Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Prevention of Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a constellation of symptoms that occurs in persons after they have suffered a traumatic event (or multiple events). Some of these symptoms include (among many likely others):

  • depression
  • anxiety,
  • lack of concentration
  • “acting out”
  • anti-social behaviors
  • self-destructive behaviors
  • difficulty sleeping
  • nightmares
  • flashbacks
  • emotional withdrawal
  • inability to participate in normal routines or behaviors
  • difficulty with relationships
  • memory loss
  • feelings of guilt or shame
  • uncontrollable thoughts about the event

Sometimes PTSD can begin close to the inciting event, while other times onset may be delayed for months or even years, depending on, among other things, the amount that the affected person is able to compensate for the trauma, cover up his or her behaviors, or suppress recollection of the event.

Someone who suffers a severe physical or emotional trauma, such as witnessing a disaster or surviving a near-death experience, is typical of the type of person who develops PTSD. Because PTSD absolutely can be debilitating, it must be recognized and managed. That is usually easier said than done, because there are large gaps in our knowledge of PTSD, including the breadth and depth of its various forms and manifestations, and how best to treat.

An informative article by AY Shalev and colleagues from the Department of Psychiatry at Hadassah University Hospital in Jerusalem, Israel is entitled “Prevention of Posttraumatic Stress Disorder by Early Treatment: Results From the Jerusalem Outreach and Prevention Study.” It was published in the Archives of General Psychiatry. The purpose of the study was to compare early and delayed exposure-based, cognitive, and pharmacologic interventions for preventing PTSD. The participants were survivors of traumatic events, such as motor vehicle accidents or terrorist attacks. From the abstract accompanying the article:

The interventions were 12 weekly sessions of prolonged exposure (PE, such as breathing-control training) or cognitive therapy (CT, therapy that helps a person identify and change dysfunctional thinking and behaviors), double blind treatment with 2 daily tablets of either escitalopram 10 mg (a drug used to treat generalized anxiety disorder or depression) or placebo, or 12 weeks in a waiting list group. The main outcome measure was the proportion of participants with PTSD after treatment, as determined by the use of the Clinician-Administered PTSD Scale (CAPS) 5 and 9 months after the traumatic event. Treatment assignment and attendance were concealed from the clinicians who used the CAPS. The results were revealing. At 5 months, 21.6% of participants who received PE and 57.1% of comparable participants on the waiting list had PTSD. At 5 months, 20.0% of participants who received CT and 58.7% of comparable participants on the waiting list had PTSD. The PE group did not differ from the CT group with regard to PTSD outcome. The PTSD prevalence rates did not differ between the escitalopram and placebo subgroups, and was much higher than the CT and PE groups. At 5 months, some of the waiting list patients elected to undergo PE sessions. At 9 months, 20.8% of participants who received PE and 21.4% of participants on the waiting list had PTSD. Participants with partial PTSD before treatment onset did similarly well with and without treatment. Participants on drug or placebo therapy never improved beyond the mid-40% range having PTSD.

The authors concluded that PE, CT, and delayed PE effectively prevent chronic PTSD in recent survivors. They felt that lack of improvement after treatment with escitalopram requires further evaluation. 

What this study shows is that PE or CT may be worthwhile therapies, and that drug treatment does not seem to be as good in treating PTSD. Indeed, if the waiting list patients in fact had a lower incidence of PTSD at nine months than did the drug-treated group, one might argue that drug therapy could even worsen the situation. This again highlights that we have much to learn about the nature and treatment of PTSD. It also stresses the importance of seeking expert guidance following a traumatic event in order to identify and manage any emotional sequelae. 

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Tags: Humanitarian Care , General Interest

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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.