Gabapentin in PTSD: A Retrospective, Clinical Series of Adjunctive Therapy

Posttraumatic stress disorder (PTSD) symptoms may improve significantly with antidepressant medications, however some phenomena often remain refractory to the most commonly used treatments. Frequently, sleep disturbances, such as insomnia and nightmares, are symptoms of PTSD that are refractory to antidepressant treatment. Gabapentin, a novel anticonvulsant agent, has been of interest as a potential anxiolytic agent, but has not been evaluated in PTSD. We reviewed records of 30 consecutive patients who had been diagnosed with PTSD according to structured interviews and had received gabapentin as an adjunctive medication. For each patient, the target symptoms that led to the initiation of gabapentin treatment were identified. Using the most recent clinical data available, the change in target symptom severity following treatment was rated as unimproved, mildly improved, moderately improved, or markedly improved. The gabapentin was often first prescribed to facilitate sleep. The majority (77%) of patients showed moderate or greater improvement in duration of sleep, and most noted a decrease in the frequency of nightmares. The dose range was 300–3600 mg/day. Sedation and mild dizziness were the most commonly reported side effects. This retrospective study suggests that gabapentin may improve in particular sleep difficulties and also other symptoms associated with chronic PTSD. Prospective, controlled studies are needed to further investigate the effects of gabapentin on insomnia, nightmares, and other core PTSD symptoms.     

The Use of a Synthetic Cannabinoid in the Management of Treatment‐Resistant Nightmares in Posttraumatic Stress Disorder (PTSD)

This is the report of an open label clinical trial to evaluate the effects of nabilone, an endocannabinoid receptor agonist, on treatment‐resistant nightmares in patients diagnosed with posttraumatic stress disorder (PTSD). Methods: Charts of 47 patients diagnosed with PTSD and having continuing nightmares in spite of conventional antidepressants and hypnotics were reviewed after adjunctive treatment with nabilone was initiated. These patients had been referred to a psychiatric specialist outpatient clinic between 2004 and 2006. The majority of patients (72%) receiving nabilone experienced either cessation of nightmares or a significant reduction in nightmare intensity. Subjective improvement in sleep time, the quality of sleep, and the reduction of daytime flashbacks and nightsweats were also noted by some patients. The results of this study indicate the potential benefits of nabilone, a synthetic cannabinoid, in patients with PTSD experiencing poor control of nightmares with standard pharmacotherapy. This is the first report of the use of nabilone (Cesamet; Valeant Canada, Ltd., Montreal, Canada) for the management of treatment‐resistant nightmares in PTSD.     

Olanzapine in the treatment-resistant,combat-related PTSD--a series of case reports

OBJECTIVE: Nightmares and insomnia in combat-related post-traumatic stress disorder (PTSD) might be resistant to treatment with selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines. METHOD: We describe five case reports of patients suffering from long-lasting and intractable nightmares and insomnia. They were given different psychotropic agents in past few years, with no improvement in their sleep disturbance. Olanzapine was added to the current treatment regimen. RESULTS: Both nightmares and insomnia improved rapidly after olanzapine institution in all of five patients. No adverse events of olanzapine were reported. CONCLUSION: Olanzapine augmentation might be useful in alleviating treatment-resistant nightmares and insomnia in patients with combat-related PTSD.     

Sleep in Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is often associated with sleep disturbances. In this review, we focus on the published literature on subjective and objective findings of sleep in patients with PTSD. Insomnia and nightmares are most commonly reported subjective sleep disturbances. Polysomnographic investigations have frequently reported rapid eye movement (REM) sleep abnormalities in PTSD. However, studies have not been consistent about the type of REM sleep dysfunction in PTSD patients. Antidepressants such as nefazodone, trazodone, fluvoxamine, and imagery rehearsal therapy are found to be beneficial in the treatment of PTSD associated sleep disturbances as well as core symptoms of this anxiety disorder. We propose use of such modalities of treatment in PTSD patients with predominant sleep disturbances. Further studies are required to clarify polysomnographic sleep changes especially role of REM sleep dysregulation and treatment of sleep disturbances in PTSD.     

