Posttraumatic Stress Disorder (PTSD)
Symptoms and Treatment in Veterans

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have increased your understanding of posttraumatic stress disorder and your ability to intervene appropriately in the assessment, diagnosis, treatment, and prevention of the disorder, especially with patients who are military veterans. Specific learning objectives include:

• Define posttraumatic stress disorder (PTSD).
• Summarize the epidemiology and etiology of PTSD.
• Identify risk factors for developing PTSD.
• Identify the symptoms and diagnostic criteria.
• Discuss the impact that caring for a person with PTSD has on family and caregivers.
• Discuss appropriate assessment and diagnosis of patients with suspected PTSD.
• Describe current interventions and outcome goals for patients.

INTRODUCTION

The Encyclopedia of Mental Disorders (EMD, 2020) defines posttraumatic stress disorder as “a complex disorder in which the affected person’s memory, emotional responses, intellectual processes, and nervous system have been disrupted by one or more traumatic experiences. It is sometimes summarized as a normal reaction to abnormal events.”

PTSD is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a “trauma and stressor-related disorder” and is the only psychiatric diagnosis (along with acute stress disorder) that depends on a factor outside the person—namely, a traumatic stressor that is outside the range of usual experience involving actual or threatened death or serious injury or assault to self or others. In addition, it is now recognized that repeated traumas or such traumas of long duration (e.g., child abuse, domestic violence, stalking, cult membership, hostage situations) may produce the symptoms of PTSD in survivors (APA, 2013; EMD, 2020).

In 1989, because of a recognized need, the National Center for Posttraumatic Stress Disorder was established within the U.S. Department of Veterans Affairs. Its mission is “to advance the clinical care and social welfare of America’s veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders” (VA, 2020).

EPIDEMIOLOGY

Prevalence and Vulnerability in the General Population

About 7 or 8 of every 100 people in the United States will have PTSD at some point in their lives, and about 8 million adults have PTSD during a given year. However, this number represents only a small portion of those who have gone through a trauma.

About 10 of every 100 women develop PTSD sometime in their lives compared with about 4 of every 100 men (Sareen, 2020; NCPTSD, 2019). The rates of PTSD for men and women are similar after events such as accidents, natural disasters, and sudden death of a loved one, but the incidence of PTSD after rape is higher in men compared to women despite the fact that women are more than 10 times more likely to be raped. The rate of PTSD, however, is lower in men after events such as molestation and physical assault.

Sexual assault is the most frequent type of traumatic event among women with PTSD. Among a representative sample of women in the United States, the lifetime prevalence of PTSD was 12.3%. Of the women who have a history of PTSD, 32% had been raped and 31% were sexually assaulted but not raped (Sareen, 2020).

To date, there have been no population-based epidemiological studies done that examine the prevalence of PTSD among children; however, research indicates that children exposed to traumatic events may have a higher prevalence of PTSD than adults in the general population.

Vulnerability is influenced both by the characteristics of the individual as well as those of the event. Traumas that are intentional have been found to be more closely associated with PTSD than those that are unintentional or nonassaultive (Sareen, 2020).

PTSD and Military Personnel

The number of veterans with PTSD varies by service era. About 20 of every 100 veterans who served during the Iraq and Afghanistan wars have PTSD in a given year. Those who served during the Gulf War have a prevalence of 12 out of every 100 veterans, and those who served during the Vietnam War have a prevalence of 15 out of every 100 veterans. It is estimated that about 30 out of every 100 Vietnam veterans have had PTSD in their lifetime (NCPTSD, 2018a).

PTSD occurring after combat injury develops over several months and correlates with the extent of injury and the occurrence and severity of traumatic brain injury. Nearly 50% of soldiers with combat-related traumatic brain injury met criteria for PTSD (Sareen, 2020).

Another cause of PTSD in the military is military sexual trauma (MST). This includes any sexual harassment or assault, which can happen to both men and women. Among veterans who use Department of Veterans Affairs healthcare services:

• 23 of every 200 women reported sexual assault when in the military
• 55 of every 100 women and 38 of every 100 men have experienced sexual harassment
• Over half of all veterans with military sexual trauma are men
  (VA, 2018)

PTSD and Suicide

PTSD is a common risk factor for suicide. Depression, internalized anger, self-hatred, and perceived burdensomeness have been identified as mediating factors between PTSD and suicide risk.

