Posttraumatisk belastningsreaktion
(Post-Traumatic Stress Disorder, PTSD)

Mere viden

Guidelines for treatment of PTSD
Foa, Edna B.; Keane, Terence M.; Friedman, Matthew J.
Journal of traumatic stress 13(4), 539-588, 2000

Meget omfattende og brugbar oversigt, som er skrevet på baggrund af en gennemgang af både klinisk og forskningsmæssig litteratur om PTSD. Fokus er på behandlingen af PTSD og syndromets symptomer, som de er beskrevet i Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4. udg. / American Psychiatric Association (1994).

Abstract
These guidelines are intended for adults, adolescents, and children who have developed PTSD. Their objective is to assist the clinician in providing treatment to these individuals. Because clinicians with diverse professional backgrounds provide mental health treatment for PTSD, the guidelines were developed with interdisciplinary input. Psychologists, psychiatrists, social workers, creative arts therapists, marital therapists, and others actively contributed to, and participated in, the developmental process. Accordingly, the guidelines are suitable for the diversity of clinicians who treat PTSD. The Task Force explicitly excluded from consideration individuals who are currently involved in violent or abusive relationships. These individuals, ranging from children who are living with an abusive caregiver, to women or men who are currently targets of domestic abuse or violence, to those still living in a war zone, may well meet diagnostic criteria for PTSD. Yet their treatment, and the related forensic and ethical issues that arise, differs fundamentally from those individuals whose traumatic events are over. Individuals who are in the midst of a traumatic situation require special considerations from the clinician. Other practice guidelines will need to be developed for these circumstances. Little is known about the treatment of PTSD in nonindustrialized countries. Research and scholarly treatises on the topic come largely from theWestern industrialized nations. The Task Force acknowledges this cultural limitation explicitly. There is growing recognition that PTSD is a universal response to exposure to traumatic events that is observed in many different cultures and societies. Yet there is a need for systematic research to determine the extent to which the treatments, both psychological and psychopharmacological, that have proven efficacy in Western societies are effective in non-Western cultures. Finally, clinicians following these guidelines should not limit themselves to only these approaches and techniques. Creative integration of new approaches that have been found to be helpful in other conditions and that have a theoretically sound foundation are encouraged in an effort to optimize treatment outcome.

Post-traumatic stress disorder : the management of PTSD in adults and children in primary and secondary care »

National Institute for Health and Clinical Excellence (NICE)

London, 2005
National Clinical Practice Guideline, 26

Summary

The NICE clinical guideline on post-traumatic stress disorder (PTSD) covers:

• the care people with PTSD can expect to receive from their GP or other healthcare professional
• the information they can expect to receive about their condition and its treatment
• what treatment they can expect, which may include psychological therapies and drug treatment
• the services that may help them with PTSD, including specialist mental health services

Pharmacotherapy for post traumatic stress disorder (PTSD) (Cochrane Review)  »

Stein, D. J.; Ipser, J. C.; Seedat, S.

Cochrane database of systematic reviews 2006 (1). Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2.

Abstract

Background : Post traumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

Objectives : To assess the effects of medication for post traumatic stress disorder.

Search strategy We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register (CCDANCTR-Studies) on 18 August 2005, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library issue 4, 2004), MEDLINE (January 1966 to December 2004), PsycINFO (1966 to 2004), and the National PTSD Center Pilots database. Reference lists of retrieved articles were searched for additional studies.

Selection criteria : All randomised controlled trials (RCTs) of pharmacotherapy for PTSD.

Data collection and analysis: Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

Main results: 35 short-term (14 weeks or less) RCTs were included in the analysis (4597 participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference -5.76, 95% confidence intervals (CI) -8.16 to -3.36, number of participants (N) = 2507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents to placebo (relative risk 1.49, 95% CI 1.28 to 1.73, number needed to treat = 4.85, 95% CI 3.85 to 6.25, N = 1272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs.
Medication was superior to placebo in reducing the severity of PTSD symptom clusters, comorbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of 3 maintenance trials suggested that long term medication may be required in treating PTSD.

Authors' conclusions : Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of SSRIs as first line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

Plain language summary : A systematic review and meta-analysis of randomised controlled medication trials for post traumatic stress disorder.
Post traumatic stress disorder (PTSD) occurs after exposure to significant trauma and results in enormous personal and societal costs. Although traditionally treated with psychotherapy, there is increasing recognition of a theoretical basis for medication treatments. This was a systematic review of 35 short-term randomised controlled trials of pharmacotherapy for PTSD (4597 participants). A significantly larger proportion of patients responded to medication (59.1%) than to placebo (38.5%) (13 trials, 1272 participants). Symptom severity was significantly reduced in 17 trials (2507 participants). The largest trials showing efficacy were of the selective serotonin reuptake inhibitors, with long-term efficacy also observed for these medications. 

