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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.)
www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000351/ 2.) www.pbm.va.gov/default.aspx
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 -anxiet y medications.
SSRIs and SNR Is can take anywhere from 2 weeks, to 12 weeks to work, depending on how
your body responds to them. The famil y of Serotonin and Norepinephrine Reuptak e
Inhibitors are also rated at the same benefit level per VA/DoD guidelines in the treatment of
PTSD as the SSR Is, 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 to
recommend 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.
3. Begin treatment for insomnia with non-pharmacologic treatments including sleep hygiene and cognitive
behavioral treatment (See recommendation for Sleep Disturbances).
4. The selection of sleep agents for the treatment of insomnia in PTSD patients may be impacted by other
treatment decisions (e.g., medications already prescribed for the treatment of PTSD, depression,TBI, pain, or
concurrent substance abuse/withdrawal) and social/environmental/logistical concerns associated with
deployment.
a. Trazodone may be helpful in management of insomnia and may also supplement the action ofother
antidepressants.
b. Hypnotics are a second line approach to the management of insomnia and should only be used for short
periods of time. Should hypnotic therapy be indicated, the newer generation of non-benzodiazepines (e.g.
zolpidem, eszopiclone, ramelteon) may have a safety advantage by virtue of their shorter half-life and lower risk
of dependency. Patients should be warned of and monitored for the possibility of acute confusional
states/bizarre sleep behaviors associated withhypnotic use. Benzodiazepines can be effective in chronic
insomnia but may have significant adverse effects (confusion, sedation, intoxication) and significant risk of
dependency.
c. Atypical antipsychotics should be avoided due to potential adverse effects but may be of value when
agitation or other symptoms are severe.
d. If nightmares remain severe, consider adjunctive treatment with prazosin. [B]
e. If symptoms persist or worsen – refer for evaluation and treatment of insomnia.
Additional information of management of insomnia can be found in VHA Pharmacy Benefit
Management(PBM) guideline for Insomnia: http://www.pbm.va.gov/ClinicalRecommendations.aspx”
BENZODIAZEPINES:
Benzodiazepines were given a VA/DoD rating of “No Benefit” and can even cause “Harm”. They should be
avoided in the treatment of PTSD. These are also called “Valium Family medications”. They also should be
avoided in any patient with a family history of alcoholism or substance abuse.
Some of the medications in this family are called Valium, Klonopin, Ativan, Temazepam, and Xanax. These
medications can block the formation of new memories while they are in your system (anterograde amnesia),
similar to an alcohol related “black-out.” They cause sedation, can cause and/or worsen existing depression.
They can cause apathy, and contribute to or worsen many symptoms of PTSD like avoidance behaviors, and
social isolation. Psychological treatments for PTSD and other anxiety disorders require patients experience
some anxiety while they practice the new “tools”/coping skills they have learned—Benzodiazepines can
completely block anxiety and therefore block the new learning that needs to occur from psychological PTSD
treatments. Benzodiazepines can be both psychologically habit forming “I have to have the medicine.”, and
can also cause physiologic tolerance; where your body can require more and more of the medication to maintain
the same effect. Remember, they block anxiety so much, that if you are on enough of it, the world could be
ending, and you would not care. Many patients have a “love affair” with their Xanax, for example; and that is
always a “Red-Flag” clinically, that addiction could be present.
PANIC ATTACKS and AS-NEEDED MEDICATIONS FOR THEM:
Anyone with anxiety, can have a panic attack, where your body’s “fight-flight-freeze” response is activated to
keep you alive for a brief period of time. It is as if your body thinks there is a tiger there, about to attack you,
when in fact there is no tiger. Panic attacks by definition last less than 10 minutes, as your body cannot mount
such a strong energy output response for longer than that amount of time. No “as-needed medication”,
including Xanax, will have to treat a panic attack, as the panic attack will be over before any as-needed
medication will get into your blood stream. Acute increases in anxiety symptoms that last longer than 10
minutes are called anxiety attacks.
OPIOID PAIN MEDICATION ISSUES:
Many patients have a medical cause for pain, however, opioid pain medication cause sedation, cause problems
with attention, concentration, and therefore with learning and the formation of new memories. Often times,
patients will require higher and higher doses of these types of pain medications to have the same effect on their
pain treatment, as their bodies develop tolerance to them.
MEDICATIONS FOR SUBSTANCE ABUSE TREATMENT:
For alcohol dependence: Naltrexone, Campral, Antabuse, Topiramate (FDA off-label use)
For Opioid Dependence: Suboxone, Methadone, Naltrexone
(this section needs work still)
ADDITIONAL RESOURCES (this section is a work in progress):
Please remember to only go to reputable websites, as there is a lot of misinformation on the internet. In general,
websites that end in “.gov” for government websites, and “.edu” for educational institution, are more trustworthy. Please avoid reading “blogs” and “chat forums”.
1.) Veterans Administration and Department of Defense Clinical Practice
Guidelines:www.healthquality.va.gov
This is a great website to see the recently updated guidelines for the treatment of PTSD, INCLUDING
MEDICATIONS for PTSD; which were updated in 2010.
2.) MEDICATION EDUCATION FOR PATIENTS:
You can use the search-engine, and type in the name of the medication your are interested in, at this website:
www.ncbi.nlm.nih.gov/pubmedhealth
2.) The Veterans Administration “National Center for PTSD”: www.ptsd.va.gov
3.) Substance Use Disorders (SUD) and SUD with PTSD:
Sharepoint files at http://vaww.national.cmop.va.gov/MentalHealth/default.aspx)
4.) Veterans Administration Mental Health information for OEF/OIF Veterans:
www.mentalhealth.va.gov/OEFOIF
5.) Veterans Administration “MyHealtheVet” www.myhealth.va.gov
6.) The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms
[Paperback]
7.) Resource for Panic attacks and Anxiety Attacks, and Panic Disorder:
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