Web-only article from "Trauma" issue of Visions Journal, 2007, 3(3)
Introducing Ms. T
Ms. T is a young college student, who came to my clinic complaining of depressed mood, irritability and inability to concentrate in her class. She was raped by an acquaintance about three years ago during Christmas time. Since the incident, she has experienced repeated intrusive memories about the event, and nightmares of being chased or cornered. She sometimes wakes up in the middle of the night to check if the door is locked. She feels nervous, irritable, and hypervigilant (i.e., intensely aware of her surroundings, on guard). She has a more difficult time during Christmas, and keeps herself isolated as much as possible to avoid any close relationships or situations that would remind her of what happened.
Ms. T received one year of psychological counselling after the trauma, which enabled her to cope better. However, Ms. T continues to avoid situations that would remind her about her trauma, and still has trouble developing close relationships.
A couple of months ago, in her psychology class, Ms. T was reading a chapter on rape victims. All of a sudden, she had a flashback of exactly what happened to her three years ago. She experienced nausea and sweating, and felt everyone in the class was watching her. She felt she couldn’t breathe and had to leave the class immediately.
Since then, she has been unable to focus in classes, and has become more hypervigilant and isolated. Initially, she thought she could deal with it by herself; however, her symptoms kept getting worse. She couldn’t focus on final exams, even after she had withdrawn from her psychology course. Her teacher recommended that she see a doctor.
PTSD, SSRIs and more . . .
Ms. T has typical symptoms of post-traumatic stress disorder (PTSD).1 PTSD is one of the most common anxiety disorders, affecting about 8% of the US population. It occurs following exposure to traumatic events (e.g., war, rape, assault, motor vehicle accident).2
Typical symptoms include: repeated re-experiencing of the trauma (intrusive memories, nightmares, flashbacks); avoiding reminders of the trauma (e.g., close relationships, certain situations); numbing of emotional feelings; and symptoms of increased arousal (e.g., poor sleep, irritability, nervousness, nausea, sweating, hypervigilance).
PTSD is a psychiatric disorder, with well-known associated changes in brain function. Taking these changes into account may help us better understand and treat the disorder.3
Medications can regulate the chemical imbalances that occur in the brain and thus reduce emotional and physical over-reactivity. According to the International Psychopharmacology Algorithm for PTSD,4 the first-line medication is usually a serotonin-selective reuptake inhibitor (SSRI) or a serotonin-and-norepinephrine reuptake inhibitor (SNRI). The reuptake inhibitors block the reabsorption of serotonin or norepinephrine by nerve cells, making the chemicals more available for transmitting signals in the brain. Meaningful symptom reduction usually takes place four to 12 weeks after beginning the medication.
Common adverse (bad) reactions to these medications include dry mouth, nausea, drowsiness, headache, diarrhea, constipation and disordered sexual function. Most of these adverse reactions tend to disappear over time, although this may not be the case for sexual side effects. Adverse reactions can usually be successfully managed with selection of the “right” medication, gradual dose escalation, or use of another medication to minimize the adverse reactions.
Many other medications are available for PTSD patients who do not respond to initial treatment.5 These include tricyclic antidepressants and monoamine oxidase inhibitors, anticonvulsants, benzodiazepines, adrenergic inhibitors and antipsychotics. Tricyclic antidepressants and monoamine oxidase inhibitors are older-generation antidepressant medications. They are effective for PTSD, but tend to have more side effects than SSRIs or SNRIs. Anticonvulsants are seizure medications, but are also effective for mood swings and impulse control problems. Benzodiazepines can be used to treat panic attacks and anxiety, but should be used with caution as they can be addictive. Adrenergic inhibitors reduce adrenaline effects and can be used to treat physical arousal such as palpitation, sweating, nausea, shaking and nightmares. Antipsychotic medications are effective to treat agitation, paranoia, aggression or other behaviour disturbances. Choice of medication is based on a patient’s specific symptoms, other accompanying disorders, previous medication trials, drug–drug interactions and adverse effects.
Most patients tolerate medication very well and the inconvenience of side effects is mostly outweighed by the medication’s benefits. The patient who has an excellent response to the medication should generally be treated for a minimum of one year.
Back to Ms. T
As for Ms. T, she was recommended to start a combination of medication and psychotherapy. She was put on a medication with a gradual increase in dosage. She tolerated her medication very well and showed an excellent response within one month. She resumed her college classes after two weeks of medication. She has improved mood, energy, concentration and sleep, and has reduced intrusive memories. After six months of treatment, she continues to do well with the maintenance medication.
About the author
Joseph Wang is a medical Fellow, Wei Zhang is the Director and Jonathan Davidson is a Professor and former director at the Anxiety and Traumatic Stress Program in Psychiatry at Duke University School of Medicine, Durham, NC
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (4th ed.). Washington, DC: Author.
Kessler, R.C., Sonnega, A., Bromet, E. et al. (1995). Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12): 1048-1060.
Liberzon, I. & Phan, K.L. (2003). Brain-imaging studies of post-traumatic stress disorder. CNS Spectrums, 8(9): 641-650.
Davidson, J.R., Bernik, M., Connor, K.M. et al. (2005). A new treatment algorithm for post-traumatic stress disorder. Psychiatric Annals, 35(11): 887-900.
Schoenfeld, F.B., Marmar, C.R. & Neylan, T.C. (2004). Current concepts in pharmacotherapy for post-traumatic stress disorder. Psychiatric Services, 55(5): 519-531.