Veterans have a 21% higher suicide rate compared with the nonveteran population. Among those with the highest risk are soldiers recently discharged from inpatient psychiatric hospitalizations. Rates are higher in junior enlisted soldiers deployed either in their first year of service or in those with less than expected promotion for their rank. Rates were also higher among women than men during deployment, and marriage had a protective effect only during deployment (Roy & Perkins, 2020; Giacomoni, 2018).

ETIOLOGY

Although PTSD is always triggered by an external event, it may have roots in one’s biology as much as experience. Researchers suspect that genetics may contribute to a person’s susceptibility to PTSD through an interaction with environmental factors.

Pathophysiology

The pathophysiology of PTSD is unclear, but some studies have found that PTSD frequently leads to changes in the anatomy and neurophysiology of the brain. These changes include:

• Reduced size of the hippocampus, which is probably both a predisposing factor and result of trauma
• Overly reactive amygdala, which is involved in processing emotions and modulating the fear response
• Smaller and less responsive medial prefrontal cortex, which exhibits inhibitory control over the stress response and emotional reactivity of the amygdala

Alterations in neurohormonal and neurotransmitter functioning have also been found:

• Normal to low circulating levels of cortisol despite ongoing stress and elevated levels of corticotropin releasing factor (CRF)
• Hyperactivity of the sympathetic branch of the autonomic nervous system causing changes in heart rate, blood pressure, skin conductance level, and other psychophysiological measures
• Elevated noradrenergic reactivity to pharmacological challenges
• Altered functioning of other neurotransmitter systems, including serotonin, gamma aminobutyric acid (GABA), glutamate, neuropeptide Y, and endogenous opioids

Another theory, the Dual Representation Theory, highlights the presence of two separate systems for memory:

• Verbally accessible memory is recorded in the hippocampus and later in general brain memory storage and is able to be modified by reflection. This is characteristic of most nontraumatic memories.
• Situationally accessible memory is nonverbal and associated with very strong emotions that engage the amygdala. This is where traumatic memories tend to be stored. They are harder to process, are readily triggered by associations, and more likely to cause emotional distress when activated.
  (Sareen, 2020; Gore, 2018)

Risk Factors

Factors that make individuals more likely to develop PTSD after a traumatic event may include:

• Female gender
• Younger age at time of trauma
• Lower education
• Lower socioeconomic status
• Being separated, divorced, or widowed
• Lack of a good support system
• Previous trauma
• Experiencing intense or long-lasting trauma
• Initial severity of reaction to the trauma
• Drug, alcohol, and other substance misuse
• General childhood adversity
• Personal and family psychiatric problems, including anxiety or depression
• Reported childhood abuse
• Occupation choice (e.g., firefighter, EMS, military, police)
• Sleep disorders such as insomnia or sleep apnea
  (Sareen, 2020; PTSD Alliance, 2020)

Resilience

Many people are affected by traumatic events, but a majority of them recover from stress reactions and do not go on to develop PTSD. The ability to recover quickly from or adjust easily to traumatic events involves a degree of resilience.

Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress. Resilience involves “bouncing back” from difficult experiences, but it can also involve profound personal growth, allowing an individual to grow and improve life.

Resilience involves behaviors, thoughts, and actions that can be learned and developed. Increasing resilience takes time and intention, focusing on four major components: connection, wellness, healthy thinking, and meaning. These include:

• Building connections with others
• Fostering wellness of body and mind
• Finding purpose and meaning
• Learning healthy ways of thinking (e.g., keeping things in perspective)
• Seeking professional help when needed
  (APA, 2020)

SYMPTOMS, ONSET, AND COURSE

Symptoms

The DSM-5 divides PTSD symptoms into four clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity (APA, 2013).

