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Post-Traumatic Stress Disorder: Evidence-Based Research for the Third Millennium

Introduction

❶These findings confirmed earlier Cochrane-based systematic reviews 67 , Evidence-based research in medicine goes beyond the routine narrative literature review.

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Allostasis refers to the psychobiological regulatory process that brings about stability through change of state consequential to stress. Psycho-emotional stress can be defined as a perceived lack, or loss of fit of one's perceived abilities and the demands of one's inner world or the surrounding environment i.

Traumatic events that trigger PTSD are perfect examples of such onerous demands that lead to the conscious or unconscious perception on the part of the subject of not being able to cope The perception of stress is often associated with psychological manifestations of anxiety, irritability and anger, sad and depressed moods, tension and fatigue, and with certain bodily manifestations, including perspiration, blushing or blanching of the face, increased heart beat or decreased blood pressure, and intestinal cramps and discomfort.

These signs mirror the spectrum of psychobiological symptoms in PTSD. These manifestations are generally associated with the nature of the stress, its duration, chronicity and severity. A group of symptoms, now referred to as the sickness behavior, is also noted that is associated with clinically relevant changes in the balance between the psychoneuroendocrine and the immune systems 35 — By the early s, Walter Cannon — proposed that organisms engage in a dynamic process of adjustment of the physiological balance of the internal milieu in response to changing environmental conditions.

Stress alters the regulation of both the sympathetic and the parasympathetic branches of the autonomic nervous system, with consequential alterations in hypothalamic control of the endocrine response controlled by the pituitary gland.

Autonomic activation and the elevation of hormones, including those produced by the hypothalamic-pituitary-adrenal axis, play a pivotal role in regulating cell-mediated immune surveillance mechanisms, including the production of cytokines that control inflammatory and healing events 35 , In brief, the perception of stress leads to a significant load upon physiological regulation, including circadian regulation, sleep and psychoneuroendocrine-immune interaction.

In brief, stress is profound alterations in the cross-regulation and interaction of the hormonal-immune regulatory axis. The experience of stress, as well as that of traumatic events and the anxiety-laden recollections thereof, produce a primary endocrine response, which involves the release of glucocorticoids GCs. GCs regulate cellular immune activity in vivo systemically and locally. They block the production of pro-inflammatory cytokines e. IL-2 at the molecular level in vitro and in vivo , but may have little effects upon TH2 cytokines e.

The net effect of challenging immune cells with GC is to impair immune T cell activation and proliferation, while maintaining antibody production. The secretion of GC by the adrenal cortex is under the control of the anterior pituitary adrenocorticotropin hormone ACTH. Immune challenges release pro-inflammatory cytokines e. Stressful stimuli also lead to the significant activation of the sympathetic nervous system and a rise in the levels of pro-inflammatory cytokines i.

It follows that the consequences of stress are not uniform. The psychopathological and the physiopathological impacts of stress may be significantly greater in certain people, compared with those of others. The impact of stress is dynamic and multifaceted and the same person may exhibit a variety of manifestations of the psychoneuroendocrine-immune stress response with varying degrees of severity at different times.

The outcome of stress can be multivalent Allostatic regulation now signifies the recovery and the maintenance of internal balance and viability amidst changing circumstances consequential to stress. It encompasses a range of behavioral and physiological functions that direct the adaptive function of regulating homeostatic systems in response to challenges 37 — The cumulative load of the allostatic process is the allostatic load.

The pathological side effects of failed adaptation are the allostatic overload. Allostasis pertains to the psychobiological regulatory system with variable set points. These set points are characterized by individual differences. They are associated with anticipatory behavioral and physiological responses and are vulnerable to physiological overload and breakdown of regulatory capacities 39 , Type 1 allostatic load utilizes, as it were, stress responses as a means of self-preservation by developing and establishing temporary or permanent adaptation skills.

The organism aims at surviving the perturbation in the best condition possible and at normalizing the normal life cycle. In Type 2 allostatic load, the stressful challenge is excessive, sustained or continued and drives allostasis chronically. An escape response cannot be found. Type I versus type II allostatic responses curiously reiterate Myers' observations that his patients seem to abandon themselves to the emotion and the fear that assailed them, rather than engage in the effort to counter and to overcome the challenge, which normal subjects typically undertook.

Future research in PTSD from the perspective of allostasis may reveal a learned helplessness component, which could become key in the development and evaluation of treatment interventions Fig.

Allostatic regulation describes the recovery and the maintenance of internal balance and viability amidst changing circumstances consequential to stress.

It encompasses the Type 1 allostatic load that reflects the utilization by the organism of the range of behavioral and physiological functions that direct the adaptive function of regulating homeostatic systems in response to challenges i.

