Post-Traumatic Stress Disorder was originally conceived as reflecting a typical type of psychological reaction to having witnessed or experienced a sudden, traumatic event, such as natural disasters.  To this has been added events like the Twin Towers destruction, war violence, concentration camps, childhood physical abuse, childhood sexual abuse, rape, beatings, muggings, being shot at, etc.  Unfortunately, it is an extremely flexible diagnosis that can be used for almost everybody, victims and perpetrators alike, e.g., both the victims of war and the soldiers who commit the violence.  

PTSD is a favorite diagnosis for women who have been victims of sexual abuse in childhood and is often given regardless to their presenting symptoms.  Any kind of childhood abuse is good enough.  One study concluded that over 25% of the general public can be given the diagnosis.  Thus, it is of little value in guiding research or therapy in my experience.  Some doctors like to give a lot of diagnoses to the same patients and some patients seem to enjoy having a long list of diagnoses.  You can always add PTSD to the list.  As expected, medication treatment is all over the place.

The diagnostic criterion are very flexible and can be stretched to fit any situation.  First, the person experienced or witnessed or was "confronted with" an event or events which involved actual or threatened death or injury or a threat to physical integrity of self or others.  So, you don't event have to see the event or be there.  Seeing it on television is good enough.  The response must involve intense fear, helplessness, or horror.  However, the response can come even years after the event!

Second, the traumatic event has to be repeatedly reexperienced as 1) intrusive, distressing recollections, or 2) recurrent distressing dreams, or 3) acting or feeling as if the traumatic event were recurring, or 4) intense discomfort on exposure to something that reminds one of the event, or 5) physical reactions to something that reminds one of the event.  Almost any stressful event will cause one of these.

Third, persistent avoidance of things associated with the events and/or a numbing of responsiveness as shown by three of the following: 1) avoiding thoughts, feelings, or conversations about the event, 2) trying to avoid activities, places, or people associated with the event, 3) inability to remember important details of the event, 4) markedly diminished interest in activities, 5) feeling detached from others, 6) restricted feelings (e.g. inability to have love feelings), and 7) expecting a shortened life or not to have a job, marriage, child, etc. 

And fourth, persistent, increased arousal as reflected by at least two of the following: 1) insomnia, 2) anger, 3) difficulty concentrating, 4) hypervigilance, and 5) exaggerated startle response.  Thus, almost any stress reaction will do. Finally, the symptoms have to last more than 1 month. 

Many medications have been found to help PTSD at least a little bit and there is little research comparing treatments.  Here are a few of the studies, but I haven't done an in-depth review yet.  Usually, the medications researched are new, expensive patented medications, with which the manufacturer is trying to find more ways of increasing profits.  Thus, older medications, which might be as good or better, will almost never have an article written.

Risperdal Said Helpful in Very Small Study: In an 8-week DB PC study of just 21 adult female outpatients with posttraumatic stress disorder (PTSD) related to childhood physical, sexual, verbal, and emotional abuse, the 12 given risperidone 0.5 to 8 mg/day had a greater reduction in total score on the CAPS-2 (p = .015) and greater reductions in the intrusive (p < .001) and hyperarousal (p = .006) subscale scores of the CAPS-2.

Symptoms of PTSD No Different From Major Depression: Many patients suffering from severe depression "test positive" for post-traumatic stress disorder, regardless of whether or not they have actually experienced trauma.  In a study of 101 patients with severe depression questioned about whether they had suffered symptoms of PTSD such as intrusive thoughts, emotional numbing, flashbacks and hopelessness. However, when two independent experts analyzed whether they had experienced a traumatic event, using standard tests issued by the American Psychiatric Association (APA) of witnessing or experiencing "actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others," the same percentage of patients experiencing major trauma (53%) had all the symptoms of PTSD (78%) as for those patients who had not experienced trauma. Post-traumatic stress depression is no different from other depression. Therapists often encourage trauma victims to confront what they fear, but this form of therapy can be counterproductive and actually worsen depression. Alexander Bodkinet al. Harvard's McLean Hospital. Journal of Anxiety Disorders 3/2007.

SSRI Equal to Nefazodone (Serzone) for PTSD: In a 12-weeu DB study of just 37 patients with posttraumatic stress disorder, patients received nefazodone (maximum dose 600 mg /day; average dose 463 mg/day) or sertraline (Zoloft) (maximum dose 200/day; average dose 153 mg/day). Both groups improved equally well on the Clinician Administered PTSD Scale, Part 2 (CAPS-2), the Clinical Global Impression Improvement Scale (CGI-I), the Davidson Trauma Scale (DTS), the Top-8 PTSD Rating Scale, Sheehan Disability Scale (SDS), Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Scale (HAM-A), and Pittsburgh Sleep Quality Index (PSQI). Comparison of nefazodone and sertraline for the treatment of posttraumatic stress disorder. McRae AL, Brady KT, Mellman TA, Sonne SC, Killeen TK, Timmerman MA, Bayles-Dazet W. Medical University of South Carolina. Depress Anxiety. 2004;19(3):190-6. Ed: Unfortunately, the absence of a placebo group makes it unclear how much of the improvement was due to medication.