INTRUSION

Intrusion, one of the core symptom clusters of PTSD, can take the form of unwanted and obsessive thoughts, feelings, sensory experiences, or any combination of the three relating to the experienced trauma. These can include:

• Involuntary, recurrent, and intrusive memories
• Traumatic distressing dreams or nightmares
• Dissociative reactions (flashbacks) in which the person feels or acts as if the traumatic event(s) were recurring
• Intense or prolonged distress postexposure to internal or external cues symbolizing the event(s)
• Marked physiological reactivity postexposure to internal or external cues

AVOIDANCE

Efforts persist to avoid distressing trauma-related stimuli , including:

• Trauma-related thoughts or feelings
• Trauma-related external reminders, such as persons, places, activities, situations, or objects

NEGATIVE ALTERATIONS IN COGNITION AND MOOD

Such alterations in cognitions and mood begin or worsen after the traumatic event and include:

• Inability to recall important feature(s) of the event (dissociative amnesia)
• Persistent and often distorted negative beliefs and expectations about self or others
• Persistent blaming of self or others for the cause of the traumatic event or the consequences following the event
• Persistent negative emotions related to the trauma, such as fear, anger, guilt, shame, or horror
• Greatly reduced interest in normal activities
• Feeling detached or estranged from others
• Persistent inability to experience positive emotions

ALTERATIONS IN AROUSAL AND REACTIVITY

Alterations in arousal and reactivity begin or worsen after the traumatic event and include:

• Irritability or aggressive behavior
• Self-destructive or reckless behavior
• Hypervigilance
• Exaggerated startle response
• Problems concentrating
• Sleep disturbance

Onset and Course

The onset and course of PTSD is unpredictable, and the severity and timing of symptoms are different for each individual. Symptoms may appear immediately but generally present themselves within the first three months following exposure to trauma. There may, however, be a delay of months or even years before criteria are met for the establishment of a PTSD diagnosis.

The course of the illness also varies. Some people recover within 6 months, while others have symptoms that last for months or years. In some people, the condition becomes chronic (NIMH, 2019).

The prognosis of PTSD varies based on a number of factors, including resilience, secondary stresses, the level of support the person has, prior traumatic experiences, ongoing injury, and severity of the stress (Gore, 2018).

Comorbidities and Consequences

Psychiatric comorbidity is high in patients with PTSD. Data from the National Comorbidity Survey suggests that 16% of patients with PTSD have one coexisting psychiatric disorder, 17% have two disorders, and 50% have three or more. Depressive disorders, anxiety disorders, and substance abuse are two to four times more prevalent in those with PTSD. Approximately 20% have reported use of alcohol or other substances in attempts to self-medicate and relieve tension.

People with PTSD also have increased rates of borderline personality disorder and antisocial personality disorder. These individuals have increased risk of suicide attempts and high levels of traumatic events in childhood.

Traumatic events and PTSD are also associated with physical health problems that include:

• Bone and joint diseases
• Neurologic, cardiovascular, respiratory, and metabolic diseases
• Cardiovascular and pulmonary risk factors, including obesity, dyslipidemia, tobacco use, hypertension, and type 2 diabetes in women
• Autoimmune and vascular dementia
• Traumatic brain injury (TBI) among both civilians and military personnel
  (Sareen, 2020)

IMPACTS OF PTSD ON FAMILY

Living with survivors of trauma who are suffering with PTSD symptoms can have profound effects on those closest to them.

Research has found that combat veterans with PTSD have more marital problems and family violence, their partners have more distress, and their children have more behavior problems than those of veterans without PTSD. Veterans with the most severe symptoms have families with the worst functioning. It is believed these veterans have difficulty feeling emotions and may feel detached from others. They experience lower satisfaction in parenting because of the numbing and avoidance that occurs with PTSD. Family members may experience:

• Sympathy. Family members may feel sorry for the person, which can be helpful initially. It can have a negative effect, however, when it leads to low expectations of the sufferer, eroding his or her confidence in the ability to recover from the trauma.
• Depression. Changes in how the family functions because of the effects of PTSD symptoms on the sufferer can lead to feelings of pain or loss, increasing the risk for the development of depression. If PTSD lasts for a long time, family members may lose hope that the family will ever be “back to normal.”
• Fear and worry. When a PTSD sufferer is worried, fearful, and preoccupied with trying to feel safe, it can make others in the family feel unsafe also. Fear is also experienced when the PTSD sufferer is angry or aggressive.
• Avoidance. Family members may avoid talking about the traumatic event and avoid the same things the PTSD sufferer does because they do not want to cause further pain or are fearful of the person’s reactions.
• Guilt and shame. A family member may feel guilt or shame for many reasons, but especially if he or she feels responsible in same way for the trauma, for example, being unable to protect the person from the trauma.
• Anger. Family members may feel angry about the trauma, its effect on their lives, and with whomever is believed to be responsible for the event. They also may feel anger toward the PTSD sufferer who cannot “get beyond the trauma and move forward in life.” Family members may also feel angry and irritable in response to the anger and irritability the trauma survivor directs toward them.
• Negative feelings. Family members may begin to feel the person is no longer the same one they knew before the trauma. They may feel negatively about behavior exhibited by the sufferer both during and following the traumatic event. Sometimes family members have these negative feelings even when they know that their assessment of the situation is unfair.
• Drug and alcohol use. Family members may attempt to escape from bad feelings by using drugs or alcohol. A child or a spouse might spend time drinking with friends to avoid having to go home. In other situations, spouses may abuse drugs or alcohol to keep the trauma survivor company when the person is drinking or using drugs to avoid trauma-related feelings.
• Sleep problems. When the person with PTSD cannot sleep, it may be difficult for family members to sleep as well. Sleep problems may also be due to depression.
• Health problems. Bad habits (e.g., drinking, smoking, not exercising) may worsen among family members, and with extended stress, they may become more likely to develop stomach or bowel problems, headaches, muscle pain, and other health problems.
  (Carlson & Ruzek, 2019; NCPTSD, 2020a)

ASSESSING AND DIAGNOSING PATIENTS WITH KNOWN OR SUSPECTED PTSD

Soldiers, veterans, and civilians injured by trauma should be screened systematically for PTSD and connected to high-quality mental health services. Primary care patients with new anxiety, fear, or insomnia should be asked about a history of trauma and also screened for PTSD. Others in which PTSD may be a factor are those with anxiety symptoms, social isolation, and increased substance use.

Clinical Interview

Individuals who screen positive for PTSD are referred for additional evaluation, which is typically a face-to-face interview by a health professional trained in diagnosing psychiatric disorders. A face-to-face interview is the optimal method of assessment to determine a PTSD diagnosis. Clinical interviews can be structured, semi-structured, or unstructured.

Formal Assessment Tools

Structured and semi-structured interviews are most often conducted utilizing a formal assessment tool. The following are used in the assessment of PTSD in adults:

• Primary Care for PTSD Screen (PC-PTSD). A 4-item, self-administered screening tool for use in primary care settings.
• Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). A 30-item, structured interview administered by clinicians and appropriately trained paraprofessionals to make a current or lifetime diagnosis of PTSD and to assess PTSD symptoms over the previous week. The full interview takes 45 to 60 minutes to administer (Sareen, 2020).
• PTSD Checklist for DSM-5 (PCL-5). A 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. It is used to monitor symptom change during and after treatment, screen for PTSD, and make a provisional PTSD diagnosis. This tool takes 5 to 10 minutes to complete and can be completed by patients in a waiting room (Sareen, 2020).
• Life Events Checklist for DSM-5 (LEC-5). A self-report measure that screens for potentially traumatic events in a patient’s lifetime. It is often used in combination with other tools. There are three formats for LEC-5, including the standard self-report that establishes whether an event has occurred, the extended self-report that establishes the worst event if more than one, and the interview to establish if Criterion A stressor has been met (NCPTSD, 2018b).

ASSESSING THE OLDER ADULT

Assessment of trauma and related symptoms should be routine. Older adults may not readily report traumatic experience or they may minimize their importance, especially if the event(s) occurred a long time in the past.