Type 1 allostatic responses translate the organism aims at surviving the perturbation in the best condition possible and at normalizing the normal life cycle. By contrast, the Type 2 allostatic responses reflect a load to the organism that is excessive, sustained, or continued, and drives allostasis chronically and that precludes effective escape from the stress.

It is clear that stress research and PTSD research are intertwined. Psychobiological manifestations in PTSD and in complex PTSD disorder of extreme stress evidently pertain to the same domain of mind—body interactions, which are elucidated in psychoneuroimmunology research.

The stress response, more than likely, underlies the psychobiological sequelae of PTSD. The relevance of the field of current research on allostasis to PTSD is all the more evident when one considers that subjects position themselves along a spectrum of allostatic regulation, somewhere between allostasis i. In brief, the recent advances in our understanding of the adaptation of the organism to stressful challenges, the allostatic process, present a new and a rich paradigm for research in the psychobiology of PTSD.

Future research must investigate whether or not the dichotomy of Type I and Type II allostatic responses will provide an effective theoretical model for the development of novel and improved modes of intervention to treat PTSD. The treatment of PTSD is complex, both in terms of available treatments and the myriad of trauma possibilities that cause it. This should be followed by treatments with various degrees of demonstrated efficacy Historically, it was in the early eighties when research on the treatment efficacy for PTSD began, with multitude of case studies dealing with different kinds of PTSD having been produced since then.

Overall, both cognitive behavioral approaches and selective serotonin reuptake inhibitor regimes have been proved to be effective to deal with different kinds of PTSD. At the same time, there is also evidence that other treatment modalities, such as psychodynamic psychotherapy, hypnotherapy, eye movement desensitization and reprocessing can be effective as well; albeit their evidence is derived from less numerous and less well-controlled studies i.

PTSD intervention is complicated further by the fact that co-morbidities e. Particularly in situations where co-morbidity exists, a combined approached should be considered. Of interest due to the perilous state of the world i.

According to experts, combat veterans with PTSD may be less responsive to treatment that other victims of other traumatic exposures 41 , Following is a list of possible reasons:. Combat-caused PTSD is often associated with other psychiatric disorders, including depression, anxiety, mood disorders and substance abuse disorders It is usually believed that the most effective treatment results are obtained when both PTSD and the other disorder s are treated together rather than one after the other.

It is becoming increasingly critical to ascertain this position because the prevalence of PTSD and disorder of complex stress is bound to rise sharply in the next decade consequential to the present multinational state of alert and anxiety following ongoing tragic, wanton and widespread terrorism and particularly with respect to combat-related PTSD in present times.

Some have more proven efficacy than others. Some of these approaches may be appropriate to address the initial stages of trauma. Psychological debriefing is an intervention given shortly after the occurrence of a traumatic event.

The goal is to prevent the subsequent development of negative psychological effects. In fact, psychological debriefing approaches to PTSD can be described as semi-structured interventions aimed at reducing initial psychological stress.

Strategies include emotional processing via catharsis, normalization and preparation for future contingencies Gulf War veterans who underwent psychological debriefing showed no significant differences in their scores of two scales measuring PTSD when compared with the control group In general, there is little evidence of psychological debriefing approaches effectively acting to prevent psychopathology, although participants seem to be open to it, which may indicate its usefulness as a rapport builder or as a screening tool.

In general however, there is a lack of rigorously conducted research in this area. To this day there is paucity in the data to orient the treatment of combat-related PTSD for veterans The International Consensus Group on Depression and Anxiety supports that exposure psychotherapy is the most appropriate approach for this disorder 41 , although this approach does not show a significant influence on PTSD's negative symptomatology, such as avoidance, impaired relationships or anger control In terms of proven efficacy, cognitive behavior therapy and eye movement desensitization and reprocessing are effective approaches to deal with PTSD 50 — 54 , while other psychotherapeutic approaches e.

Cognitive-behavioral psychotherapy encompasses a myriad of approaches i. Vietnam veterans receiving exposure therapy displayed improvement as evidenced in terms of reducing intrusive combat memories 55 , physiological responding, anxiety 56 , depression and feelings of alienation, while also promoting increased vigor and skills confidence Exposure therapy, combined with a standard treatment also showed effectiveness with other Vietnam veterans in terms of subject self-report symptoms related to the traumatic experiences, sleep and subjective anxiety responding to trauma stimuli In fact, typically, there is a combination of psychotherapy and medication treatments to treat chronic PTSD In general, the different co-morbidities associated with PTSD play a role in the kinds of pharmacotherapeutic treatments used for its treatment.

Antidepressants and other medications commonly used are tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, antianxiety and adrenergic agents and mood stabilizers Sertraline has been found effective to reduce PTSD symptomatology 61 , Sertraline and fluoxetine have produced clinical improvements among PTSD patients in randomized clinical trials Paroxetine, another selective serotonin reuptake inhibitor like sertraline, is also habitually used to treat chronic PTSD Mirtazapine was another successful agent when used in the treatment of PTSD afflicted Korean veterans In addition, Olanzapine and fluphenazine have been successfully used with combat-induced PTSD subjects from the Balkans.