Nefazodone (Serzone) Helped in Small DB: In a small 41-patient, DB PC study of chronic PTSD combat veterans, patients on nefazodone showed an improvement in the Clinician-Administered PTSD score compared with those on placebo (P = 0.04; effect size = 0.6). No significant group differences were found in the Clinician-Administered PTSD Scale criterion B, C, or D subscale. The Hamilton Rating Scale for Depression showed significant improvement compared with placebo (P = 0.008). A Placebo-Controlled Study of Nefazodone for the Treatment of Chronic Posttraumatic Stress Disorder: A Preliminary Study. Davis LL, Jewell ME, Ambrose S, Farley J, English B, Bartolucci A, Petty F. University of Alabama, Johns Hopkins, Creighton University. J Clin Psychopharmacol. 2004 Jun;24(3):291-297

Nefazodone (Serzone) Claimed to Help: 15% Vietnam vets have PTSD. One-third of people with PTSD have long-term symptoms. Nefazodone blocks 5-HT2 postsynaptically and inhibits 5HT reuptake. Trazodone helps PTSD and sleep. In an open-label study with 100-200 mg/d of nefazodone, all 10 patients much improved. Mike Hertzberg, Duke, J Clin Psychiatry 59:460-4 9/98. Many different meds have been used for PTSD, especially anti-depressants and anti-manic agents. Open trials are worthless and this one should never have been published in my opinion.  Serzone has some real drawbacks.

Psychological Debriefing Doesn’t Help, May Worsen: The most widely used PTSD intervention, psychological debriefing, seeks to prevent symptoms by having trauma survivors share memories or relive the experience. Scientific studies have raised substantial concerns about the actual impact this and similar methods. This review found "no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma." Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress? 11/03 Psychological Science in the Public Interest, Richard J. McNally, Harvard University; Richard A. Bryant, University of New South Wales; and Anke Ehlers, Institute of Psychiatry, King's College London.

Writing About Trauma Made Worse Temporally and No Benefit in Long Run: A study of 57 college students found by screening for PTSD experiences were instructed to write for 15 minutes a day for four days over two weeks either about their traumatic experience or about a trivial topic. Initially, at two weeks, the students writing about their trauma got more anxious and depressed while those writing about a trial issue got better.  At 6 week follow-up, both groups were equally improved. Univ. S. Mississippi. Does writing reduce posttraumatic stress disorder symptoms? Deters PB, Range LM. Violence Vict. 2003 Oct;18(5):569-80

OK to Witness a Failed Resuscitation: Study of effect on bereaved relatives found no harmful impact from viewing failed resuscitation. Lancet 8/22/98

Lamotrigine Helps in Small DB: 14 pt 10 weeks 25mg/d increased to 500/d if needed. 50% v 25% responders. Biol Psych ’99;45;1226, Hertzberg, Duke

Topiramate in Open Trial: Civilian PTSD, 35 patient, 28 as add-on med and 7 as monotherapy. Topiramate supposedly decreased nightmares in 79% (19/24) and flashbacks in 86% (30/35) of patients, with full suppression of nightmares in 50% and of intrusions in 54% of patients with these symptoms. Of course, such conclusions are absolutely impossible in an open trial.  Nightmares or intrusions were claimed to have partially improved in a median of 4 days and were fully absent in a median of 8 days. Response was seen in 95% of partial responders at a dosage of 75 mg/day or less, and in 91% of full responders at a dosage of 100 mg/day or less. Berlant, U Wash Seattle, J Clin Psychiatry 2002 Jan;63(1):15-20. Ed: Another worthless and unethical report in my opinion.  There is absolutely no reason why they shouldn't have done a double-blind study.

2 Cases Risperidone Said to Have Helped: Military-related cases. Mil Med 99;164:605. Ed: Case reports are of no value whatsoever.

Cyproheptadine No Benefit PTSD Nightmares: J Clin Psychoph 99;19:486

Prazosin Relieves PTSD Nightmares: Two veterans given prazosin for benign prostatic hypertrophy were relieved of PTSD nightmares. Then 4 more vets in open trial with PTSD and high blood pressure were given prazosin 1 mg/d which was optionally increased to a max of 10/d. All experienced relief and were able to tolerate at least 5 mg/d.  Nightmares were eliminated. Raskind, U Wash, J Clin Psych 00;61:129

Thomas E. Radecki, M.D., J.D.

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