, especially with depressive symptoms (Morrison 1993). 
• Stramonium—for anxiety disorders after a shock, with generalized fear and night terrors (Morrison 1993). 
• Staphasagria—for the sequellae of trauma that have made the person feel fearful, powerless or unable to speak up or defend themselves (Jonas and Jacobs 1996). 

Although not the only focus of the article, a case history of a Vietnam veteran with PTSD reported significant improvement in the following symptoms after a 12-week course of electroacupuncture treatments combined with relaxation via guided imagery (Ulett 1996):

• Insomnia
• Recurrent nightmares
• Panic attacks

The release of endorphins from acupuncture may be the mechanism responsible for improvements in these symptoms (Novey 2000; Ulett 1996).

In acutely stressful situations, early intervention is generally undertaken with the goal of preventing the development of PTSD. The most effective form of such intervention has not been firmly established, but suggested methods include:

• Formal crisis intervention
• Support groups
• Focused psychotherapy
• Prophylactic psychopharmacology

Single post-trauma "debriefing" sessions do not seem to be effective either in reducing psychological distress in adults or in preventing the onset of PTSD.

PTSD is associated with high rates of lifetime psychiatric comorbidity, including:

• Major depression (4 to 7 times greater than the general population)
• Substance abuse (3 times greater than the general population)
• Panic disorder (3 to 20 times greater than the general population)

If symptoms of PTSD persist for longer than 3 months, the condition is considered chronic. Chronic PTSD may diminish in severity even if untreated, with a median time to recovery of 3 to 5 years. However, because of its high chronicity and comorbidity, PTSD can be severely debilitating in some cases; this, in turn, can contribute to high levels of functional and social disability, somatic complaints, and need for ongoing, frequent use of healthcare systems and personnel.

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