The recommendations for assessment of an older adult include a full mental status examination, including a cognitive screening. The same “gold standard” assessment tool, CAPS-5, is recommended for the older adult. If dementia is suspected, the patient should be referred for a comprehensive diagnostic evaluation. If delirium or possible medication interaction is suspected, the patient should be referred for medical evaluation.

When interviewing older adults, it should be understood that older patients may talk about problems or respond to questions differently than younger people. They may be less likely to identify problems from a psychological point of view and be more likely to report physical concerns or pain, sleep difficulties, cognitive problems, or gastrointestinal issues. In addition, the older adult is likely to have more medical problems, co-occurring psychiatric problems, and cognitive problems that can complicate the assessment and treatment of PTSD.

Suicide assessment is particularly important in older patients. Older veterans are at greater risk for completed suicide than are middle-aged veterans (Hermann, 2019).

Physical Examination

Any patient presenting with symptoms of PTSD should have a complete history and physical examination to rule out any other causes for symptomatology, such as endocrine, cardiovascular, and neurological disorders. A review of systems and social history should also address the use of over-the-counter medications and mood-altering substances such as prescribed medications, alcohol, marijuana, or other substances of abuse.

Medical Diagnosis

A medical diagnosis is the naming of a disorder based on an assessment of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. The DSM-5 establishes the criteria required in order to make the medical diagnosis of PTSD, as described in the table below.

MEDICAL DIAGNOSIS OF PTSD

Criterion	Requirement
(APA, 2013)
A. Stressor	Must be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Must have one of the following: Direct exposure Witnessing, in person Indirect exposure, by learning that someone close was exposed to trauma, and if involved, actual or threatened death must be violent or accidental Repeated or extreme indirect exposure to details of traumatic event(s) such as experienced in the course of occupation (e.g., EMS personnel, police, firefighters); does not include indirect nonprofessional exposure through electronic media, television, movies, or pictures
B. Intrusion	Must have one of the symptoms in this symptom cluster (see “Symptoms” earlier in this course)
C. Avoidance	Must have one of the symptoms in this symptom cluster (see “Symptoms” earlier in this course)
D. Negative alterations in cognitions and mood that worsened after the traumatic event	Must have two of the symptoms in this cluster (see “Symptoms” earlier in this course)
E. Alterations in arousal and reactivity that began or worsened after the traumatic event	Must have two of the symptoms in this cluster (see “Symptoms” earlier in this course)
F. Duration	Symptoms having persisted for more than one month
G. Functional	Must be significant symptom-related distress or functional impairment in activities of daily living such as socialization and occupation
H. Exclusion	Disturbance not due to medication, substance use, or other illness
Specify whether the person experiences dissociative symptoms	Depersonalization: Recurrent experiences of feeling detached from one’s mental processes or body Derealization: Persistent or recurrent experiences of unreality of surroundings
Specify if with delayed expression	Diagnostic criteria not met until at least 6 months after the event

Nursing Diagnosis

NANDA International (2018) defines a nursing diagnosis as “a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.”

PTSD is classified as an anxiety disorder, and nursing diagnoses that are appropriate to the patient suffering from PTSD include, but are not limited to:

• Hopelessness/powerlessness
• Fear
• Deficit knowledge
• Ineffective coping
• Sleep pattern disturbance
• Dysfunctional grieving
• Impaired social interaction
• Ineffective relationships
• Social isolation
• Impaired individual resilience
• Risk for suicide and/or self-destructive behavior
  (Vera, 2019)

INTERVENTIONS

Caring for the patient diagnosed with PTSD involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment.

Interventions for PTSD are generally divided into psychotherapy and pharmacology, with psychotherapy being the primary choice. There are a number of treatment modalities. Some patients respond well to one treatment modality, while others may require a combination of modalities.

