Addressing Sleep Impairment in Treatment Guidelines for PTSD

The Complexity of Complex PTSD

The purpose of this study was to examine factors predicting the development of posttraumatic stress symptoms after a traumatic event, the 1991 Oakland/Berkeley firestorm. The major predictive factors of interest were dissociative, anxiety, and loss of personal autonomy symptoms reported in the immediate aftermath of the fire; contact with the fire; and life stressors before and after the fire. Subjects were recruited from several sources so that they would vary in their extent of contact with the fire. Of 187 participants who completed self-report measures about their experiences in the aftermath of the firestorm, 154 completed a follow-up assessment. Of these 154 subjects, 97% completed the follow-up questionnaires 7-9 months after the fire. The questionnaires included measures of posttraumatic stress and life events since the fire. Dissociative and loss of personal autonomy symptoms experienced in the fire's immediate aftermath, as well as stressful life experiences occurring later, significantly predicted posttraumatic stress symptoms measured 7-9 months after the firestorm by a civilian version of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Impact of Event Scale. Dissociative symptoms more strongly predicted posttraumatic symptoms than did anxiety and loss of personal autonomy symptoms. Intrusive thinking differs from other kinds of posttraumatic symptoms in being related directly to the trauma and previous stressful life events. These findings suggest that dissociative symptoms experienced in the immediate aftermath of a traumatic experience and subsequent stressful experiences are indicative of risk for the later development of posttraumatic stress symptoms. Such measures may be useful as screening procedures for identifying those most likely to need clinical care to help them work through their reactions to the traumatic event and to subsequent stressful experiences.

Back to table of contents Previous article Next article Communications and UpdatesFull AccessResponse to Ticlea et al.Anne Germain, Ph.D.Anne GermainSearch for more papers by this author, Ph.D.Published Online:1 Sep 2013https://doi.org/10.1176/appi.ajp.2013.13050641rAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I wish to thank Ticlea et al. for correcting the statement that there was no available guideline for the treatment of sleep disturbances comorbid with posttraumatic stress disorder (PTSD). Drs. Bajor, Ticlea, and Osser (1) have indeed suggested sensible and evidence-based guidelines for the management of nightmares and insomnia as the first decision point in the pharmacological treatment of PTSD in adults. Specifically, they recommend the use of prazosin and trazodone for nightmares and insomnia, respectively. They also offer additional recommendations in case of nonresponse.Similar efforts to guide the management of sleep disturbances comorbid with PTSD using cognitive-behavioral strategies, or with the combination of pharmacological and psychological treatments, are lacking. As noted in the original article (2) and by Ticlea et al., the restoration of consolidated sleep, through pharmacological or psychological treatments, is likely to play a critical role in providing the neural milieu necessary to facilitate sleep-dependent learning processes involved in PTSD recovery.From the Department of Psychiatry, University of Pittsburgh, Pa.The author’s disclosures accompany the original article.References1 Bajor LA, Ticlea AN, Osser DN: The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder. Harv Rev Psychiatry 2011; 19:240–258Crossref, Medline, Google Scholar2 Germain A: Sleep disturbances as the hallmark of PTSD: where are we now? Am J Psychiatry 2013; 170:372–382Link, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 170Issue 9 September 2013Pages 1059-1059 Metrics PDF download History Accepted 1 June 2013 Published online 1 September 2013 Published in print 1 September 2013

Toward Rational Pharmacotherapy for Posttraumatic Stress Disorder: Reprise

This study sought to determine whether a set of symptoms interpreted as complicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation of physiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects' spouses, and follow-up data were collected from 56 of the subjects 18 months after the baseline assessments. Candidate items for assessing complicated grief came from a variety of scales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the Brief Symptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. A principal-components analysis conducted on intake data (N = 82) revealed a complicated grief factor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated grief scores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment.

Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.

Distressing and intrusive reexperiencing of the trauma is a hallmark symptom of posttraumatic stress disorder (PTSD; American Psychiatric Association, 1994). However, unwanted memories of trauma are not a sign of pathology per se. In the initial weeks after a traumatic experience, intrusive memories are common. For most trauma survivors, intrusions become less frequent and distressing over time. A central question for understanding and treating patients with PTSD is therefore what maintains distressing intrusive reexperiencing in these people. Three factors appear to be important: (1) memory processes responsible for the easy triggering of intrusive memories, (2) the individuals’ interpretations of their trauma memories, and (3) their cognitive and behavioral responses to trauma memories.

