Post Traumatic Stress Disorder Education and Coping Skills Patient Education Hand-out:
(Please remember to NOT diagnose yourself or others when you read this information. Only a doctor or a trained mental health clinician can diagnose you with PTSD.)
Why do people get PTSD? :
Exposure to traumatic event or events in which intense fear is experienced can lead to PTSD. Some people might have an acute stress reaction. Of those people, some people develop acute PTSD. Resolution of PTSD symptoms can come in weeks to months depending on the nature and frequency of the trauma. However, a small portion of people with Acute PTSD go on to develop Chronic PTSD. We do not understand why some people develop chronic PTSD. Some of the theories include the “multiple hit” hypothesis; that the greater the number of traumas experienced, the greater the risk of PTSD. There is an association between childhood abuse and chronic PTSD; approx 10% of people with PTSD have a history of childhood abuse; but not all people with childhood abuse have Chronic PTSD.
Post Traumatic Stress Disorder (PTSD) is a diagnosis given for a collection of symptoms. Not everyone with PTSD presents the same way. Sometime people with PTSD think they are “going crazy” or “losing it” or that they are “a bad person for feeling the way I do”. It is important to learn about PTSD so that you understand it is not your fault, but rather symptoms of PTSD that are leading to the problems.
Some of the possible symptoms of PTSD:
Affect dysregulation: mood changes, depression, anger, irritability, anxiety
Symptoms of depression can include changes in sleep, interest in activities, feeling of guilt and worthlessness, feeling hopeless about the future, decreased energy, difficulty concentrating, changes in appetite, feeling slowed down “like my body is moving through molasses”, or even thoughts about death or suicide. Depression often accompanies PTSD because your mind and body get “run-down” from being on “high alert” all of the time.
Feeling anxious all of the time, “keyed-up” or on edge, or anger, or fear because you body’s “fight or flight” response is over-activated.
Not feeling safe anywhere, which can lead to avoidance of people or places; which can make trusting others difficult.
Re-experiencing a traumatic event: in the form of recurrent intrusive/unwanted thoughts, nightmares, or feeling as if you are re-living the event while you are awake- and you lose track of time and space around you (this is called a flashback).
Safety or checking behaviors: For example: 1.) Checking locks on door or windows 2.) Scanning the area for danger, or suspicious people, or suspicious vehicles. 3.) Always keeping your back to the wall, and scanning for escape routes.
Isolation: wanting to be alone “no one understands what I am going through”, possibly due to depression, or fear of being around others.
Emotional numbing: “I don’t have any feelings”, lack of ability to feel love or joy
Lack of interest in things that you previously enjoyed, which is called anhedonia. This can be associated with PTSD and also with depressive disorders.
Interpersonal problems: either at work or with friends or family
Sleep problems: difficulty getting to sleep, tossing and turning at night, waking early, nightmares, sleep-related breathing disorders are common. There is an overlap of PTSD and obstructive sleep apnea. If you snore, talk with your doctor about this.
Survivor Guilt: Feeling guilty or sad that you lived while another/others died in a traumatic event, or wishing it was you who had died instead.
Grief: For people who have died in one of your past traumatic exposures, or grief for relationships lost as a consequence of PTSD.
Engaging in thrill-seeking or dangerous activities: which can have several causes, including countering the emotional numbing and lack of interest, or due to feelings of guilt or grief.
Disappointment: For losses in your life, or missed opportunities, or past decisions, or mistakes you feel you made.
Things that are not helpful:
- Denial that there are problems
- Misbelieve that “I can handle it on my own”
- Using drugs, alcohol to regulate mood or sleep: these might initially help some but lead to problems and worsening of PTSD symptoms over time.
- Stimulants: Nicotine from cigarettes, caffeine from coffee tea and soda, “energy drinks”: These stimulants increase heart rate, blood pressure, and also increase anxiety and PTSD symptoms and can cause sleep problems. Remember, that these things can still be in your blood stream in small amounts for several hours after you take them. Even several cups of coffee in the morning can cause sleep problems at night.