Both medicines were successful in ameliorating both PTSD and psychotic symptomatology Rigorous, well-controlled methods are necessary for conducting studies on the efficacy of PTSD treatments. Well-controlled studies are characterized by the following characteristics:. Future clinical research in PTSD requires the stringent, rigorous and systematic approach provided by evidence-based medicine. Evidence-based research in medicine goes beyond the routine narrative literature review.

It systematically evaluates the strength of the available evidence and generates a consensus statement of the best available evidence in the form of a systematic review of the available research Fig. What are the interventions being looked at, e. Are the interventions being compared or are predictions being drawn, i.

What is the outcome of interest, e. The second step involves methodology, including the sampling of the research literature, and the tools for the critical analysis of the reports. The fourth step is concerned with the analysis of the data gathered in the evidence-based research process. This commonly entails meta-analytical and meta-regression techniques, as well as individual patient data analysis e. Depending upon the tools utilized to evaluate the scientific literature, scores about the completeness and quality of research methodology, design and statistical handling of the findings are generated SESTA, systematic evaluation of the statistical analysis.

These values are analyzed by acceptable sampling statistical protocols to establish whether or not the sample of research reports studied by means of the evidence-based process was statistically acceptable to produce reliable inferences. The last step is a cumulative synthesis, which summarizes the process and the findings.

The process is applied to the performance of systematic reviews, which are all-encompassing of the available literature. Best case studies in evidence-based research entail a random performance of the process of evidence-based research with a random sample of the available literature. The future of clinical and translational research in PTSD lies in the systematic evaluation of the research evidence in treatment intervention for the patients. The collected evidence is then evaluated for research quality along certain standards [e.

Timmer scale, Jadad scale and Wong scale The data from separate reports are pooled, when appropriate, for meta-analysis, meta-regression and individual patient data analyses. The data are analyzed from the perspective of Bayesian modeling in order to interpret data from research in the context of external evidence and judgments In the context of the treatment of patients with PTSD and co-morbidities, it is important and timely to generate a systematic review of the clinical research evidence for joint and simultaneous treatment of PTSD and the co-morbidities versus a staggered approach.

The summative evaluation of the outcome of such a systematic review will generate a consensus statement that will establish whether or not the problem was framed in a clinically relevant manner e. The statement must discuss the validity of the process of integration e.

Was the search comprehensive and explicitly described? Was the validity of the individual studies adequately assessed?

Were the process of study selection, searching, assessing validity and data abstraction reliable? The statement also produces evidence about the rigor of the process by which information was integrated e.

Are the summary findings representative of the largest and most rigorously performed studies? The quality, presentation and relevance of the findings must be discussed e.

Are the key elements of each study clearly displayed? Is the magnitude of the findings statistically significant? Are the findings homogeneous or heterogeneous? Are sensitivity analyses presented and discussed? Do the findings suggest an overall net benefit for patients with PTSD? This concerted, systematic and scientific-process driven mode of evaluating current treatment interventions for subjects with PTSD is timely and urgent to insure that the medical establishment will be prepared to handle the fast-approaching wave of PTSD cases in the next decade.

This method-driven approach for the evaluation of clinical data has merit that its product, the consensus statement, must also generate a cost-effectiveness analysis i. The relevant findings in this cost-effectiveness analysis are usually expressed as the incremental cost-effectiveness between joint and simultaneous treatment of PTSD and its co-morbidities versus a staggered approach.

The incremental cost-effectiveness ratio, i. The consensus statement evaluates each competitive strategy, usually by means of the Markov model-based decision tree.

This approach permits to model events that may occur in the future as a direct effect of treatment or as a side effect. The model produces a decision tree that cycles over fixed intervals in time and incorporates probabilities of occurrence. Even if the difference between the two treatment strategies appears quantitatively small, the Markov model outcome reflects the optimal clinical decision, because it is based on the best possible values for probabilities and utilities incorporated in the tree.

The outcome produced by the Markov decision analysis is generally obtained by means of the sensitivity analysis to test the stability over a range of probability estimates and thus reflects the most rational treatment choice Fig. The purpose of evidence-based research in medicine is to elucidate the best available evidence in response to a stated clinical problem e. Following the scientific process of evidence-based research and the generation of the consensus statement Fig. Effectiveness and utilities data are estimated e.

Markov model to aid the final clinical decision-making process The process of evidence-based research in medicine has begun its integration in the domain of PTSD.