The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program (PAPHSS) published algorithms for bipolar depression in 1999 and 2010. Developments over the past 9years suggest that another update is needed. The 2010 algorithm and associated references were reevaluated. A literature search was conducted on PubMed for recent studies and review articles to see what changes in the recommendations were justified. Exceptions to the main algorithm for special patient populations, including those with attention-deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), substance use disorders, anxiety disorders, and women of childbearing potential, and those with common medical comorbidities were considered. Electroconvulsive therapy (ECT) is still the first-line option for patients in need of urgent treatment. Five medications are recommended for early usage in acute bipolar depression, singly or in combinations when monotherapy fails, the order to be determined by considerations such as side effect vulnerability and patient preference. The five are lamotrigine, lurasidone, lithium, quetiapine, and cariprazine. After trials of these, possible options include antidepressants (bupropion and selective serotonin reuptake inhibitors are preferred) or valproate (very small evidence-base). In bipolar II depression, the support for antidepressants is a little stronger but depression with mixed features and rapid cycling would usually lead to further postponement of antidepressants. Olanzapine+fluoxetine, though Food and Drug Administration (FDA) approved for bipolar depression, is not considered until beyond this point, due to metabolic side effects. The algorithm concludes with a table of other possible treatments that have some evidence. This revision incorporates the latest FDA-approved treatments (lurasidone and cariprazine) and important new studies and organizes the evidence systematically.

Posttraumatic stress disorder (PTSD) is one of the few psychiatric conditions in which a subjective decrease in emotional range serves as a diagnostic criterion. In order to investigate whether veterans with chronic PTSD also experienced objective limitations in emotional perception, the authors administered the Aprosodia Battery to a group of 11 veterans with chronic PTSD, nine subjects with right hemisphere damage, seven subjects with left hemisphere damage, and 12 comparison subjects. The patients with PTSD displayed significant deficiencies in the comprehension and discriminative components of affective speech, similar in severity and performance profile on the Aprosodia Battery to the individuals with focal right hemisphere damage due to ischemic infarction.

IntroductionThe lifetime prevalence of comorbid posttraumatic stress disorder (PTSD) in patients with bipolar disorder (BD) is approximately 20%. Guidelines for BD give adequate pharmacological treatment options when there is a ‘pure’ bipolar disorder but lack of treatment options when there is a comorbid disorder present.ObjectivesThe present study aimed to review the pharmacological treatment options for comorbid PTSD in patients with BD.MethodsLiterature research was conducted via PubMed, Embase and the Cochrane Library. Search terms included ‘bipolar disorder’, ‘posttraumatic stress disorder’, ‘PTSD’, ‘pharmacotherapy’ and ‘treatment’. Relevant studies were reviewed.ResultsNo randomized controlled trials have been conducted in patients with bipolar disorder and comorbid PTSD. Most studies included open-label studies and case-reports. No convincing scientific evidence for pharmacological treatment of comorbid PTSD in patients with BD was found. Selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of PTSD. However, SSRIs or other antidepressants are complicated due to potential induction of a manic episode or promote rapid cycling. Nevertheless, it is important to treat the bipolar patient with a mood stabilizer first before antidepressants are prescribed.ConclusionsThe findings of this study show that there is no convincing scientific evidence for the pharmacological treatment of comorbid PTSD in patients with bipolar disorder. Therefore, psychotherapy is preferable. When psychotherapy is not effective, pharmacotherapy can be considered. However, randomized controlled trials are needed to obtain scientific evidence for pharmacological treatment options.DisclosureNo significant relationships.

Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established. We undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1-4-month follow-up, and remission post-treatment. We included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) -2.07; 95% credible interval (CrI) -2.70 to -1.44], combined somatic/cognitive therapies (SMD -1.69; 95% CrI -2.66 to -0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD -1.46; 95% CrI -1.87 to -1.05) and self-help with support (SMD -1.46; 95% CrI -2.33 to -0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1-4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence. EMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.