- Alcohol: initially relaxes, and makes you tired, but over time addiction can occur. Also, alcohol keeps you in a lighter and less restful state of sleep. Alcohol worsens sleep related breathing disorders. Remember that withdrawal from a substance like alcohol causes the opposite effects you feel while it is in your body; for example, withdrawal from alcohol causes increased anxiety, can worsen PTSD symptoms and even cause anxiety or panic attacks. For example, having several drinks on just occasion can worsen PTSD symptoms the next day.
-Night-shift work tends to worsen sleep habits and might make anxiety depression or PTSD worse.
- Some things you watch or do can make PTSD symptoms worse; for example headline news about the war, war-related movies or certain conversations.
Things that might be helpful:
***Remember that PTSD is an anxiety disorder, so the more anxious you are, the worse your PTSD symptoms can become. It is very important for you to take care of your physical and mental health on a daily basis to try and decrease stress and anxiety. You are not “crazy”, for the most part PTSD is how your body adapts to traumatic events.***
- Medication: Serotonin reuptake inhibitors like sertraline and paroxetine are used to treat PTSD. There are other medications that can help with symptoms of PTSD, including sleep medications. Talk with your doctor or psychiatrist about these options. (See Medication Section Below)
- Group Therapy
- Individual therapy
- Relaxation training/counseling
- Good sleep habits: Good sleep habits are an important part of PTSD treatment and improve mental health. (see the below “Tips to Help Improve Sleep Habits”). Sleep habits education and training is helpful.
- Regular exercise: helps to decrease anxiety and stress, and improves sleep. ***Cardiovascular exercise: 1.) It increases your bodies own “feel good” chemicals beta-endorphins, and they are increase during exercise and for several hours after exercise. 2.) It increases blood-flow to your brain by building many new small blood vessels- a process called “neovascularization” 3.) It increases a chemical in your brain called “brain derived neurotrophic factor (BDNF) – which helps your brain to heal itself and even to form new brain cells!***
- Yoga: Yoga includes aspects of meditation and exercise and stretching. It has been shown to decrease anxiety and PTSD symptoms. It affects the neurotransmitter in your brain, GABA, which is involved the feeling of relaxation.
- Do more things that make you calm and feel relaxed: Some additional ideas are picture puzzles, reading a relaxing book or magazine, Sudoku puzzles or crossword puzzles, going for a walk in nature.
- Pet animals can decrease anxiety and decrease feelings of loneliness.
- Meditation is great to “decrease the white noise in my head”, decreases anxiety and therefore PTSD symptoms.
- Couples or family therapy/education about PTSD: can be helpful. Regardless, it is important to also educate significant others and family members about PTSD.
- You might have to fight yourself to avoid isolation. Isolation makes PTSD worse. It is important to reach out to your social supports. Supports can include anyone you can talk with, or “lean-on” for support; for example, family, treators, friends, religious organization, faith or belief in a higher power. People with PTSD who have more social supports tend to get better quicker and stay better longer. If you do not have any supports, then think of ways you can get or build them.
SLEEP PROBLEMS
Tips to Help Improve Sleep Habits:
Do you have problems with sleep? Remember, your body’s natural sleep is better than medication-induced sleep. Discuss your sleep problems with your doctor. Many people have sleep habits and other habits that get in the way of healthy sleep.
1.) Note: As time goes on, people "normally" sleep less soundly, with more brief nighttime awakenings, and for fewer hours than when we were younger. People often develop habits which are detrimental to a rejuvenating night's sleep.
2.) Choose what time of day you would like to wake up and get out of bed, and get up for the day at that time 7 days per week no matter how much sleep you had that night.
