A review of the psychobiology and pharmacotherapy of posttraumatic stress disorder

Disaster Care: Psychological Considerations

Disasters are tragic events that disrupt the normal functioning ofa community and overwhelm personal and community resources. The people who experience or simply witness traumatic events can be affected emotionally and develop a range of physical and emotional responses, which in turn can produce psychological, social, and physiological dysfunction. The challenge for health care providers is to recognize the range of emotions and to be able to identify when professional help is indicated. This article provides an overview of the human stress response and describes sources of stress that follow disasters, acute stress disorder, post-traumatic stress disorder, and interventions and resources used to care for victims after disasters.

The role of endogenous opioids in the placebo effect in post-traumatic stress disorder

The concept of the placebo effect has received a considerable attention over the past several decades. The placebo effect has been observed in different psychiatric disorders, including post-traumatic stress disorder (PTSD), a chronic and severe disorder precipitated by exposure to a psychologically distressing event. The placebo response rates in patients with PTSD range from 19% to 62%. A considerable number of research publications suggest that endogenous opioids are involved in the mechanisms of the placebo effect. Endogenous opioid peptides play an important role in stress response and in the pathophysiology of PTSD. Therefore, endogenous opioids may be involved in the neurobiology of the placebo effect in PTSD. Possibly, the endogenous opioid system mediates the effect of placebo on all 3 PTSD symptom clusters (re-experiencing symptoms, avoidance and numbing, and physiologic arousal). The placebo effect-related activation of the endogenous opioid system may result in an improvement in intrusive symptomatology and symptoms of increased arousal because the administration of exogenous opioids improve these symptoms. The placebo effect-related activation of the endogenous opioid system may have a mood-enhancing effect, and, consequently, diminish avoidance and numbing. Multiple neurotransmitter and neuroendocrine pathways may be involved in the mechanisms of the placebo effect in PTSD. Further studies of the neurobiology of the placebo effect on patients with PTSD and other psychiatric disorders may produce interesting and important results.

Higher cerebrospinal fluid homovanillic acid levels in depressed patients with comorbid posttraumatic stress disorder

Major depression and posttraumatic stress disorder (PTSD) are often comorbid, resulting in more impairment compared than with either diagnosis alone. Both major depression and PTSD are thought to be associated with monoamine transmitter abnormalities. This study compared clinical features and cerebrospinal fluid (CSF) monoamine metabolites in drug-free depressed subjects with a current major depressive episode (MDE) without comorbid PTSD, subjects with a current MDE and comorbid PTSD, and healthy volunteers. Depressed subjects with comorbid PTSD had higher CSF homovanillic acid (HVA) levels compared with depressed subjects without comorbid PTSD or healthy volunteers. Higher HVA was present after adjustment for sex, lifetime aggression severity and depression scores, alcoholism, tobacco smoking, comorbid cluster B personality disorder, reported childhood abuse, and psychosis. We found no group difference in CSF 5-hydroxyindolacetic acid (5-HIAA) and 3-methoxy-4-hydroxyphenylglycol (MHPG) levels. Higher dopaminergic activity may contribute to alterations in memory and other cognitive functions, anhedonia, and hypervigilance observed in PTSD.

Relação entre estressores, estresse e ansiedade

Os autores apresentam uma breve revisão de literatura sobre a relação entre ansiedade, eventos estressores e estresse. São descritas as diferentes situações estressoras, a definição de evento de vida estressor e os aspectos cognitivos, comportamentais e fisiológicos da resposta frente ao estresse. A neuroanatomia e os principais neurotransmissores envolvidos na resposta fisiológica de ansiedade ao estresse são descritos. Estudos genéticos que evidenciam a relação entre os eventos de vida estressores como fator de risco para ansiedade são apresentados. A relação causal entre os eventos de vida estressores e o aparecimento de ansiedade é abordada a partir de estudos realizados com adultos e adolescentes.

To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors

Standard psychiatric classification (DSM-IV-TR) traditionally attributes post-traumatic sleep disturbance to a secondary or symptomatic feature of a primary psychiatric disorder. The DSM-IV-TR paradigm, however, has not been validated with objective sleep assessment technology, incorporated nosological constructs from the field of sleep disorders medicine, or adequately addressed the potential for post-traumatic stress disorder (PTSD) sleep problems to manifest as primary, physical disorders, requiring independent medical assessments and therapies. This paradigm may limit understanding of sleep problems in PTSD by promulgating such terms as "insomnia related to another mental disorder," a.k.a. "psychiatric insomnia." Emerging evidence invites a broader comorbidity perspective, based on recent findings that post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). In this model of complex sleep disturbance, the underlying sleep pathophysiology interacts with PTSD and related psychiatric distress; and this relationship appears very important as demonstrated by improvement in insomnia, nightmares, and post-traumatic stress with successful SDB treatment, independent of psychiatric interventions. Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. Related findings and clinical experience suggest that other types of chronic insomnia may also be related to SDB. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia. We discuss potential neurohormonal pathways and neuroanatomatical sites that may be involved in this proposed interaction between insomnia and SDB.

