Combat-stress-related Post Traumatic Stress Disorder
by: The American Psychotherapy Association
verbatim from website
Winter 2007 www.americanpsychotherapy.com
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By Harpriya A. (Sonya) Bhagar, MBBS and Alan D. Schmetzer, MD, Fellow of the
American Psychotherapy Association, and Master Therapist
A number of veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)
are returning home with signs of combat-stress-related Post Traumatic Stress
Disorder (PTSD). In a recent study, 16.6% of the soldiers met the screening
criteria for PTSD. On average, they showed a significant increase in sick
visits, missed workdays, severity of somatic symptoms, and poorer overall health
(Hoge et al., 2007). In another study, the youngest age group, 18–24 years, was
at greater risk compared with veterans 40 years of age or above. Diagnosis was
made early (median of 13 days), and most of them were detected in primary care
clinics (Seal et al., 2007).
Upon return from the war zone, veterans frequently report intrusive thoughts,
flashbacks, increased vigilance, avoidance of social situations, hyperarousal,
and nightmares. Treatment involves integration of mental health, primary care,
physical medicine, attention to substance abuse, and vocational services. The
mental health portion involves an initial screening of the combat veteran for
PTSD and other mental illnesses, followed by a full assessment. Both
pharmacotherapy and psychotherapy (individual, couple, and group) are offered
From a pharmacological perspective, several studies have found the traditional
anti-depressants effective in PTSD. Selective serotonin reuptake inhibitors (SSRIs),
like sertraline (Zoloft®), paroxetine (Paxil®), and fluoxetine (Prozac®), have
been studied extensively for PTSD, and sertraline and paroxetine have been
approved by the Food and Drug Administration for PTSD. SSRIs have been found to
be effective both in short-term trials and long-term maintenance treatment for
relapse prevention (Asnis et al., 2004). However, earlier studies have focused
mainly on PTSD secondary to interpersonal trauma in a civilian setting. In a
multicenter study, venlafaxine extended release (Effexor XR®), a serotonin
norepinephrine reuptake inhibitor, was found to improve both the re-experiencing
and the avoidance symptoms of PTSD, but not hyperarousal. The drug was effective
and well tolerated in both short-term and continuation treatment of PTSD
(Davidson et al., 2006). In a small study, mirtazapine (Remeron) was found to be
effective in both short-term and continuation treatment of combat-stress-related
PTSD without any serious side effects (Kim et al., 2005). In addition, sedation
from mirtazapine can even prove beneficial in improving sleep in PTSD. In a
randomized trial comparing phenelzine (a monoamine oxidase inhibitor) and
imipramine (a tricyclic antidepressant), both significantly reduced combat
stress related PTSD symptoms (Kosten et al., 1991). Benzodiazepines are used in
PTSD for panic attacks or anxiety states. They provide temporary relief but run
the risk of tolerance and addiction.
Veterans with PTSD find it hard both to fall asleep and to maintain sleep due to
hyperarousal and vivid nightmares related to combat. Significant others often
report that patients scream in their sleep and may even wake up soaked in sweat.
Prasozin and clonidine both decrease the central nervous system’s noradrenergic
activity. They have been found to be effective in decreasing hyperarousal
symptoms and improving sleep (Boehnlein, 2007). Other drugs used for sleep are
the benzodiazepine class of drugs, like temazepam, and non-benzodiazepines, like
zolpidem (Ambien™) and ezopiclone (Lunesta™). However, caution must be taken
regarding the habit-forming potential of these drugs (Bhagar and Schmetzer,
The presence of psychotic symptoms in PTSD can further complicate the clinical
picture. In one study, 20% of the 91 males with combat-stress-related PTSD were
found to be suffering from hallucinations and delusions, and hyperarousal was
positively associated with the occurrence of psychotic symptoms (Kastelan,
2007). In a small study, augmentation of SSRI with olanzapine (Zyprexa), an
atypical antipsychotic, was effective in treating SSRI-resistant combat-related
PTSD symptoms, especially sleep (Stein, 2002). In another study, monotherapy
with typical or atypical antipsychotics, reduced both PTSD and psychotic
symptoms, and antipsychotics seemed to offer another approach to treat the
psychotic subtype of combat–related PTSD resistant to previous antidepressant
therapy (Pivac, 2006).
Overall, PTSD pharmacotherapy involves several drugs based on our experience
with PTSD in general, but well-designed studies are needed to establish
treatment guidelines specifically for combat-stress-related PTSD.
Asnis, G. M., Kohn, S. R., Henderson, M., & Brown, N. L. (2004). SSRIs versus
non-SSRIs in post traumatic stress disorder: an update with recommendations.
Drugs, 64(4), 383–404.
Bhagar, H. A., & Schmetzer, A. D. (2006). The newest medicines for sleep. Annals
of American Psychotherapy Association, 9(2), 25–26.
Boehnlein, J. K., & Kinzie, J. D. (2007). Pharmacologic reduction of CNS
noradrenergic activity in PTSD: The case for clonidine and prazosin. Journal of
Psychiatric Practice, 13(2), 72–78.
Davidson, J., Baldwin D., Stein, D.J., Kuper, E., Benattia, I., Ahmed, S., et
al. (2006). Treatment of post traumatic stress disorder with venlafaxine
extended release: a 6-month randomized controlled trial. Archives of General
Psychiatry, 63(10), 1158–1165.
Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S. C., & Engel, C. C.
(2007). Association of post traumatic stress disorder with somatic symptoms,
health care visits, and absenteeism among Iraq war veterans. American Journal of
Kastelan, A., Franciskovi,? T., Moro, L., Roncevic-Grzeta, I., Grkovic, J.,
Jurcan, V., et al. (2007). Psychotic symptoms in combat-related post traumatic
stress disorder. Military Medicine, 172(3), 273–277.
Kim, W., Pae, C. U., Chae, J. H., Jun, T. Y., & Bahk, W. M. (2005). The
effectiveness of mirtazapine in the treatment of post-traumatic stress disorder:
A 24-week continuation therapy. Psychiatry and Clinical Neurosciences, 59(6),
Kosten, T. R., Frank, J. B., Dan, E., McDougle, C. J., & Gille, E. L., Jr.
(1991). Pharmacotherapy for posttraumatic stress disorder using phenelzine or
imipramine. Journal of Nervous and Mental Disease, 179(6), 366–370.
Martényi, F. (2005). [Three paradigms in the treatment of posttraumatic stress
disorder]. Neuropsychopharmacol Hung, 7(1), 11–21.
Pivac, N., & Kozari?-Kovaci,? D. (2006). Pharmacotherapy of treatment-resistant
combat-related posttraumatic stress disorder with psychotic features. Croatian
Medical Journal, 47(3), 440–451.
Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007).
Bringing the war back home: mental health disorders among 103,788 US veterans
returning from Iraq and Afghanistan seen at Department of Veterans Affairs
facilities. Archives of Internal Medicine, 167(5), 476–482.
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