3.) Plan to go to bed 7 to 9 hours before your chosen wake-up time every night. If you can't fall asleep within 20 to 30 minutes, get up out of bed and go to another room. Do something until you feel tired enough to go to sleep, then go back to bed and try again to fall asleep. Repeat this process as many times as it takes for you to fall asleep.
4.) Try a hot bath, massage, comforting sexual experience, meditation, or relaxation before bedtime.
5.) Use the bathroom, brush your teeth, take your bedtime medications, lower the lights a little bit-- all about one hour before going to sleep. Then do something slightly boring until you feel a wave of sleepiness; and then go directly to bed.
6.) Try deep abdominal breathing as you close your eyes, relaxing with each breath. Try to think about something positive that happened during your day. If your mind is busy, continue to gently re-focus on your in and out breathing.
7.) If you wake up in the night, do not check the clock. Set your alarm for your chosen wake-up time and turn the clock around so you can't see the time.
8.) Try not to do things in bed like work, or things that will make you more awake. Reading a relaxing book helps a lot before going to sleep. Avoid books that are stimulating “page-turners”. Avoid stress and arguments in the bedroom.
9.) Do not take naps during the day, if naps interfere with or worsen your nighttime sleep.
10.) Keep your bedroom cool (65 degrees is recommended), and quiet. Wear loose-fitting, comfortable nightclothes.
11.) Avoid caffeine. For some people even one or two cups of coffee (or tea, or caffeinated soda, or chocolate) in the morning can have a significant effect on sleeping difficulties. At the least, consume no caffeine after noon.
12.) Avoid alcohol. Although people often use alcohol as a sedative at night, this is not a sound practice. Even one or two alcoholic drinks can cause a restless night's sleep and can prevent the brain from entering into the deeper stages of sleep. The net result is that the quality of sleep is poor, and problems such as anxiety or depression often worsen.
13.) Food: Do not eat heavy or sweet foods within 3 hours of your bedtime. Eating close to bedtime can worsen stomach acid reflux and therefore worsen sleep for people who have problems with acid reflux.
14.) Exercise: Moderate, daily, cardio-vascular exercise improves sleep and improves mood. Do not exercise vigorously within 3 hours of your bedtime.
15.) Cigarettes worsen sleep:Cigarettes contain nicotine, which is a central nervous system stimulant. In addition to causing multiple medical illnesses, smoking will also cause poor quality sleep.
16.) Cold preparations and analgesics might contain decongestants or caffeine. Know what you are taking, and avoid these stimulants. Many asthma or breathing medications can make sleep more difficult. Check with your doctor about this possibility.
17.) Most energy drinks contain stimulants which can worsen sleep, anxiety, and PTSD. Low energy can be caused by many different things. Discuss your low energy with your doctors.
* If you follow all of the above recommendations, your sleeping pattern and quality should improve. Remember to discuss your sleep problems and sleep habits with your doctors.
Smoking Cessation: There are several options to help you to quit smoking, including: 1.) various types of nicotine replacement therapy that your doctor can prescribe for you 2.) a prescription medication called buproprion (brand names= Wellbutrin and Xyban) that is an antidepressant, but has been shown to help with smoking cessation 3.) smoking cessation programs 4.) individual smoking cessation counseling 5.) and a medication call
Varenicline (brand name = Chantix). Please note that this medicine has guidelines for whom it should not be prescribed, because of possible side effects, and mental health side effects. I do not prescribe this medication. For more information about Varenicline, please refer to: the following resources: 1.) 2.)
MEDICATION TREATMENT FOR PTSD
Currently the family of antidepressants called Serotonin Reuptake Inhibitors (SSRIs) are first-line medication treatment of PTSD. Sertraline and Paxil are two drugs in the SSRI family that are FDA approved for treatment of PTSD. Medications are prescribed FDA “off-label use often, if there is clinical data/evidence that they can be helpful. There is data that shows other members of the SSRI family in addition to Sertraline and Paxil, to also be effective treatment for PTSD. All antidepressants are also anti-anxiety medications. SSRIs and SNRIs can take anywhere from 2 weeks, to 12 weeks to work, depending on how your body responds to them. The family of Serotonin and Norepinephrine Reuptake Inhibitors are also rated at the same benefit level per VA/DoD guidelines in the treatment of PTSD as the SSRIs, but they can have more possible side effects that the SSRIs.