These findings confirmed earlier Cochrane-based systematic reviews 67 , In a separate line of study, systematic reviews established clear support of the research evidence for serotonin reuptake inhibitors as the preferred first line treatment for PTSD, whereas mood stabilizers, atypical neuroleptics, adrenergic agents and newer antidepressants were shown to show promise, but to require further controlled trials to establish their efficacy and efficaciousness 60 , The future of clinical and translational research in PTSD also lies in its judicious integration of complementary and alternative medicine CAM.

For instance, whereas PTSD symptoms are common in patients with breast cancer, this symptomatology is more effectively reduced by traditional psychosocial interventions compared with CAM-oriented intervention Research will determine whether this observation is true across all forms of PTSD-inducing stress and trauma and across all subjects.

In conclusion, it is timely to design similar evidence-based research studies to establish the strength of the evidence in support of complementary approaches for the treatment of PTSD. For example, use of complementary therapies e. This trend appears to be particularly evident among native American veterans, who usually choose not to seek treatment at VAMC facilities, in part because of the preference they hold for alternative and complementary treatments, which are usually not available at those facilities This population of patients is therefore at serious risk of remaining underserved.

Taken together, these developments should produce important novel information about the fundamental nature of PTSD from the perspective of allostasis and about its optimal treatment using the best available evidence obtained from systematic reviews. This concerted approach will be particularly important as the prevalence of PTSD with its complex psychobiological co-morbidity rises and as alternative and complementary medical treatments for PTSD emerge and take hold.

Such is, in our view, the future of research in PTSD, in order to establish a registry of regular critical evaluation updates of the available evidence for the immediate service of the clinical research community and the benefit of patients with PTSD, their families and society at large.

National Center for Biotechnology Information , U. Evid Based Complement Alternat Med. Negoita Neagos 2 Psychoneuroimmunology Group, Inc. Received Jun 10; Accepted Sep Published by Oxford University Press. This article has been cited by other articles in PMC. Abstract The stress that results from traumatic events precipitates a spectrum of psycho-emotional and physiopathological outcomes. The research they did was a cross sectional study, which means that they used different people who had similar interests to the study, and then got willing participants to take part in the research.

The results showed that of the 96 participants, 40 of them indicated a diagnosis of PTSD Abeyasinghe That means that This study shows that even though we give our soldiers the medical attention they need, they are not getting all of it and that should be fixed.

There was an experiment done about the medical research done on twins, combat exposed and non-combat exposed, along with comparing previous studies of PTSD to their medical research. They used PTSD patients and a control group.

Their hippocampal area was also enlarged when compared to the control twins who had no PTSD and a low risk factor Pitman The article goes through every part of the brain and compares the scans of the combat exposed and combat unexposed twin groups, control and experimental, comparing the area of study, like the prefrontal cortex.

Which is the area of the brain that corresponds to Brodmann area and can also be called anterior mid-cingulate cortex Pitman It goes through every biological aspect you could think of and speculates off of the research previously done to the medical tests they have conducted to show how PTSD affects the brain, hormones, genes, and animal studies.

Then their conclusions at the end to tell you how this will help future medical treatments of PTSD. Even placebo-trials of other medications for PTSD have failed and recent studies of medications that are approved have failed to show desired results in patients Pitman The article is basically going over the effects of the drugs that are usually used to treat PTSD like noradrenergic, serotonergic, endogenous cannabinoid and opioid systems along with hypothalamic-pituitary adrenal HPA axis and then from figuring out what works with these and what does not, a possible future pharmacological intervention that could actually work and show results Pitman They then go into detail of each drug, explaining what it is made up of and how it does and does not work in relation to PTSD, including studies that have been done previously, charts, references to other works and explanations for the large words and confusing terminology.

The conclusion of the article states that biological markers alone are not sufficient by themselves, especially since treatment is limited to symptom management rather than fixing the biological cause Pitman To conclude, there is a lot of research done on PTSD, statistics, experiments, biological aspects, pathophysiological aspects and so much more.


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Post-traumatic Stress Disorder Research Paper Post-traumatic Stress Disorder research papers diagnose the disorder and give the main characteristics of the disease. Professional writers at Paper Masters will custom write research papers on any aspect of post-traumatic stress disorder or PTSD.

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Post Traumatic Stress Disorder Many people throughout the world suffer from Post Traumatic Stress Disorder also known as PTSD. This is a disorder that must be diagnosed and can be caused from a variety of reasons. Specifically, this research paper will focus on PTSD, or in other words: post traumatic stress disorder. PTSD has shown up as a factor from many wars, but for some reason, one war in particular stands out from all others regarding the the PTSD numbers.

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PTSD Research Paper. Posttraumatic stress is a set of psychological and physical symptoms that follow a traumatic experience READ MORE HERE. RESEARCH PAPER APPROVAL THE EPIDEMIC OF POST TRAUMATIC STRESS DISORDER AMONG VETERANS By Tai Hawk A Research Paper Submitted in Partial Fulfillment of .