Why PTSD is difficult to diagnose and treat

Post-traumatic stress disorder can cause people to shut themselves out — they tend to withdraw into themselves, hesitate to talk about their experiences, and often fail to trust others or themselves — yet many of the main treatments for the illness are aimed at doing just that.

Treatment for PTSD includes various forms of psychotherapy and medication, which work for many patients but not for everyone. Treatment can be expensive, and can be so painful that patients drop out before treatment is complete.

“The field has recognized for years that we need to do better for patients,” Dr. Jerry Rosenbaum, a professor of psychiatry at Harvard Medical School, said Tuesday at a panel of experts tasked with advising the Food and Drug Administration on whether to approve the first new drug for PTSD in decades.

The treatment uses the psychoactive drug MDMA, also known as ecstasy, in combination with talk therapy to ease symptoms of the disorder that can cause intrusive thoughts, flashbacks and nightmares, and increase the risk of death from suicide or other causes. Proponents say the drug can help ease patients' fears and anxieties, and allow patients to feel compassion for themselves as they overcome trauma in treatment. Two clinical trials have shown promising results, but Experts express concern Regarding data reliability and drug safety.

almost 6 percent Seventy percent of the U.S. population will develop PTSD at some point in their lives. Currently, only a small percentage of those patients recover, Dr. Tiffany R. Falcione, director of the FDA's Office of Psychiatric Products, said at the conference Tuesday. And many people with PTSD symptoms Struggling to get a diagnosis in the first place.

How is PTSD diagnosed?

The gold standard for diagnosing PTSD is the Clinician-Administered PTSD Scale, known as the CAPS-5. Clinicians ask patients about their symptoms and their severity, how often they re-experience unwanted memories, and what measures they take to avoid remembering the traumatic event.

Yet many people with this disorder never even receive an evaluation for their disability.

One reason is that patients may not recognize the signs of the disorder, especially if the person exhibiting symptoms isn't a veteran, said Edna Fore, a professor of psychiatry at the University of Pennsylvania's Perelman School of Medicine. Public perception of the disorder is still so closely tied to the idea of ​​military combat that survivors of natural disasters or sexual assault may not realize they're also experiencing trauma.

Dr. Shaili Jain, a PTSD specialist at Stanford University, said a patient's primary care doctor, who may be the first to hear about their sleep problems or mood changes, may not recognize some symptoms as signs of the disorder.

PTSD is also an avoidance disorder: people with the condition typically avoid reminders of the traumatic event and may be unwilling to talk about it or seek treatment.

“One of the problems with PTSD is that it makes you withdrawn,” says Dr. John Markowitz, professor of clinical psychiatry at Columbia University. “You feel like you can't trust people, so you avoid them and may not seek help even if you need it.”

How is PTSD currently treated?

Psychotherapy is the treatment of choice, and one common and effective approach developed by Dr. Fore is called prolonged exposure. Patients are asked to describe in detail a traumatic event they experienced, then work through a list of people, places, and situations they have avoided since the event, gradually encouraging them to confront their fears.

Another mainstream approach is cognitive processing therapy, in which mental health professionals help patients understand how their disorder has changed the way they see themselves and the world.

“If you can help someone balance their thinking, their emotions and behaviors will follow,” says Matthew A. Robinson, program director of the McLean Trauma Continuum of Care at the Hill Center in Massachusetts.

Other treatment options include Eye movement desensitization reprocessing therapy When patients describe a traumatic event, both sides of the brain become activated. Interpersonal psychotherapy, A type of talk therapy that focuses on how trauma affects relationships.

These treatments can be very effective for people with PTSD, but studies have shown Between a quarter and a half Many patients do not respond to cognitive therapy, and Many people stop treatment prematurely. On average, almost 20 percent Seventy percent of participants in clinical trials for PTSD treatments drop out, and researchers believe the figure is likely much higher, in part because patients are uncomfortable reliving their worst memories in such detail.

Treatment costsJain said issues with insurance coverage and a shortage of mental health providers can also be barriers to treatment.

The FDA has approved two selective serotonin reuptake inhibitors for the treatment of PTSD: sertraline and paroxetine. Clinicians also use drugs not specifically approved for the treatment of PTSD to treat the disorder. Prazosin, Studies have shown that blood pressure medications can reduce nightmares, and while medications can help relieve symptoms, they don't address the underlying causes of PTSD.

Dr. Rosenbaum said at the FDA meeting on Tuesday that 40 to 60 percent of people treated for PTSD still meet diagnostic criteria for the disorder.

Over the past decade or so, treatments, including MDMA-assisted psychotherapy, have become Virtual Reality Therapy and Neurofeedback, This treatment, which involves regulating brain activity, is gaining attention.

Experts say the more effective options there are to address the disorder, the better off patients will be.

Dana Smith contributed reporting.