Pharmacotherapy of post-traumatic stress disorder

In the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-III-R and DSM-IV, the diagnosis of post-traumatic stress disorder (PTSD) requires the presence of three symptom clusters: re-experiencing, avoidance and hyperarousal. The selective serotonin reuptake inhibitors (SSRIs), in particular sertraline and paroxetine, have emerged as the treatment of choice for trauma victims experiencing these three symptom clusters. While not approved by the U.S. Food and Drug Administration, other pharmacological agents are often used, some for symptoms found in victims of early, chronic or extreme stress. Referred to as having type II trauma, complex PTSD, disorders of extreme stress and enduring personality change after catastrophic experience, these patients, with symptoms such as dissociation, somatization and self-injurious behavior, need to be recognized as suffering from a trauma-related disorder qualitatively different from that presently captured in the DSM-IV. In this paper we will refer to DSM-IV's construct as simple PTSD (sPTSD); to complex PTSD/disorders of extreme stress as cPTSD/DES; and to both as PTSD. We will review existing evidence for the efficacy of SSRIs in treating sPTSD as well as different pharmacological interventions that are necessary for the treatment of cPTSD/DES. In addition, since both sPTSD and cPTSD/DES frequently coexist with other mental disorders, treatment of comorbid PTSD will be addressed. Finally, given that existing rating scales are not designed to measure symptoms of cPTSD/DES, we will describe the Symptoms of Trauma Scale (SOTS), designed to measure symptoms of both sPTSD and cPTSD.