3,4-methylenedioxymethamphetamine-assisted therapy (MDMA-AT) is currently being evaluated for treatment of patients with moderate or higher severity post-traumatic stress disorder (PTSD). To provide a comprehensive summary of investigational MDMA-AT and current treatments for PTSD. A search was conducted in PubMed and Embase (December 20, 2023). Populations included adults with chronic, treatment-resistant, moderate or higher severity PTSD. Interventions were MDMA-AT and comparators based on PTSD treatment guidelines. The primary outcome of interest was the Clinician-Administered PTSD Scale (CAPS) score. Other outcomes observed were Beck Depression Inventory (BDI), and loss of diagnosis (LOD). Studies observing chronic, moderate or higher severity treatment-resistant PTSD in adults were included. Only randomized controlled trials published in English were considered. The NICE quality appraisal checklist was used to assess risk of bias in included studies. We provided qualitative synthesis of evidence presented in extraction tables. Overall, 77 studies were included. Phase II/III trials consistently reported significantly greater CAPS improvement with MDMA-AT vs. placebo with therapy (PT) after two or three interventional sessions. Durability was observed in a long-term follow-up trial (mean duration, 45.4 months) with a 0.9-point CAPS decrease from post-treatment. FDA-approved and off-label medications used for PTSD treatment did not yield a consistently greater CAPS decrease vs. control arms across trials. Significant CAPS improvement was consistently observed in venlafaxine ER, olanzapine, propranolol (with traumatic memory reactivation), nefazodone, and nabilone placebo-controlled trials. Most psychotherapy trials lacked between-group statistical assessments. Significant CAPS decrease compared to the waitlist was reported for cognitive therapy (CT), cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), prolonged exposure (PE), and group cognitive exposure therapy. CAPS improvement was persistent for CPT and PE in long-term follow up (mean duration 6.2 years). MDMA-AT demonstrated significant improvement in BDI-II score compared to PT (19.7-point vs. 10.8-point decrease, respectively; p = 0.003). The percentage of participants with LOD after two or three active-dose MDMA-AT sessions ranged from 41.7-83.3%. This systematic review suggests current treatments for PTSD are associated with heterogeneous evidence and the majority do not demonstrate sustained effects. Results from MDMA-AT showed consistent improvements in CAPS, BDI and LOD.