Psychological treatment of post-traumatic stress disorder (PTSD) (Cochrane Review)  »

Bisson J,; Andrew, M.

Cochrane database of systematic reviews 2007 (3). Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub3.

Abstract
Background

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).
Objectives

To perform a systematic review of randomised controlled trials of all psychological treatments following the guidelines of The Cochrane Collaboration.
Search strategy

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.
Selection criteria

Types of studies - Any randomised controlled trial of a psychological treatment.
Types of participants - Adults suffering from traumatic stress symptoms for three months or more.
Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT); eye movement desensitisation and reprocessing (EMDR).
Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.
Data collection and analysis

Data were entered using Review Manager software. Quality assessments were performed. Data were analysed for summary effects using Review Manager 4.2.
Main results

Thirty-three studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms measured immediately after treatment TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.40; 95% CI, -1.89 to -0.91; 14 studies; n = 649). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31). EMDR did significantly better than waitlist/usual care (SMD = -1.51; 95% CI, -1.87 to -1.15; 5 studies; n = 162). There was no significant difference between EMDR and TFCBT (SMD = 0.02; 95% CI, -0.28 to 0.31; 6 studies; n = 187). There was no significant difference between EMDR and SM (SMD = -0.35; 95% CI, -0.90 to 0.19; 2 studies; n = 53). EMDR did significantly better than other therapies (self-report) (SMD = -0.84; 95% CI, -1.21 to -0.47; 2 studies; n = 124).
Authors' conclusions

There was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management were more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups. The considerable unexplained heterogeneity observed in these comparisons, and the potential impact of publication bias on these data, suggest the need for caution in interpreting the results of this review.
Plain language summary
Psychological treatments can reduce symptoms of post traumatic stress disorder (PTSD). Trauma focused treatments are more effective than non-trauma focused treatments.

This review concerns the efficacy of psychological treatment in the treatment of PTSD. There is evidence that individual trauma focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There is some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management are more effective than other therapies. There is insufficient evidence to show whether or not psychological treatment is harmful. Trauma focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD.

Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder  »
American Psychiatric Association, 61 s., 2004

Delvis udgivet som supplement til American journal of psychiatry (præcise oplysninger haves ikke december 2004)

Guide to Using This Practice Guideline
The Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder consists of three parts (Parts A, B, and C) and many sections, not all of which will be equally useful for all readers.

Part A, “Treatment Recommendations,” is published as a supplement to The American
Journal of Psychiatry and contains general and specific treatment recommendations. Section I summarizes the key recommendations of the guideline and codes each recommendation according to the degree of clinical confidence with which the recommendation is made. Section II provides further discussion of the formulation and implementation of a treatment plan as it applies to the individual patient. Section III, “Specific Clinical Features Influencing the Treatment Plan,” discusses a range of clinical considerations that could alter the general recommendations discussed in Section I.

Part B “Background Information and Review of Available Evidence,” provides an overview of ASD and PTSD, including general information on natural history, course, and epidemiology. It also provides a structured review and synthesis of the evidence
that underlies the recommendations made in Part A.

Part C “Future Research Needs,”draws from the previous sections and summarizes areas for which more research data are needed to guide clinical decisions.

Traumatiserede flygtninge på sprogcentre - symptomer og behov »
Svendsen, Grethe
I : Udlændinge med særlige undervisningsbehov : en antologi
Kleivan, Karina; Skadhauge, Jette; Vedel, Peter Villads (red)
Ministeriet for Flygtninge, Indvandrere og Integration, 2002

Artiklen giver en god, lettilgængelig beskrivelse af PTSD.

National Center for Post-traumatic Stress Disorder (PTSD) »
Dette amerikanske center er oprindelig oprettet med det formål at styrke behandlingen af amerikanske krigsveteraner med PTSD. Siden 1989 har centret blandt andet forsket og undervist i behandlingen af PTSD og andre stressrelaterede sygdomme.

Meget indholdsrig hjemmeside om PTSD og andre varige konsekvenser af traumatisk stress. Informationer og dokumenter om blandt andet behandling, symptomer og epidemiologi.