Treating PTSD: What I Learned From Veterans
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Hani Raoul Khouzam MD, MPH, FAPA
For 26 years I have had the privilege of working at the Department of Veteran Affairs (VA) and treating veterans who suffer from posttraumatic stress disorder (PTSD). The caring for and treatment of veterans with PTSD offers a unique perspective into the complexity of this psychiatric condition and has taught me how to treat patients with PTSD.
PTSD emerged in the psychiatric profession due to the plight of Vietnam War veterans who presented with multiple psychiatric symptoms that did not fit a specific psychiatric diagnosis. The diagnosis of PTSD first appeared in the American Psychiatric Association’s Diagnostic and Statistical Manual Mental Disorders, Third Edition (DSM-III) in 1980, and the latest edition was published in 2013 as DSM-5.1 Since 1980, the VA has taken the lead, not just in the United States but worldwide, in accurately diagnosing and managing PTSD using the most comprehensive and integrated evidence-based treatment approaches.
Here are 7 pearls of wisdom that I learned about the identification and treatment of veterans with PTSD:
- Address and treat co-occurring medical, psychiatric, and substance use disorders concurrently with PTSD. Traditional approaches of either sequential or parallel treatment of medical, psychiatric, and substance use disorders are usually ineffective when PTSD symptoms are adversely affected by the presence of underlying medical conditions and co-occurring psychiatric or substance use disorders.2
- PTSD is associated with multiple comorbidities, including increased incidence of hypertension and dementia in World War II veterans, prostate cancer and type 2 diabetes in Vietnam War veterans, amyotrophic lateral sclerosis in Gulf War veterans, traumatic brain injuries in Afghanistan and Iraq Wars veterans, and chronic pain in many veterans.3
- Pharmacotherapy is often necessary. Though the US Food and Drug Administration (FDA) only approved 2 antidepressants, sertraline and paroxetine, for the pharmacological treatment of PTSD, many veterans require various classes of medications and sometimes a combination of medications,4 such as other antidepressants, antiadrenergic agents, anticonvulsants/mood stabilizers, and atypical antipsychotics for the management of the various symptom clusters associated with PTSD—including intrusion, avoidance, negative alterations in cognitions and mood, and the alterations in arousal and reactivity.1
- Some pharmacological therapies do not improve symptoms. Benzodiazepines and hypnotic agents such as zolpidem, zaleplon, and zopiclone are relatively contraindicated in the treatment of veterans with PTSD. This is due to their association with the lack of improvement of symptoms and possible contribution to the worsening of overall severity of symptoms, psychotherapy outcomes, disinhibition, depression, and substance use disorders.5
- Many veterans with PTSD have difficulty initiating or maintaining sleep. Increased PTSD severity is associated with increased sleep disturbance. It is of paramount importance to address and manage these sleep disturbances by implementing various psychotherapeutic rather than pharmacological interventions, with the exception of using Prazosin for the management of nightmares.6
- Nonpharmacological intervention and Psychotherapy are important as well. Prolonged Exposure and Cognitive Processing Therapy are considered the 2 trauma-focused psychotherapies with the strongest evidence base for the treatment of veterans with PTSD.7 However, some veterans have also benefited from Acceptance and Commitment Therapy.8,9
- Intervention saves lives. Social and spiritual intervention and the inclusion of families, friends, and significant others are of integral importance for the successful overall management of veterans with PTSD, especially in those who are experiencing the associated symptoms of social avoidance, interpersonal isolation, survivor guilt, and those who are at risk of suicide.8-10
Hani Raoul Khouzam MD, MPH, FAPA, is a former professor of psychiatry at Geisel Medical School at Dartmouth, in Hanover, New Hampshire, and a former health sciences clinical professor of psychiatry at the UCSF-Fresno Medical Education Program in Fresno, California. He is currently a psychiatrist at the General Mental Health Clinic and the PTSD Program at the Sacramento VA Northern California Health Care System in Mather, California.
- Friedman MJ. Finalizing PTSD in DSM-5: getting here from there and where to go next. J Trauma Stress. 2013;26(5):548-556. doi:10.1002/jts.21840.
- Bohnert KM, Sripada RK, Mach J, McCarthy JF. Same-day integrated mental health care and PTSD diagnosis and treatment among VHA primary care patients with positive PTSD screens. Psychiatr Serv. 2016;67(1):94-100. doi:10.1176/appi.ps.201500035.
- Breland JY, Greenbaum MA, Zulman DM, Rosen CS. The effect of medical comorbidities on male and female Veterans’ use of psychotherapy for PTSD. Med Care. 2015;53(4 Suppl 1):S120-127. doi:10.1097/MLR.0000000000000284.
- Khouzam HR. Posttraumatic stress disorder: the pharmacological treatment plan. Consultant. 2013;53(9):643-665.
- Lund BC, Bernardy NC, Vaughan-Sarrazin M, Alexander B, Friedman MJ. Patient and facility characteristics associated with benzodiazepine prescribing for veterans with PTSD. Psychiatr Serv. 2013;64(2):149-155. doi:10.1176/appi.ps.201200267.
- LaMotte AD, Taft CT, Weatherill RP, et al. Sleep problems and physical pain as moderators of the relationship between PTSD symptoms and aggression in returning veterans. Psychol Trauma. 2017; 9(1):113-116. doi:10.1037/tra0000178.
- Shiner B, D’Avolio LW, Nguyen TM, et al. Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health. 2013;40(4):311-318. doi:10.1007/s10488-012-0421-0.
- Orsillo SM, Batten SV. Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behav Modif. 2005;29(1):95-129.
- Khouzam HR, Mathew JJ, Nile LM, Galvez SR. Case study of acceptance commitment therapy for childhood onset posttraumatic stress disorder: a patient’s unique use of the lord’s prayer. J Trauma Stress Disor Treat. 2016;5(2). doi:10.4172/2324-8947.1000155.
- Gradus JL, Smith BN, Vogt D. Family support, family stress, and suicidal ideation in a combat-exposed sample of Operation Enduring Freedom/Operation Iraqi Freedom veterans. Anxiety Stress Coping. 2015;28(6):706-715. doi:10.1080/10615806.2015.