Goals and Outcomes

The overall goal for patients with PTSD is to regain a sense of control over life. Following are examples of specific goals and outcomes for a patient diagnosed with PTSD:

• Maintain safety of self and others
• Demonstrate control
• Distinguish between the present and memories
• Recognize triggers
• Receive treatment for comorbid conditions, such as alcohol/drug misuse, depression, anxiety disorders, and panic attacks
• Recognize ineffective coping strategies that correlate to negative outcomes
• Attend support group meetings
• Expand social support network
• Have increased restful sleep periods
• Have fewer nightmares and flashbacks
• Express decreased irritability
• Report feeling control over factors likely contributing to fear
• Demonstrate effective anxiety-reducing techniques, either cognitive or behavioral
  (Varcarolis, 2018)

Psychotherapy

Psychotherapy is clearly more effective than medication, and the most effective types of psychotherapy for treatment of PTSD are various forms of trauma-focused cognitive behavioral therapy (TF-CBT), with the strongest evidence for prolonged exposure (PE) and eye movement desensitization and reprocessing (EMDR).

Cognitive approaches assist patients to correct false perceptions. They are based on the theory that the meanings we impose on events contribute to our emotional states. Therefore, changing how we think about them can reduce PTSD symptoms and promote a sense of well-being.

Trauma-focused psychotherapies use cognitive, emotional, or behavior techniques to assist in processing the traumatic event, with the trauma focus being the central component of the therapeutic process and including both image exposure and live exposure to safe situations that have been avoided because they elicit reminders of the trauma (Hamblen et al., 2020).

Cognitive Processing Therapy

Cognitive processing therapy (CPT) is one of the most widely researched cognitive approaches, with a primary focus on challenging and modifying maladaptive beliefs related to a trauma. CPT has four main elements and includes a written exposure component:

• Education about PTSD symptoms and how treatment can help
• Developing awareness of thoughts and feelings
• Learning new skills for challenging thoughts and feelings (cognitive restructuring)
• Learning and developing an understanding about the common changes in beliefs that occur after going through trauma

This form of therapy requires 12 regular sessions of 60 to 90 minutes each with a therapist as well as completing practice assignments at home outside of therapy to help improve skills. CPT can be done individually or in a group. Assignments often include hand writing impact statements that address topics such as why the traumatic event occurred and what it means to the patient (NCPTSD, 2020).

PROLONGED EXPOSURE

Exposure-based treatments involve having patients repeatedly re-experience the traumatic event. They are intended to help patients face and gain control of overwhelming fear and distress following the traumatic experience.

Prolonged exposure (PE) is delivered in 8 to 15, 90-minute sessions, usually on a weekly basis. The key components of PE are:

• Psychoeducation about treatment, common reactions to trauma, and breathing retraining
• Imaginal exposure, requiring using the imagination to repeatedly retell the trauma memory out loud in present tense with eyes closed, and having the patient listen to an audio recording of the narrative between treatment sessions
• Live exposure to places, things, and situations that are being avoided because they cause distress and anxiety, in some cases using virtual reality technology when live exposure is not practical
• Emotional processing, focusing on reviewing the experience of exposure and the impact on thoughts related to the self, the world, and the trauma
  (Sweeney et al., 2019)

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

EMDR is another form of cognitive-behavioral therapy that can help change how a person reacts to memories of a traumatic event. It is fairly new, and guidelines have been issued by more than one professional organization, boosting its credibility. No one yet knows how this process works, but the mechanisms of EMDR are likely similar to that of other trauma-focused exposure and cognitive therapies, allowing the patient to better control upsetting thoughts.

EMDR does not rely on talk therapy or medications. Instead, it uses a patient’s own rapid, rhythmic eye movements. These eye movements dampen the power of emotionally charged memories of past traumatic events. A session can last up to 90 minutes and involves the therapist moving his/her fingers back and forth in front of the patient’s face and asking the patient to follow the movement with the eyes. At the same time, the patient is asked to recall the disturbing events, which will include emotions and body sensations that accompany it. Gradually, the therapist guides the patient to shift thoughts to more pleasant ones (Bhandara, 2019).

Psychopharmacology

Studies indicate that cognitive-behavioral therapies have greater effects in improving PTSD symptoms than medications, and while a number of medications have been tried, few have been shown to have any efficacy.

The therapeutic goals of pharmacologic therapy are to decrease intrusive thoughts and images, phobic avoidance, pathological hyperarousal, hypervigilance, irritability and anger, and depression. Drug therapies have been most beneficial in decreasing hyperarousal and mood symptoms (e.g., irritability, anger, depression), but are somewhat less effective for symptoms of re-experiencing, emotional numbing, and behavior avoidance (Stein, 2019).

