Trauma Ch. 12

• Trauma survivors in regular psychotherapy

  • Take psychiatric medications of one type or another
  • Drug side effects can have significant differences between adolescent and adult biology
• Appropriate psychiatric referrals and recommendations are needed for severely traumatized individuals
• Psychobiology of trauma


  • Multiple biologic pathways to posttraumatic stress, no one model will suffice
  • PTSD as a collection of outcomes that vary depending on individual differences in genetics, underlying neurophysiology, stress response, and exposure to traumatic events
  • Unlikely there will be one ideal medication, range of pharmacological agents needed
• Normal response of body to stress

  1. Activate both the adrenergic and glucocorticoid systems, releasing norepinephrine and cortisol

  2. Two systems regulate one another, cortisol acts as a "brake" on the adrenergic system, preventing sustained sympathetic activity
• Balance not maintained


  Dysregulation occurs
• Adrenergic system (sympathetic nervous system)

  • Fight or flight response, returning to usual baseline of arousal appears disrupted in PTSD
  • Hyperactivity, release of multiple neurotransmitters and neurohormones as well as increased levels of metabolites in individuals with PTSD
• HPA axis


  • Exists in adrenal glands, cortisol release
  • Decreased cortisol and Neuropeptide Y (NPY) levels in individuals living under chronically stressful conditions
  • Exposure to trauma sensitizes the HPA axis
  • With PTSD, enhanced negative feedback loop, glucocorticoid receptors hypersensitive in some traumatized individuals
• There is a neurobiological window for optimal stress response, within which various brain compounds operate to "inhibit the continued release of (norepinephrine) so that the sympathetic nervous system doesn't overshoot
• In posttraumatic stress

  Co-occurrence of increased adrenergic activity and cortisol + NPY modulation imbalance may lead to rapid and powerful consolidation of emotionally laden traumatic memories
• Biology of trauma


  • Highly complex, with multiple systems and circuits, which overlap and interact
  • Associated with changes in serotonin levels, serotonin transporters, thyroid dysregulation, and altered immune functioning
  • PTSD impairs neurogenesis (the production of new cells within the nervous system)
• Neuroimaging findings in PTSD

  • Associated with amygdaloid hyperactivity, smaller brain white/gray matter, smaller hippocampal volumes, and smaller anterior cingulate volumes or loss
  • Decreased activation of hippocampus and dorsolateral prefrontal cortex (DLPFC), which appears to increase in size
• Integrating biological models with the self-trauma model


  Symptoms of posttraumatic stress arise from excessive activation of the sympathetic nervous system, probably in combination with dysregulation of the HPA axis and related neurohormones, leading to overconsolidation of traumatic memories
• Normal psychobiological process


  • The mind's attempts to desensitize traumatic memory by repeatedly evoking it in the context of safety
  • The normal exposure/disparity/extinction process "works" only to the extent the reexperiencing does not exceed the individual's capacities to regulate and tolerate the associated painful affect
• Psychologically resilient individuals


  Maintain sympathetic activation within a window of adaptive elevation, high enough to respond to danger but not so high as to produce incapacity, anxiety, and fear
• Treatment


  1. Carefully titrated exposure to traumatic memory so as not to overwhelm

  2. Attempts to increase emotional/stress regulation through such interventions and with medications to stabilize limbic systems and the HPA axis

  3. Reduction in overall anxiety/arousal "load"

  4. Use of medications to treat comorbid diagnoses
• Current available medications are rarely sufficient on their own for trauma treatment
• Trauma psychopharmacology concerns and recommendations

  • Close follow-up, patience regarding unwillingness, slow dose titration, adequate education on side effects, gentle encouragement and support, consideration of potential abuse, documented informed consent, avoidance of over-medication
• Psychotropic medications


  Can be useful adjunct to trauma-focused psychotherapy, providing some initial relief or reduction in intense distress, allowing clients to engage in the often difficult work of trauma-focused psychotherapy
• PTSD is highly comorbid with other psychiatric diagnoses
• Pregnancy and lactation


  • Pregnancy is a time of increased vulnerability, with higher risk for victimization and negative outcomes
  • Most psychiatric medications not studied enough on pregnant women, avoid during first trimester, medications secreted in breast milk

  
• Careful risk-benefit analysis is essential for all recommendations of psychotropic medications with pregnant women

  
• Complementary and alternative medicine

  Alternative group of therapeutic modalities involving herbal remedies, homeopathy, potential risks when combining with mainstream medication
• Maintaining a supportive, nonjudgmental attitude is essential during any discussion of complementary and alternative medicine
• Psychopharmacology for trauma


  • Antidepressants (SSRIs, not necessarily curative), other serotonergic agents, monoamine oxidase inhibitors, tricyclic antidepressants, benzodiazepines (highly addictive), mood stabilizers, adrenergic agents, antipsychotics, medications for sleep, medications for dissociation (research sparse), medications for traumatic brain injury
• Treatment approach


  1. First-line: SSRI or SNRI, sleep medications (SSRI and trazodone or prazosin), hyperarousal medications (alpha or beta blocker), psychosis medications (atypical antipsychotic with SSRI)

  2. Second-line: Trial of second SSRI if not responding, adjunctive low-dose antipsychotic if prominent symptoms remain, mood stabilizer if significant aggression or antipsychotic contraindicated, benzodiazepines only for overwhelming anxiety or acute distress
• Medications by themselves rarely resolve most cases of PTSD, but can provide initial symptom relief before psychotherapy effects take place, increasing compliance and reducing clinical dropout, sleep deprivation, and/or hyperarousal contributing to distress