NEW ORLEANS – Recent studies have confirmed that posttraumatic stress disorder can be triggered by health-related stress such as stints in the ICU and life-threatening medical emergencies, but most psychiatrists may not be aware of the latest research, according to an expert in mental trauma.
“This is true among children as well as adults, but it is not generally appreciated by psychiatrists and not at all by non-physicians,” said Charles B. Nemeroff, MD, PhD, professor and chair of the department of psychiatry and behavioral sciences at the University of Texas at Austin’s Dell Medical School, in a presentation at the annual meeting of the American Psychiatric Association. “It’s something that we all need to educate our colleagues about.”
Courtesy University of Texas, Austin
Dr. Charles B. Nemeroff
As Dr. Nemeroff noted in a wide-ranging discussion about the latest trends in PTSD diagnosis and treatment, the DSM-5 doesn’t yet mention medical trauma in its definition of PTSD but refers more vaguely to triggering events that involve “actual or threatened death, serious injury, or sexual violence.”
However, multiple recent studies have linked medical trauma to PTSD. A 2019 study in Intensive Care Medicine found that 25% of 99 patients who were treated for emergency respiratory or cardiovascular crises showed PTSD symptoms at 6 months, and the percentage of childhood cancer survivors with PTSD was estimated at as high as 22%, according to research published in Frontiers in Psychology.In 2013, a meta-analysis suggested that 23% of stroke survivors have PTSD symptoms within 1 year, and 11% after 1 year.
PTSD is unique
Dr. Nemeroff noted that PTSD is the only diagnosis in the DSM-5 that’s directly linked to an environmental event. Specifically, he said, PTSD is caused by “very unexpected traumatic events that occur outside the normal repertoire of human behavior.”
In response, “most people that have an acute stress disorder response will fundamentally extinguish it and end up returning to the baseline level of functioning,” he said. But those with PTSD do not recover.
Dr. Nemeroff recommends the use of the 20-question self-report tool known as PCL-5. “It’s your friend,” he said. “It takes a few minutes for the patients to fill out while in the front office, and it doesn’t cost anything. Most patients who have PTSD will have a score of 50-55, maybe 60. You’re going to try to get them down to below 30, and you’re going to give this to them every time they come to your office to follow their progress. It works like a charm.”
As for treatment, psychotherapy and medications remain standard, he said, although “PTSD is a tough disorder to treat.”
According to him, brief cognitive behavioral therapy (CBT) – 4-5 sessions – has shown the greatest benefit and highest level of evidence in support when initiated within 4-30 days of trauma. Group therapy may be helpful, while it’s not clear if spiritual support and “psychological first aid” are useful during this time period.
There’s no evidence that medications such as SSRIs and atypical antipsychotics will prevent PTSD from developing; typical antipsychotics are not recommended. Individual or group “debriefing” is highly not recommended, Dr. Nemeroff said, because the experience can re-traumatize patients, as researchers learned after 9/11 when encouraging people to relive their experiences triggered PTSD and heartbreak.
Also not recommended: Benzodiazepines and formal psychotherapy in people without symptoms.
Exposure-based CBT has been proven to be successful, Dr. Nemeroff said, but it must be provided by a trained professional. “Going for a weekend course isn’t sufficient,” he said, and research suggests that group CBT is not as helpfulas individual CBT.
As for medication over the longer term, research supports SNRIs and SSRIs such as sertaline (Zoloft) and paroxetine (Paxil). Dr. Nemeroff is a fan of venlafaxine (Effexor): “It has a wide dose range. I can go from 75 to 150 milligrams at the low end and 450 and even 600 milligrams at the high end. I’ve had some amazing successes.”
In addition, atypical antipsychotics can be helpful in non-responders or psychotic PTSD patients, he said.
Dr. Nemeroff said he’s skeptical of ketamine as a treatment for PTSD, but he’s most hopeful about MDMA-assisted therapy due to “impressive data” regarding PTSD that was released last year. A bid for FDA approval is in the works, he said.
He added that data is promising from trials examining transcranial magnetic stimulationand (in work by his own team) electroconvulsive therapy. Both therapies are worth considering, he said.
Dr. Nemeroff reported multiple disclosures including research/grant support, stock holdings, scientific advisory board service, consulting relationships, board of director service, and patents.