Per the Veterans Administration and Department of Defense Clinical Practice Guidelines for Pharmacotherapy Treatment for PTSD, last updated 2010; after review of all related study results:
The following medications were rated as “Some Benefit” in the treatment of PTSD:
“Mirtazapine
Prazosin (for sleep/nightmares)
TCAs (Tricyclic antidepressants)”
“C-2 Monotherapy:
11. Strongly recommend that patients diagnosed with PTSD should be offered selective serotoninreuptake inhibitors (SSRIs), for which fluoxetine, paroxetine, or sertraline have the strongest support,or serotonin norepinephrine reuptake inhibitors (SNRIs), for which venlafaxine has the strongestsupport, for the treatment of PTSD. [A]
12. Recommend mirtazapine, nefazodone, tricyclic antidepressants (amitriptyline and imipramine), ormonoamine oxidase inhibitors (phenelzine) for the treatment of PTSD. [B]
13. Recommend against the use of guanfacine, anticonvulsants (tiagabine, topiramate, or valproate) as monotherapy in the management of PTSD. [D]
14. The existing evidence does not support the use of bupropion, buspirone, trazodone, anticonvulsants (lamotrigine or gabapentin), or atypical antipsychotics as monotherapy in the managementof PTSD. [I]
15. There is evidence against the use of benzodiazepines in the management of PTSD. [D]
16. There is insufficient evidence to support the use of prazosin as monotherapy in the managementof PTSD. [I]
C-3 Augmented Therapy for PTSD:
17. Recommend against the use of risperidone as adjunctive therapy [D]. There is insufficient evidence torecommend for or against the use of any other atypical antipsychotic as an adjunctive therapy for thetreatment of PTSD. [I]
18. Recommend adjunctive treatment with prazosin for sleep/nightmares. [B]
19. There is insufficient evidence to recommend a sympatholytic or an anticonvulsant as an adjunctive therapy for the treatment of PTSD. [I]”
“Annotation C. Pharmacotherapy for PTSD
C-1 General Recommendations:
1. Risks and benefits of long-term pharmacotherapy should be discussed prior to starting medication and should be a continued discussion item during treatment.
2. Monotherapy therapeutic trial should be optimized before proceeding to subsequent strategies by monitoring outcomes, maximizing dosage (medication or psychotherapy), and allowing sufficient response time (for at least 8 weeks).
3. If there is some response and patient is tolerating the drug, continue for at least another 4 weeks.
4. If the drug is not tolerated, discontinue the current agent and switch to another effective medication.
5. If no improvement is observed at 8 weeks consider:
a. Increasing the dose of the initial drug to maximum tolerated
b. Discontinuing the current agent and switching to another effective medication
6. Recommend assessment of adherence to medication at each visit.
7. Recommend assessment of side effects and management to minimize or alleviate adverse effects.
8. Assess for treatment burden (e.g., medication adverse effects, attending appointments) after initiating or changing treatment when the patient is non-adherent to treatment or when the patient is not responding to treatment.
9. Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely; however, it is recommended that maintenance treatment should be periodically reassessed.
10. Providers should give simple educational messages regarding antidepressant use (e.g., take daily, understand gradual nature of benefits, continue even when feeling better, medication may cause some transient side effects, along with specific instructions on how to address issues or concerns, and when to contact the provider) in order to increase adherence to treatment in the acute phase.”
INSOMNIA MEDICATIONS:
“A-2 Insomnia:
1. Monitor symptoms to assess improvement or deterioration and reassess accordingly.
2. Explore cause(s) for insomnia, including co-morbid conditions.