The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia, and PTSD

Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity.

Olanzapine in the treatment of post-traumatic stress disorder: a pilot study

Because the atypical antipsychotic olanzapine may be efficacious in treating post-traumatic stress disorder (PTSD) symptoms, we conducted a 10-week, double-blind, placebo-controlled evaluation in which 15 patients were randomized 2:1 to either olanzapine or placebo. The initial dosage was 5 mg/day and was titrated to a maximum of 20 mg/day. Eleven patients completed the study. Patients in both groups showed improvement in PTSD symptoms, but no between-group differences in treatment response were observed and a high placebo response rate was found. Both treatments were tolerated well, although the olanzapine treatment group had more weight gain. Olanzapine fared no better than placebo in this preliminary study in the treatment of PTSD. The lack of difference between olanzapine and placebo may in part be due to olanzapine's not being effective in PTSD or, alternatively, a small sample size, a high placebo response in certain forms of PTSD and the chronicity of PTSD symptoms in some patients.

A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing

OBJECTIVE

To assess the impact of treatment for co-morbid sleep-disordered breathing (SDB) on patients with nightmares and post-traumatic stress.

METHODS

Twenty-three chronic nightmare sufferers (15 with post-traumatic stress disorder, PTSD) who also suffered co-morbid SDB (obstructive sleep apnea, OSA, n=16; upper airway resistance syndrome, UARS, n=7) completed a telephone interview, on average, 21 months after having been offered treatment for SDB at a university sleep disorders clinic.

RESULTS

At follow-up, 14 reported maintaining treatment (Treatment Group) and 9 reported discontinuing treatment (No-Treatment Group). More patients in the Treatment Group reported improvement in sleep (93% vs. 33%) and in daytime well being (93% vs. 33%) compared with those in the No-Treatment group. The Treatment Group reported a median improvement in nightmares of 85% compared with a median 10% worsening in the No-Treatment Group. In the PTSD subset (n=15), nine in the Treatment Group reported a median 75% improvement in PTSD symptoms whereas six in the No-Treatment Group reported a median 43% worsening.

CONCLUSION

In this small sample of patients, treatment of SDB was associated with improvements in nightmares and PTSD. Relationships between nightmares, PTSD and SDB are discussed.

Acute effects of glucocorticoids: behavioral and pharmacological perspectives

There has been evidence since the early eighties that glucocorticoids, apart from their well known chronic effects, may have acute, short-term effects. However, a lack of understanding of the molecular mechanisms of action has hampered appreciation of these observations. Mounting evidence over the years has continued to confirm the early observations on a fast corticosterone control of acute behavioral responses. We summarize experimental data obtained mainly in rats but also in other species which show: (1) that glucocorticoid production is sufficiently quick to affect ongoing behavior; (2) that there exist molecular mechanisms that could conceivably explain the fast neuronal effects of glucocorticoids (although these are still insufficiently understood); (3) that glucocorticoids are able to stimulate a wide variety of behaviors within minutes; and (4) that acute glucocorticoid production (at least in the case of aggressive behavior) is linked to the achievement of the behavioral goal (winning). The achievement of the behavioral goal reduces glucocorticoid production. It is argued that glucocorticoids are regulatory factors having a well-defined behavioral role. Both the acute (stimulatory) effects and the chronic (inhibitory) effects are adaptive in nature. The acute control of behavior by corticosterone is a rather unknown process that deserves further investigation. The pharmacologic importance of the acute glucocorticoid response is that it may readily affect the action of pharmacologic agents. An interaction between acute glucocorticoid increases and noradrenergic treatments has been shown in the case of offensive and defensive agonistic behavior. Non-behavioral data demonstrate that acute increases in glucocorticoids may interfere with other neurotransmitter systems (e.g., with the 5HT system) as well. These observations show the importance of taking into account endocrine background and endocrine responsiveness in behavior pharmacological experiments.

The prevalence of posttraumatic stress disorder in an adolescent inpatient unit

OBJECTIVE

To examine the prevalence and comorbidity of posttraumatic stress disorder (PTSD) in an adolescent inpatient population. A 2-year retrospective chart study was conducted.

METHOD

Computer-registered data of discharge records from 1993 and 1994 were recovered. Patients were grouped by diagnosis; frequency and chi-square statistical analyses were performed to ascertain the prevalence and the comorbidity of various diagnoses with PTSD.

RESULTS

A total of 187 patients, 114 females and 73 males, with a mean age of 15 years were reviewed, and 42% (79) of all patients had a diagnosis of PTSD using DSM-III-R criteria. There were 54 females and 25 males with PTSD; however, gender effect was not clinically significant. Associated comorbidity reaching clinical significance included other anxiety disorders (P = 0.008) and depressive disorders (P = 0.003). Asthma was diagnosed as a significant clinical disorder (P = 0.05) comorbid with PTSD. PTSD diagnoses correlated strongly with a history of abuse (P = 0.0001).

CONCLUSIONS

PTSD occurs frequently in adolescent inpatients and is commonly comorbid with other diagnostic presentations. These findings may affect the management of PTSD and prognosis for this population.