Clinical neuropharmacology of sleep disorders

Within the context of the comprehensive treatment of sleep disorders, which includes medical, neurologic, psychiatric, and social interventions, use of medication is often indicated. Among the three benzodiazepine hypnotics that are available in the United States for the treatment of insomnia, flurazepam is effective for both sleep induction and maintenance, and it retains most of its efficacy over a 4-week period of nightly administration; temazepam is effective only for sleep maintenance, and triazolam improves both sleep induction and maintenance with initial but not with continued administration. Rebound phenomena are more frequent and intense with the more rapidly eliminated drug, triazolam, and to a lesser degree with temazepam. Also, with triazolam, certain behavioral side effects, such as amnesia and psychotic-like symptoms, have been reported. With flurazepam, which is a slowly eliminated benzodiazepine, daytime sedation is more frequent than with the other two drugs. When insomnia is secondary to major depression, antidepressant medication should be administered. Methylphenidate, amphetamines, or other stimulant medications are used for the symptomatic treatment of the sleepiness and sleep attacks of narcolepsy and hypersomnia. For cataplexy and the other two auxiliary symptoms of narcolepsy, imipramine or other tricyclics are the drugs of choice. Protriptyline and medroxyprogesterone have been used in treating mild cases of obstructive sleep apnea, but their efficacy is limited. Similarly, for the treatment of central sleep apnea, medroxyprogesterone and acetazolamide have shown only limited effects. Medication for patients with sleepwalking, night terrors, or nightmares should be prescribed judiciously, and primarily when treatment of an underlying psychiatric condition is desired. The neuropharmacology of sleep should also consider drugs that may cause sleep disorders. Medications with sleep disturbing effects include various antihypertensives, bronchodilators, and the energizing antidepressants. Withdrawal of REM-suppressant drugs, such as the barbiturates, may cause nightmares in association with a REM rebound. Occasionally, a drug or a combination of drugs may produce somnambulistic-like activity in some patients.     

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

Purpose of Review

Comorbidity of posttraumatic stress disorder (PTSD) and insomnia, nightmares, and obstructive sleep apnea (OSA) is high. We review recent research on psychotherapeutic and pharmacological interventions for sleep disorders in PTSD.

Recent Findings

PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low.

Summary

Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

     

Exploring differences between the ICD-11 and DSM-5 models of PTSD: Does it matter which model is used?

Alternative symptom profiles for posttraumatic stress disorder (PTSD) are presented in the DSM-5 and ICD-11. This study compared DSM-5 PTSD symptom profiles with ICD-11 PTSD symptom profiles among a large group of trauma-exposed individuals from Denmark. Covariates, and rates of co-occurrence with other psychiatric disorders were also investigated. A sample of treatment-seeking adult survivors of childhood sexual abuse (n = 434) were assessed using self-report measures of PTSD and other psychiatric disorders. A significantly larger proportion of individuals met caseness for DSM-5 PTSD (60.0%) compared to ICD-11 PTSD (49.1%). This difference was largely attributable to low endorsement of the ICD-11 re-experiencing criteria. Replacement of the ‘recurrent nightmares’ symptom with the ‘recurrent thoughts/memories’ symptom seemed to balance the proportion of individuals meeting caseness for both taxonomies. Levels of co-occurrence with anxiety and thought disorder were higher for the DSM-5 model of PTSD compared to the ICD-11 model. Current results merit careful consideration in the selection of symptom indicators for the new ICD model of PTSD, particularly with respect to the re-experiencing symptom category.     

Place des thérapies comportementales dans la prise en charge des insomnies

Insomnia is among the most common health complaints in medical practice and the most prevalent of all sleep disorders. Generally, hypnotics and sedative drugs are widespread used, despite new knowledge in medical literature. Chronic insomnia can be a symptom, a syndrome and co morbid disorder. Its diagnostic relies on subjective reports from patient and sleep diary. Different subtypes of insomnia are defined: prolonged sleep latency (sleep onset insomnia), difficulties in maintaining sleep (sleep maintenance insomnia), early insomnia or a mix of different sleep complaints (mixed insomnia). Beside nights complaints, diurnal consequences are reported, include fatigue, mood disruption impaired attention… First, identification and treatment of primary psychiatric disorders or medical conditions or specific sleep disorders (apnea syndrome or periodic limb movement) are essential and associated with sleep hygiene (therapeutic education). If this first step is not sufficient, behavioral therapy (BT) (stimulus control and sleep restriction) or cognitive-behavioral therapy (CBT) of insomnia have demonstrated considerable efficacy within randomized clinical trials. Other techniques exist: relaxation, biofeedback… But CBT or BT is gold standard. Nevertheless, treatment of insomnia is an individual course of care.     

Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind,placebo-controlled study

OBJECTIVE: Posttraumatic stress disorder (PTSD), particularly in combat veterans with chronic illness, is often refractory to standard pharmacological interventions. There is a need to test adjunctive treatments to boost response. METHOD: Subjects were 19 patients with PTSD who were minimally responsive to 12 weeks of treatment with a selective serotonin reuptake inhibitor (SSRI) at maximum tolerated dose. Outcomes were compared among subjects whose treatment was augmented with 8 weeks of double-blind olanzapine or placebo administration. RESULTS: Olanzapine augmentation was associated with statistically significantly greater reduction than placebo in specific measures of posttraumatic stress, depressive, and sleep disorder symptoms. Clinician-rated global response rates did not, however, significantly differ between groups. CONCLUSIONS: This is most likely the first double-blind, placebo-controlled study of an adjunct to SSRIs for PTSD. Despite the small group size, the findings suggest a role for olanzapine or other atypical antipsychotics in treating SSRI-resistant PTSD. Sleep symptoms may especially benefit.     

An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD.

OBJECTIVE: Insomnia and nightmares are perceived as secondary phenomena in posttraumatic stress disorder (PTSD). Scant treatment research has targeted these two sleep disturbances. This study reports on an open-label trial of cognitive behavior therapy for insomnia and disturbing dreams in crime victims with PTSD. The relationship among nightmares, sleep disturbances, and PTSD symptoms is discussed. METHOD: Sixty-two participants completed a 10-hour group treatment consisting of imagery rehearsal for nightmares and sleep hygiene, stimulus control, and sleep restriction for insomnia. Nightmare frequency, sleep quality, sleep impairment, and ratings for PTSD, anxiety, and depression symptoms were assessed at baseline and at the 3-month follow-up. RESULTS: All measures demonstrated improvement that was roughly equivalent to changes in clinical severity from severe to moderate for sleep quality, sleep impairment, and nightmare frequency, from borderline severe to borderline moderate for PTSD symptoms, and from extremely severe to borderline severe for anxiety and depression symptoms. CONCLUSIONS: In this uncontrolled study, successful treatment for insomnia and nightmares in crime victims was associated with improvement in symptoms of PTSD, anxiety, and depression. Participants with clinical improvements in PTSD symptoms demonstrated significantly greater improvement in sleep quality and nightmare frequency than those whose PTSD symptoms did not improve.     

A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing

OBJECTIVE: To assess the impact of treatment for co-morbid sleep-disordered breathing (SDB) on patients with nightmares and post-traumatic stress. METHODS: Twenty-three chronic nightmare sufferers (15 with post-traumatic stress disorder, PTSD) who also suffered co-morbid SDB (obstructive sleep apnea, OSA, n=16; upper airway resistance syndrome, UARS, n=7) completed a telephone interview, on average, 21 months after having been offered treatment for SDB at a university sleep disorders clinic. RESULTS: At follow-up, 14 reported maintaining treatment (Treatment Group) and 9 reported discontinuing treatment (No-Treatment Group). More patients in the Treatment Group reported improvement in sleep (93% vs. 33%) and in daytime well being (93% vs. 33%) compared with those in the No-Treatment group. The Treatment Group reported a median improvement in nightmares of 85% compared with a median 10% worsening in the No-Treatment Group. In the PTSD subset (n=15), nine in the Treatment Group reported a median 75% improvement in PTSD symptoms whereas six in the No-Treatment Group reported a median 43% worsening. CONCLUSION: In this small sample of patients, treatment of SDB was associated with improvements in nightmares and PTSD. Relationships between nightmares, PTSD and SDB are discussed.     

Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares

BACKGROUND: Trazodone is commonly used in the treatment of insonmia and nightmares in patients with PTSD. There is little evidence in the literature for this practice. METHOD: Seventy-four patients from the Palo Alto Veterans Affairs Health Care System in California who were admitted to a specialized 8 week inpatient treatment program for PTSD were surveyed regarding their use of trazodone in the treatment of insomnia or nightmares. Patients were asked to complete a questionnaire regarding trazodone's effectiveness, side effects, and optimal doses. RESULTS: Of 74 patients surveyed, 60 patients were able to maintain an effective dose of trazodone. The other 14 patients were unable to tolerate the medication. Seventy-two percent of the 60 patients assessed found trazodone helpful in decreasing nightmares, from an average of 3.3 to 1.3 nights per week (p<.005). Ninety-two percent found it helped with sleep onset, and 78% reported improvement with sleep maintenance. There was a significant correlation between the effectiveness in decreasing nightmares and improving sleep (r= .57, p < .005). The effective dose range of trazodone for 70% of patients was 50 to 200 mg nightly. Of the 74 patients surveyed, 9 (12%) reported priapism. CONCLUSION: Trazodone appears effective for the treatment of insomnia and nightmares associated with chronic PTSD. However, controlled trials are needed before any definite conclusions can be drawn. The higher than expected occurrence of priapism warrants clinicians asking directly about this side effect.     

