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disorder and the possibility of subtypes the market) are available, there will be (e.g. anxious or depressed subtype) rather I(PTSD), since the drug treatment As an introduction to clinical research • Selective serotonin reuptake
in this area, it is important to know that inhibitors(SSRIs) have been successful
most randomized clinical trials (drug vs. anxiety, panic disorder, depression, and (fluoxetine), open trials, and case reports those of us who work in the trauma field trials of significant length have reduced know, our patients meet the criteria for a traumatization or acute vs. chronic PTSD. dissociative disorders, substance abuse/ combat), the first such clinical report, sexual disorders, sleep disorders, eating within clusters A, B, and C. In addition, “dissociative symptoms” used in this Classes of Medications Used with
illnesses in Axis III (as mentioned in the clinical experience is that medication has • The tricyclic antidepressants (TCAs)
defenses, particularly amnestic barriers. in 1992 (this is not yet a DSM diagnosis, published; amitriptyline, imipramine and • Trazodone and nefazodone, the other
serotonergic antidepressants, have and
are being studied. A recent open trial of trials. It describes a clinical syndrome in • A comprehensive review of all counteract the sleep disturbance of PTSD. published findings on monoamine
oxidase inhibitors (MAOIs) showed
There is one open trial report showing a pathological changes in relationships and insomnia. Buspirone, an anxiolytic, also mutilation and revictimization). Synthesis contrast, there is a growing literature on has serotonergic properties; it has been the use of MAOIs for “treatment-resistant depression”, which includes many trauma • Benzodiazepines are antianxiety agents
nightmares, intrusive recollections, and which exert their effect by enhancing the startle reactions. Since there is adrenergic and anxiety. Gabapentin, given at night, agents should be used with caution. Many is helpful for sleep. I use the atypical patients have gotten into difficulty with by large numbers of brain cells. It is the brake on the excitatory pathways and thus results in decreased anxiety and arousal. • The opioid antagonists have been
suggested to counteract the stress release syndrome” (descriptive term courtesy of Dr. Norman Sussman). “Poop-out” refers benzodiazepines in clinical practice, the medication that had previously resulted in a clinical response. Whether this is due to treatment for self-mutilation; two reports the biological complexity of the disorder • Antipsychotics have no specific
sensitivity) is not clear. Before moving small doses on a routine basis give more efficacy in the treatment of PTSD and are on to another medication, I have learned consistent results than p.r.n. usage. The their short- and long-term side effects. benzodiazepine-like properties, but is not In summary, the literature and research addictive. It may be a useful adjunct in • The mood stabilizers, carbamazepine
clinical experience and sense of direction psychiatric colleagues in the field, the axioms appear to be “keep it simple” and disorder. The new atypical antipsychotics “trial and observation.” I always tell (risperidone, olanzapine, quetiapine) have patients that psychotherapy is the heart of fewer side effects and, we hope, less risk of tardive dyskinesia. They are now being adjunctive. I have sometimes jested that in two studies. The newer anticonvulsant times of intense agitation and crisis, but gabapentin, are being used clinically, but “rescuer” countertransference (these it is too early to determine their efficacy. patients are in great distress). In this era controlled trials on the use of lithium in Suggested Treatment Algorithm
References
instability and irritability/outbursts in the sertraline or paroxetine, with a small dose of trazodone for sleep. This is first-line focus on safety and few side effects. If Neurobiology and pharmacotherapy. CNS Antiadrenergic agents suppress the
there is no response, I will usually switch Spectrums, 3(7) [suppl. 2], 43-51. buspirone or bupropion (small dose). If a anxiety, I prefer the use of clonazepam, Trauma and recovery. New York: Basic been exhausted, I will try mirtazapine or noted to be effective in open trials. There significant reductions in re-experiencing because of the lethality of small doses. Either clonidine or propranolol is useful to treat intense hyperarousal if there are (Ed.), Psychological trauma (Ch. 5). was relapse after discontinuation of the

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