ANTIDEPRESSANTS

These medications can help reduce symptoms of depression and anxiety. They can also help improve sleep problems and concentration. There are only two FDA-approved medications for treatment of PTSD, sertraline (Zoloft) and paroxetine (Paxil). Sertraline may be particularly useful in women who have experienced sexual or physical assaults.

These medications belong to the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). (Serotonin is important in regulating mood, anxiety, appetite, sleep, as well as other bodily functions.) SSRIs are the first-line medications for treatment of PTSD. They do, however, have significant side effects and carry a “black box” warning for suicidal ideation (Gore, 2018).

ANTI-ANXIETY MEDICATIONS

These drugs can relieve severe anxiety and related problems; however, they are not recommended for use in PTSD, as they can worsen symptom outcome. They also have potential for abuse. If benzodiazepines are used, it should be short term (e.g., no more than five days), with frequent re-evaluation for side effects. These medications include:

• Lorazepam (Ativan)
• Clonazepam (Klonopin)
• Alprazolam (Xanax)
• Diazepam (Valium)
  (Jeffreys, 2019)

Occupational Therapy

PTSD can be debilitating, with negative impacts in many areas of a person’s life, making it difficult to carry out the normal activities of daily living. Broad areas affected can include health and safety, money management, self-care, transportation, work, relationship duties, and community participation. PTSD also affects a person’s executive planning abilities such as time management and concentration or paying attention.

Occupational therapists work with patients who have PTSD across the lifespan and in all phases of recovery. Following a comprehensive and collaborative evaluation to identify the individual’s strengths and barriers to occupational performance and their causes, OTs provide individual and group therapy sessions that are often done in collaboration with other professionals. Occupational therapy interventions include, but are not limited to:

• Providing individual and/or group sessions that focus on:
  • Trauma triggers and warning signs
  • Developmental issues related to early childhood trauma
  • Symptom stabilization
  • New coping, health, and wellness strategies such as stress management, relaxation techniques, and sensory processing-related techniques
• Training clients, caregivers, and interdisciplinary staff in:
  • Adaptive or modified self- and home care, work, or school-based strategies to avoid inadvertent triggering of hypersensitivity patterns, dissociation, flooding, or flashbacks
• Assisting patients to increase participation in meaningful roles and activities, such as:
  • Creating and using a daily schedule to identify triggers and helpful strategies
  • Identifying and obtaining the type and amount of supports necessary for successful participation
  • Creating and using a sensory diet (a plan of specific activities and experiences used to help balance the nervous system and sensory processing)
  • Implementing exposure techniques
• Assisting patients and caregivers in determining needs and resources for home modification for those with physical barriers to participation
• Promoting veterans’ awareness of the impact of wartime driving experiences on PTSD and assisting them in addressing reactions to civilian driving situations
  (AOTA, 2015)

Physical Therapy

Physical therapists are not involved in the primary treatment of PTSD but may work with those patients who have experienced an injury sustained during a trauma event that requires physical therapy interventions. Additionally, those with PTSD often experience chronic pain as a result of the complexity of the disorder, in which case the role of the physical therapist in PTSD management is one of mitigating chronic pain.

Chronic pain often occurs concurrently with PTSD, and the occurrence of both disorders tends to negatively affect the treatment outcome for each. Because of the high incidence of comorbidity of PTSD and chronic pain, physical therapists should evaluate patients with PTSD for the presence of chronic pain using a pain measure instrument, such as:

• West Haven-Yale Multi-dimensional Pain Inventory (WHYMPI), a self-report questionnaire that may be administered by a qualified therapist or research assistant and takes 20 minutes to complete
• McGill Pain Questionnaire (MPQ), a self-report questionnaire and one of the most widely used pain scales, which allows patients to describe the quality and intensity of their pain and is divided into three categories: sensory, affective and evaluative

Physical therapists are able to help patients build positive self-efficacy. This is accomplished through cognitive restructuring, development of healthy coping skills, and learning to use relaxation responses. Techniques such as situational exposure exercises and interoceptive exposure exercises are used to help decrease catastrophizing and avoidance.

