Treatment of post-traumatic stress disorder

Summary of treatment options
In traumatic situations, eg, fire, earthquake, violent incident, where PTSD could develop, it is common for a type of post-traumatic counselling known as Acute Incident Debriefing to be carried out.

If PTSD has been going on for several weeks, or is very severe, more specialist help is needed. This help is usually psychological treatment, but may include the use of medications, most commonly benzodiazepines (tranquillisers) and antidepressants.

At present there are no evidence-based guidelines for the treatment of PTSD, although there is ongoing research into which treatments are most helpful. It is important when seeking help for PTSD to see a GP or therapist who is experienced in assessing and treating this condition.

It is also important that any treatment recommended is seen as a strategy to resolving the symptoms and will not necessarily lead to long term use of medication.

Psychosocial treatments

These are non-medical treatments that address the person's thinking, behaviour, relationships and environment, including their culture. Such treatments may include psychological therapies (often referred to as therapy or psychotherapy), which involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives.

Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem-solving and information giving.

Eye movement desensitisation and reprocessing (EMDR) is a fairly recent psychological technique that is undergoing research and being used in the treatment of PTSD with some claimed success.

All types of therapy/counselling should be provided to people and their families and whanau in a manner that is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices. If trained interpreters are necessary for assessment and therapy, they are to keep whatever they hear at interviews or counselling sessions strictly confidential.

Acute incident debriefing

This type of counselling aims to prevent PTSD from developing, by allowing people who have been through a stressful experience to be given the chance to talk about what happened and to express their feelings as soon as possible after the incident.  This makes it less likely they will 'block off' their feelings. Having the support of family and whanau, friends and workmates at this time is important. People need to feel that life is continuing. 

After some traumas it is also helpful to have a public ceremony to allow many people to come together and remember what has happened. For example, a religious service after a disaster in which people have died.

Psychological therapies

Psychological therapies may be useful in treating PTSD, especially if it has been going on for a long time. Therapists or counsellors involved in the treatment of PTSD practice two main strategies - one which deals with the memories and feelings about the trauma and the other which offers relaxation training to lessen anxiety and fear.

The first strategy aims to gradually bring the memories back into the person's mind, so they are not 'blocked off' any longer and the person can come to terms with them.  Over time they will become less distressing.

This type of therapy can be emotionally painful as it involves feeling and talking about the trauma, but for many people it can allow them to move on in their lives. There may, however, be some people for whom this sort of therapy is more upsetting than helpful. Not everyone finds it easy to talk about his or her feelings.

Hypnosis is sometimes used to bring back memories that have been 'blocked off'.  This should not be done without first getting advice from your doctor and other people you trust who can support you through the process. Hypnosis can potentially be distressing. It can also be that you change things as you remember them under hypnosis and this could be very confusing. There is no research evidence to show hypnosis is effective in treating PTSD.

Eye movement desensitisation and reprocessing (EMDR)
This technique is being used increasingly in the treatment of PTSD, as it is less emotionally devastating to the individual. It is a strange technique to describe, but its intention is to help the person become less anxious and upset by unpleasant memories.

In EMDR you are asked to bring to mind one of the upsetting memories then move your eyes rapidly, for example, from side to side. The theory is that this distracts you in such a way as to make the image or memory less terrifying. A growing number of therapists in New Zealand are trained in this technique, and, although the research on it is still limited, existing research is promising. It is most important to ensure that anyone using EMDR is experienced in assessing and treating people with PTSD.

Relaxation techniques
Relaxation techniques are useful to combat anxiety and sleep disturbance caused by stress. They may be enough to help a person cope, while their mind heals. Relaxation techniques are commonly used as part of PTSD therapy but can also be done alone.  There are many techniques, like listening to music, systematically tensing and relaxing the muscles, and meditation or visualisation of pleasant or inspiring things.  Breathing exercises and yoga suit some people.

Group therapy
Some people find group therapy helpful, particularly when there are a number of people who have endured a similar trauma, eg, combat or rape. In some instances the leader may be someone who has recovered from a past trauma. Some groups may offer support and a number of social activities.

Medication

Benzodiazepines (tranquillisers)
The common tranquillisers are called benzodiazepines (the Valium type of medications). They are used to treat anxiety symptoms. They increase the activity of a chemical in the brain called GABA (gamma amino butyric acid) which regulates alertness. This lessens anxiety, induces sleepiness, and makes the muscles relax.