<p dir="ltr">Background: Most people experience traumatic events, for instance a natural disaster or the unexpected death of a loved one.</p><p dir="ltr">Some people then develop posttraumatic stress disorder (PTSD), a debilitating disorder characterized by intrusion symptoms, e.g. intense distress and nightmares, avoidance, negative changes in cognitions and mood as well as changes in arousal and reactivity, e.g. startling easily and finding it difficult to concentrate. PTSD is approximately twice as common among women as among men.</p><p dir="ltr">Some people find that alcohol provides short-term relief from their PTSD symptoms, for example by reducing intense distress or being able to sleep and wake without remembering one's nightmares. Over time alcohol use can lead to alcohol use disorder (AUD), which is characterized by problematic alcohol use. There are other trajectories to comorbid PTSD and AUD, but this is the most supported by research to date. PTSD and AUD often occur together.</p><p dir="ltr">PTSD and AUD are associated with negative outcomes, e.g. other mental disorders, suicidality and ill physical health. Similarly, PTSD and alcohol use during pregnancy are associated with adverse outcomes for those pregnant as well as their expected children, including antepartum complications and fetal alcohol spectrum disorders (FASD).</p><p dir="ltr">Comorbid PTSD and AUD tend to be more severe and more impairing than either disorder on its own. For instance, higher rates of comorbid mental disorders, suicidality and homelessness have been found among people with comorbid PTSD and AUD than among individuals with either PTSD or AUD.</p><p dir="ltr">Comorbid PTSD and AUD are regarded as difficult to treat. Traditionally, sequential treatment, where AUD was treated first, then PTSD, was suggested. Patients were typically required to achieve and maintain abstinence before PTSD treatment was initiated, something which potentially is a great barrier to PTSD treatment for those with comorbid PTSD and AUD.</p><p dir="ltr">Great strides have been made in developing treatment of comorbid PTSD and AUD, but the evidence on how to treat comorbid PTSD and AUD is not yet robust. Women are overrepresented among those with comorbid PTSD and AUD, yet, underrepresented in the extant treatment research. Trials of treatment of comorbid PTSD and AUD have included mainly men. Women and men may have different treatment needs and may also respond differently to treatment. So, we need to know more about treatment of comorbid PTSD and AUD in women.</p><p dir="ltr">Objectives: The present thesis sought to estimate the current prevalence of PTSD and alcohol use during pregnancy in Stockholm, Sweden, and to investigate the safety, feasibility, and efficacy of concurrent treatment of comorbid PTSD and AUD, which does not require abstinence, in treatment- seeking women with comorbid PTSD and AUD in Swedish healthcare.</p><p dir="ltr">Methods: Cross-sectional studies were conducted to estimate the current prevalence of PTSD and alcohol use during pregnancy. A pilot study was undertaken to investigate the safety and feasibility of concurrent treatment of PTSD and AUD in treatment-seeking women in Swedish healthcare. A randomized clinical trial was conducted to investigate whether concurrent treatment of PTSD and AUD reduces PTSD symptom severity and alcohol use more than AUD treatment in treatment-seeking women with comorbid PTSD and AUD in Swedish healthcare.</p><p dir="ltr">Results: Approximately 4.1 percent of pregnant people are estimated to have current PTSD and approximately 4.2 percent estimated to use alcohol during pregnancy in Stockholm, Sweden. Concurrent treatment of PTSD and AUD in women was safe and feasible. In the randomized clinical trial, PTSD symptom severity and alcohol use decreased from baseline to 9-month follow-up for both treatments. There was a significantly greater reduction in PTSD symptom severity in the concurrent treatment arm than in the AUD treatment arm. There was no detectable difference in alcohol use between treatments.</p><p dir="ltr">Conclusions: Further efforts to spread information about alcohol use during pregnancy may be needed, continued screening for alcohol use during pregnancy is warranted as well as treatment of risky alcohol use and AUD, when necessary, to reduce the risk of adverse outcomes for those pregnant as well as their expected children. It may be useful to investigate screening for PTSD in antenatal care further, to evaluate whether systematic screening for PTSD should be introduced in antenatal care. The present findings indicate that concurrent treatment of PTSD and AUD is feasible, safe, and efficacious for treatment-seeking women with comorbid PTSD and AUD in Swedish healthcare, and that abstinence is not required before or during treatment.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Persson, A;</b> Lindmark, S; Petersson, K; Gabriel, E; Thorsell, M; Lindström, K; Göransson, M; Cardell, G; Magnusson, Å. Fear of childbirth, potentially traumatic events and posttraumatic stress disorder during pregnancy in Stockholm, Sweden: A cross-sectional study. Sexual & Reproductive Healthcare, 2020, Vol. 25, p. 100516. <a href="https://doi.org/10.1016/j.srhc.2020.100516" rel="noreferrer" target="_blank">https://doi.org/10.1016/j.srhc.2020.100516</a></p><p dir="ltr">II. <b>Persson, A;</b> Lindmark, S; Petersson, K; Gabriel, E; Thorsell, M; Lindström, K; Göransson, M; Cardell, G; Magnusson, Å. Alcohol and illicit and non-medical prescription drug use before and during pregnancy in Stockholm, Sweden: A cross-sectional study. Sexual & Reproductive Healthcare, 2021, Vol. 29, p. 100622. <a href="https://doi.org/10.1016/j.srhc.2021.100622" rel="noreferrer" target="_blank">https://doi.org/10.1016/j.srhc.2021.100622</a></p><p dir="ltr">III. <b>Persson, A;</b> Back, S E; Killeen, T K; Brady, K T; Schwandt, M L; Heilig, M; Magnusson, A. Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): A pilot study in alcohol-dependent women. Journal of Addiction Medicine, 2017, Vol. 11(2), p. 119-125. <a href="https://doi.org/10.1097/ADM.0000000000000286" rel="noreferrer" target="_blank">https://doi.org/10.1097/ADM.0000000000000286</a></p><p dir="ltr">IV. <b>Persson, A;</b> Axén, Å; Capusan, A J; Magnusson, Å; Heilig, M. Concurrent Treatment of Posttraumatic Stress Disorder and Alcohol Use Disorder in Women: A Randomized Clinical Trial. JAMA Network Open, 2025, Vol. 8(7), p. e2521087. <a href="https://doi.org/10.1001/jamanetworkopen.2025.21087" rel="noreferrer" target="_blank">https://doi.org/10.1001/jamanetworkopen.2025.21087</a></p>

This revision of previous algorithms for the pharmacotherapy of generalized anxiety disorder was developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. Algorithms from 1999 and 2010 and associated references were reevaluated. Newer studies and reviews published from 2008-14 were obtained from PubMed and analyzed with a focus on their potential to justify changes in the recommendations. Exceptions to the main algorithm for special patient populations, such as women of childbearing potential, pregnant women, the elderly, and those with common medical and psychiatric comorbidities, were considered. Selective serotonin reuptake inhibitors (SSRIs) are still the basic first-line medication. Early alternatives include duloxetine, buspirone, hydroxyzine, pregabalin, or bupropion, in that order. If response is inadequate, then the second recommendation is to try a different SSRI. Additional alternatives now include benzodiazepines, venlafaxine, kava, and agomelatine. If the response to the second SSRI is unsatisfactory, then the recommendation is to try a serotonin-norepinephrine reuptake inhibitor (SNRI). Other alternatives to SSRIs and SNRIs for treatment-resistant or treatment-intolerant patients include tricyclic antidepressants, second-generation antipsychotics, and valproate. This revision of the GAD algorithm responds to issues raised by new treatments under development (such as pregabalin) and organizes the evidence systematically for practical clinical application.