Exposure therapy involves creating a safe environment in which the patient can be exposed to the things feared and avoided. The exposure to these feared objects, activities, or situations helps reduce fear and decrease avoidance.

Interoceptive exposure is a cognitive behavioral technique that can test the expectation that the physical sensations being experienced by a patient with a disorder such as PTSD are intolerable. By triggering feared sensations, patients can gain greater tolerance to distressful feelings and can learn to refute the validity of incorrect beliefs about those sensations, resulting in reduced sensitivity to them.

Physical therapists also provide patient education regarding how PTSD and pain can facilitate each other and result in avoidance. As the individual increases participation in healthy activities, co-occurring disorders such as depression, anxiety, panic, and substance abuse may decrease, resulting in a higher quality of life (O’Sullivan et al., 2019).

Complementary and Integrative Approaches

There is a growing body of research supporting the use of complementary and integrative treatment modalities for PTSD. Clinicians can use modalities such as mindfulness-based interventions and yoga when treating patients with PTSD.

MINDFULNESS-BASED INTERVENTIONS

Mindfulness-based interventions (MBIs) involve paying attention in a particular manner, on purpose, in the present without making any judgments. Present-centered awareness and nonjudgmental acceptance may function as indirect exposure to trauma-related stimuli, both internal and external, resulting in a reduction of behavioral avoidance and physiological arousal.

Present-centered awareness diminishes worry and catastrophic thinking, and through this training, the patient is able to gain an understanding that cognitions and beliefs are mental phenomena rather than facts. Hyperarousal and the behavioral elements of PTSD are also affected positively or lessened by MBIs.

Several benefits may result from using MBIs to strengthen evidence-based, trauma-focused psychotherapies that do not already emphasize mindfulness. These interventions can assist with engagement, facilitate preparation for involvement in trauma-focused psychotherapies, and foster adherence to treatment. MBIs can also help maintain the patient’s commitment to the further development of the skills learned in treatment (Sornborger et al., 2017).

YOGA

Yoga involves a combination of physical postures, controlled breathing, meditation, and yogic ethics and philosophy. Yoga has been associated with improvement in depression, anxiety, and stress, with few to no side effects.

Yoga is believed to restore balance in the autonomic nervous system and enhance interoceptive awareness. Its effects may also be mediated by increased mindfulness and self-compassion. This can assist trauma survivors to approach symptoms with acceptance and potentially decrease reactivity and avoidance behaviors.

Clinicians should be aware that it is important that yoga be considered a possible adjunctive intervention for PTSD and not a foundational or stand-alone treatment (Gallegos et al., 2017; Sornborger et al., 2017).

Evaluation of Interventions

Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. The primary outcome is symptom reduction. This is evaluated using clinician-rated and self-reported measures that address the symptoms the patient presented with, and asks if they have lessened, remained the same, or increased. Other goals to be evaluated include:

• Have comorbid medical or psychiatric conditions been prevented or reduced?
• Has there been a remission of all symptoms?
• Has the patient’s quality of life improved?
• Has the patient effectively dealt with disability/functional impairment?
• Has the patient returned to work or to active duty?

CONCLUSION

The American Psychiatric Association first introduced the diagnosis of PTSD in 1980, and since then it has been the subject of much ongoing study and research. Evidence shows that there are numerous and variable situations that can lead to the development of PTSD as well as a variable time span in which the disorder may make itself known. There is yet much to be learned about this complex disorder and how best to treat it. It is necessary, however, that healthcare professionals, regardless of the specialty or clinical situation in which they work, have a baseline understanding of how this disorder presents and the most current interventions available to both patients and support persons.

Healthcare professionals should make veterans under their care aware that specialists provide regular outpatient care to veterans with PTSD symptoms in each VA medical center in the United States, even if there it has no specific PTSD program. Special residential or inpatient care programs can be found in each region of the country, and providers offer added PTSD care in some of the VA’s large community-based outpatient clinics. VA medical centers or clinics can also provide counseling via telemental healthcare.