Benzodiazepines work almost immediately and have few side effects. The main side effect of drowsiness or fatigue may be useful during the acute phase of distress. This usually wears off.

There are two ways of taking benzodiazepines. One is for very short periods to relieve great distress or allow you to cope with some important event you cannot avoid. The other, less common way, is to take them regularly for weeks or months to reduce anxiety. Because they are known to be addictive they are usually only prescribed for short periods (up to two weeks at a time).

Stopping them needs to be done gradually. Sudden stopping may produce withdrawal symptoms such as anxiety, insomnia, headaches, nausea and dizziness, and, occasionally, may induce epileptic seizures.

People with epilepsy must be careful, as withdrawal can also make seizures more likely. If you have trouble with addictions they are best avoided.

Benzodiazepines are not advised in pregnancy especially near birth, as they can affect the baby and some of them get into breast milk.

Benzodiazepines are safe with almost all other medicines. They magnify the effects of alcohol, so this should be avoided.

Benzodiazepines are a prescription-only medication and should be treated with the utmost respect. As with all medication, you should NOT under any circumstances take these medications without the authority of a GP, not even if a friend has PTSD and is taking this medication.

Common side effects of benzodiazepines

• Drowsiness is particularly dangerous for people who operate machinery or while driving vehicles.
• Muscle relaxation can be a risk for older people whose muscles may be weak and thereby increase their risk of falling.
• Confusion, particularly with older people.
• Breathing difficulties. Benzodiazepines can reduce breathing a little. Those people with severe breathing problems need to be careful.
• Dependency and withdrawal problems - as described above.

Antidepressants
Antidepressants may be helpful in reducing the symptoms of PTSD even if you are not depressed at the time. They are often used along with psychological therapy.

Antidepressants have no immediate effect and all need to be taken regularly, once or twice a day. They take up to three weeks to work and there are a number of side effects. You may need to try different medications to see which one suits you. One drug would be tried for eight to 12 weeks to see if it was helpful. 

Almost all are in tablet or in capsule form. They are not addictive, but there may be a small rebound effect of anxiety and insomnia if you suddenly stop taking them. The side effects vary from person to person.

There are two groups of antidepressants commonly used in treatment of PTSD - the older, tricyclic drugs (TCAs) and the newer Selective Serotonin Re-uptake Inhibitors (SSRIs).

Selective serotonin re-uptake inhibitors (SSRIs)
Over the past decade the Selective Serotonin Re-uptake Inhibitors (SSRI) antidepressants have become available. SSRIs have their effect specifically on serotonin. This type of antidepressant usually has fewer side effects than the tricyclics. 

Compared to tricyclics, SSRIs rarely cause drowsiness, although nausea, headaches and sexual problems may be more common. With SSRIs there are fewer problems with other medications, alcohol, and other illnesses, except if you have severe liver or heart disease. They can affect some medicines, especially those taken for epilepsy.

Unfortunately it is hard to predict who will respond to which medication and who will have side effects. Side effects should be reported to your doctor.

The TCAs also affect other neurotransmitter systems which in some people can cause unwanted side effects such as weight gain, dry mouth, constipation, drowsiness and dizziness. Nevertheless, TCAs can be very effective and are still useful for many people.

Each TCA has a different pattern of side effects, so when one is not tolerated there is likely to be another that causes less of that side effect. Because of these side effects, it is necessary to start on a low dose and increase slowly over two weeks or more to reach the effective dose (usually about 150mg per day).

Medicine interactions

Most psychiatric medicines tend to react with each other when taken in combination. Your doctor will, where possible, limit the number of medications prescribed. The effects of alcohol and many illegal drugs will also be heightened, so they should be avoided.

It is important your doctor knows all the medications (including any herbal medicines such as St John's Wort) you are taking, as some taken together can be dangerous. You should not mix different types of antidepressants unless instructed by your doctor, as this could be very dangerous.

Complementary therapies

Complementary therapies which enhance a person's life may be used in addition to psychosocial treatments and prescription medicines.

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it. There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms.

This is often referred to as a holistic approach. Complementary therapies often support a holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs.

Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing.

Rongoa Maori is the indigenous health and healing practice of New Zealand. Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Islands' people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress.

Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions.  It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other.

When considering taking any supplement, herbal or medicinal preparation it is advisable to consult a doctor or naturopath to make sure it is safe and will not harm your health.

Women who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and that they will not harm their own or their baby's health.

See also: PTSD; PTSD - living with

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2004. Edited by everybody, June 2005.