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Therapies for PTSD

Q. In this post 9-11 era, patients with posttraumatic stress are becoming more common. What, in your opinion, are some of the best therapies for PTSD? I had a patient ask if there was a way for a memory to be forgotten forever, such as with ECT or medication. Although I wouldn't advise attempting this, I thought it was an interesting question. Your thoughts?

A. Yes, post-traumatic stress disorder (PTSD), acute stress disorder (ASD), and sub-clinical variants of these conditions do seem increasingly common, particularly in the wake of the 9-11 attacks. With respect to the best therapies, I believe that the literature supports the use of both pharmacotherapy and psychotherapy. The medications of first choice, in my view, are the SSRIs--fluoxetine, sertraline, paroxetine, etc. Other agents, such as a mood stabilizer or an atypical antipsychotic, may be considered in selected cases.

Among the psychosocial therapies, I believe that cognitive-behavioral approaches have the most robust evidence behind them. This includes various types of imaginal and in vivo exposure, anxiety management techniques, and, arguably, Eye Movement Desensitization and Reprocessing (EMDR). For a review of these issues, see the chapter by Hembree and colleagues in "The Difficult to Treat Psychiatric Patient", edited by my colleague Mantosh Dewan MD, and myself.

Your second question is more difficult to answer. I am not aware of any therapy or medication that has been shown to remove a traumatic memory--nor, as you clearly appreciate, would most therapists advise such an approach. The goal in treating PTSD is not to induce forgetting, but to facilitate re-processing and integration of the traumatic memory, into the larger fabric of the person's emotional and psychological life. That said, there are some theoretical issues raised by your question.

For example, there is growing evidence that repeated traumas may actually lead to profound neuroendocrine changes that actually impair brain structure and function; e.g., alterations in the hypothalamus and pituitary eventually lead to damage in the hippocampus. (For a thorough discussion of this, see R. Yehuda, Psychological Trauma, 1998). In theory, early use of appropriate medication in PTSD could mitigate some of these pathological processes--leading not to forgetting of the traumatic memory, but to a better-adapted brain, in the long run.

However, I know of no empirical studies corroborating this hypothesis. It is also theoretically possible that very early use of a benzodiazepine, such as diazepam, might actually interfere with permanent encoding of traumatic memories--but that, too, is very speculative. At the very least, early psychosocial treatment of traumatic stress disorders may enable the individual to learn ways of modulating the affective charge of traumatic memories.

April 2002

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