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The authors’ observations
Medication. APA treatment guidelines support using SSRIs to treat all three PTSD symptom clusters—re-experiencing, avoidance, and hyperarousal—as well as coexisting depression. Evidence also supports use of the tricyclics amitriptyline and imipramine and some monoamine oxidase inhibitors (MAOIs).6-10 Dietary restrictions associated with MAOIs, however, can pose a problem for teenagers.
Benzodiazepines can decrease anxiety and improve sleep, but they can be addictive and their efficacy in treating PTSD has not been established. Alpha-2-adrenergic agonists such as prazosin and clonidine may decrease hyperarousal and trauma-related nightmares.11,12
Obtain informed parental consent before starting a child or adolescent on an antidepressant. These medications contain a black-box warning that the drug may increase suicide risk in youths.
Psychotherapy. Varying levels of evidence support psychotherapy models in PTSD (Box 2). Julie can benefit from psychoeducation, supportive therapy, psychodynamic psychotherapy, and cautious re-exposure to trauma where possible.
Psychoeducation provided a safe starting point for Julie’s therapy, engaged her parents and select school counselors and teachers, and helped her understand PTSD’s effects. This allowed us to teach stress reduction and coping strategies.
Supportive techniques helped Julie contain painful affects. She could then network with community resources such as AlaTeen and a peer support group via a local Native American mental health program. This approach helped us gain Julie’s trust, and we anticipate more in-depth work with time.
Trauma re-exposure helps some patients but worsens others’ symptoms. For Julie, trauma re-exposure has been minimal because of the many other issues she was facing.
Developing a trusting relationship over time is crucial to successful trauma re-exposure. Re-exposure should be gradual to keep affective arousal moderate. This will minimize dissociation and affective flooding, which can frustrate treatment.
Cognitive-behavioral therapy (CBT) might help Julie understand the automatic thoughts of failure and defeat that flood her when she is stressed. CBT could help her master her feelings and lay a foundation for improved coping.
Psychodynamic psychotherapy may be started later to help Julie verbalize feelings and modulate how she expresses affect. This model could promote her development, improve her self-image, and treat her depression.
Evidence supporting psychotherapy models in PTSD
Recommended with substantial clinical confidence (Level I)
Cognitive-behavioral therapy
Psychoeducation
Supportive techniques
Recommended with moderate clinical confidence (Level II)
Exposure techniques
Eye movement desensitization and reprocessing
Imagery rehearsal
Psychodynamic therapy
Stress inoculation
May be recommended in some cases (Level III)
Present-centered group therapy
Trauma-focused group therapy
Not recommended (no evidence)
Psychological debriefings
Single-session techniques
Source: APA practice guideline for PTSD (see Related resources)
Follow-up: Back to school
After 2 months under our care, Julie begins to show improvement. Because of her progress and the fact that her parents drive 45 minutes each way to get to our clinic, we reduce visit frequency from weekly to biweekly.
Julie now attends school 2 hours daily, is earning additional credits through home study, and plans to graduate early and attend community college. Her depression has lifted, and she continues to take fluoxetine, 40 mg/d and extended-release dextroamphetamine, 20 mg/d. She still struggles with social isolation, failure to reach age-appropriate developmental milestones, and a poor body image.
- American Psychiatric Association. Practice guideline for treating acute stress disorder and posttraumatic stress disorder. www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
- National Center for Post-Traumatic Stress Disorder. Information on obtaining Impact of Events Scale and Davidson Trauma Scale. www.ncptsd.va.gov/publications/assessment/adult_self_report.html
- Amitriptyline • Elavil
- Aripiprazole • Abilify
- Clonidine • Catapres
- Dextroamphetamine (extended-release) • Adderall XR
- Duloxetine • Cymbalta
- Fluoxetine • Prozac
- Imipramine • Tofranil
- Phenelzine • Nardil
- Prazosin • Minipress
- Sumatriptan • Imitrex
- Trazodone • Desyrel
Dr. Matthews is an American Psychiatric Association Bristol-Myers Squibb Co. fellow in public and community psychiatry.
Dr. Mossefin reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.
Acknowledgements
The authors thank Larry Schwartz, MD, for his help in preparing this article for publication.