Psychiatry - July 2008 - (Page 49)

for reducing nightmares, and more importantly, benzodiazepines can increase the chance of PTSD developing when administered to recently traumatized individuals.46 They can also worsen sleep apnea.46 A paucity of studies have been conducted on non-benzodiazepine GABA agonists, but there were positive results in one small study on zolpidem, which Maher notes is also less likely to exacerbate sleep apnea.46 Trazodone is a triazolopyridine derivative used as both an antidepressant and a sleep aid. It is inexpensive, but its use can be limited by nasal congestion, dry mouth, blurred vision, and priapism, among others. In a study by Warner,49 43 of 72 patients found trazodone to be helpful in reducing nightmare frequency, and 55 found it to be helpful with sleep onset. Clonidine is an α2-adrenergic agonist that has been shown to be useful in treating both daytime and nighttime symptoms of PTSD in children and adults with trauma from various sources.50 Mirtazapine may be useful for PTSD as it has both anxiolytic and sedative properties. It also may be helpful for obstructive sleep apnea.46 Tricyclics are often used as hypnotics; however, there have been insufficient studies to recommend their use in PTSD patients. Side effects and toxicity in overdose warrant caution.46 Phenelzine, a monoamine oxidase inhibitor, has been shown to improve sleep quality in PTSD.45 Several atypical antipsychotics are well known for their sedative properties and can be useful when other medications have failed, particularly when the patient suffers comorbid bipolar or psychotic illness, or even borderline personality disorder. None of these medications are FDA-approved for use in PTSD, and long-term side effects and cost are detriments. There is some evidence for the use of clozapine, olanzapine, risperidone, and quetiapine in patients with severe symptoms.51 RESIDUAL SYMPTOMS Treatment resistance. PTSD can be very difficult to treat, particularly if there are multiple and/or early traumas, which predispose the patient not only to the neurobiological alterations discussed previously but also to complex PTSD and various dissociative and personality disorders. Another consideration is the patient’s thoughts on getting better—is he willing to allow himself to heal or does he have a conscious or subconscious investment in staying ill? Unfortunately, PTSD can be easily malingered,52 and the clinician must be alert to this possibility whether or not there is obvious secondary gain. Even if the patient is not malingering, he may have some motivation for overreporting his symptoms. If the patient is not improving despite appropriate therapeutic interventions, the clinician may wish to consider referral for psychometric testing, including the Minnesota Multiphasic Personality Inventory (MMPI) if appropriate. One must also question one’s original diagnosis and reconsider whether there are additional axis I, II, or III disorders contributing to treatment resistance, including nightmares induced by medication treatments being used for the PTSD itself or another condition (Table 3).59 Case 7. Technical Sergeant (TSgt) F is a 48-year-old active duty Air Force member who presented for a Fitness for Duty examination at the request of his commander, who noticed a marked decline in TSgt’s work performance over the past three months, approximately one year after his return from Afghanistan. His unit was preparing to be redeployed soon, and TSgt F was not looking forward to going. He was having marital problems, and his wife was threatening to divorce him if he left for deployment again. “Doc, I just can’t sleep at night, and I’m having all these flashbacks about the war.” When questioned about his deployment, he stated, “I never actually left Bagram (the major air base in Afghanistan), but I heard stories about what it was like outside the wire. You can’t send me back!” Upon further questioning, TSgt F admitted his main reluctance revolved around his marital problems. Arrangements were then made for TSgt F and his wife to attend marital therapy, but as the time for deployment approached, Mrs. F could not reconcile herself with the idea of having her husband gone for another tour. They ultimately divorced. Serotonin syndrome. Patients with PTSD are often started on an antidepressant, either by a psychiatrist or a primary care provider. Signs and symptoms of mild serotonin syndrome can be mistaken for worsening PTSD, including anxiety, akathisia, and hypervigilance.53 These can all worsen sleep disturbances associated with PTSD. Case 8. Mrs. D was started on citalopram for anxiety. After her first dose, her anxiety became noticeably worse. After her second dose, she had a protracted anxiety attack lasting three hours, including symptoms of rapid heartbeat, feeling excessively warm, and shaking “that seemed to go all over my body.” She stopped the medication and reported her symptoms at her scheduled follow-up visit. Chronic pain. Patients with PTSD also often have chronic pain as a consequence of physical abuse, hypersensitivity of their nervous systems (limbic system), somatoform illness, or concurrent anxiety disorder. Primary care physicians or pain specialists may treat them with tramadol, which has a potent serotonergic effect, which may be underappreciated by practitioners. Clinicians should note that there have been several cases of serotonin syndrome reported in the literature in patients with tramadol and SSRIs.54,55 CONCLUSION PTSD is a potentially disabling condition that affects millions worldwide. Successful treatment depends on a strong therapeutic alliance, and medications may be useful adjuncts. Astute clinicians will keep in mind a careful differential diagnosis and potential axis I, II, and III disorders when working with treatment-resistant patients. [JULY] Psychiatry 2008 49

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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