Treating Trauma, PTSD and Traumatic Brain Injury
By Dr. Ofer Zur
Traumatic disorders have sometimes become fuzzy, catch-all diagnoses, and this severely affects treatment. Trauma, Post-Traumatic Stress Disorder, Traumatic Brain Injury (TBI), and bereavement all require different treatments, both psychotherapeutically and psychopharmacologically. Additionally, when depression and anxiety are co-morbid with any of these--which is often the case--the best treatment decisions are more difficult to make. The increasing awareness and diagnosis of traumatic brain injury (TBI), heightened and informed by the recent wars in Afghanistan and Iraq, and the growing awareness of head injuries in both school and professional sports has made the treatment picture even more complex and confusing. Not only does choosing the wrong treatment result in ineffective therapy, but in some cases the wrong treatment can exacerbate the primary disorder. This is especially true with PTSD and TBI: standard treatments for one condition can make the other worse.
Effective treatments for each of these conditions exist; it is essential for clinicians to have the correct diagnosis, choose the right treatments and to be informed about the various available psychotherapy treatments and medications. The competent clinician who treats a traumatized client needs to have a general perspective on how trauma undermines clients' normative assumptions about how the world and their own life operate in order to help clients re-establish a coherent perspective. It is also important to take into account the cultural perspective of traumatized clients.
Here are some facts:
- Prolonged grief and PTSD are co-morbid in 30% to 50% of individuals with PTSD.
- PTSD co-occurs with depression in 21% to 54% of individuals.
- Despite the lack of evidence for efficacy in treating bereavement, about half of obstetricians surveyed endorsed using sedatives, such as benzodiazepines, to treat bereavement following a stillbirth.
- Despite limited evidence for the efficacy of medications in treating PTSD, a study found that 60% of those diagnosed with PTSD were prescribed medications, primarily antidepressants and antipsychotics.
- Research suggests that the etiology and course of depression, anxiety, and PTSD due to bereavement may be different than for non-bereavement-related causes and therefore require different treatment.
- As TBI is associated with dysregulation of several neurotransmitter systems integral to the homeostasis of mood, emotional control and cognition, it's possible that medications which modulate these neurotransmitters might behave differently after an injury.
- TBI can result in loss of neurons in brain regions modulating emotional control and cognition, therefore the side effect profile of some psychotropic medications may be altered.
- Therapists should be advised that medications known to impact attention and memory processes could alter the efficacy of psychotherapy.