Sleep in a community sample of elderly war veterans with and without posttraumatic stress disorder.

BACKGROUND: Although sleep disturbances are commonly reported by individuals with posttraumatic stress disorder (PTSD), objective findings have been inconsistent, due in part to small sample sizes, comorbid psychiatric disorders, variations in the recentness of trauma exposure, and the use of PTSD subjects involved in psychiatric treatment. METHODS: A community sample of elderly males (n = 59) exposed to war trauma 28-50 years ago and free from sleep-affecting medications and disorders other than PTSD completed 3 nights of polysomnography. Of these participants, 30 met criteria for current PTSD; three were receiving supportive outpatient psychotherapy. RESULTS: Two statistically significant differences were observed: Those with PTSD had a higher percentage of rapid eye movement (REM) sleep and fewer arousals from non-REM sleep. The perceptions of sleep quality among the participants with PTSD were lower than the perceptions of non-PTSD participants. Although participants with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, many cases were detected on initial screening. Treatment resulted in improved sleep and increased feelings of well being. CONCLUSIONS: Alterations in REM and arousals characterized PTSD in this sample. When comorbid sleep disorders were ruled out, sleep was clinically similar across the groups. Trauma-related sleep disturbances that subjects reported as arising early in the course of the disorder appear to have declined over time.     

Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study

OBJECTIVE: Prazosin is a centrally active alpha(1) adrenergic antagonist. The authors' goal was to evaluate prazosin efficacy for nightmares, sleep disturbance, and overall posttraumatic stress disorder (PTSD) in combat veterans. METHOD: Ten Vietnam combat veterans with chronic PTSD and severe trauma-related nightmares each received prazosin and placebo in a 20-week double-blind crossover protocol. RESULTS: Prazosin (mean dose=9.5 mg/day at bedtime, SD=0.5) was superior to placebo for the three primary outcome measures: scores on the 1) recurrent distressing dreams item and the 2) difficulty falling/staying asleep item of the Clinician-Administered PTSD Scale and 3) change in overall PTSD severity and functional status according to the Clinical Global Impression of change. Total score and symptom cluster scores for reexperiencing, avoidance/numbing, and hyperarousal on the Clinician-Administered PTSD Scale also were significantly more improved in the prazosin condition, and prazosin was well tolerated. CONCLUSIONS: These data support the efficacy of prazosin for nightmares, sleep disturbance, and other PTSD symptoms.     

Sleep,suicide behaviors,and the protective role of sleep medicine

Objective/BackgroundSleep disturbance is associated with suicidal thoughts and behaviors. The relationship of specific sleep disorders to suicide attempts is less well established. Whether treating sleep disorders reduces suicide attempts remains controversial.MethodsSuicide attempts, treatment utilization, and psychiatric diagnoses were extracted from electronic medical records and a suicide attempt database from the U.S. Department of Veterans Affairs. The sample (N = 60,102) consisted of patients with any record of suicide attempt in FY13-14 and a 1:1 case-control of patients with no record of attempt, who were propensity score-matched based on age, gender, and prior year mental health treatment utilization. Associations among sleep disorders and suicide attempt were examined via logistic regression. Covariates included depression, anxiety, posttraumatic stress disorder (PTSD), bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity.ResultsInsomnia (OR = 5.62; 95% CI, 5.39–5.86), nightmares (odds ratio, OR = 2.49; 95% confidence interval, CI, 2.23–2.77), and sleep-related breathing disorders (OR = 1.37; 95% CI, 1.27–1.48) were positively associated with suicide attempt after accounting for age, gender, treatment utilization, and comorbid sleep disorders. Furthermore, when controlling for depression, anxiety, PTSD, bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity, insomnia (OR = 1.51, 95% CI, 1.43–1.59) remained positively associated with suicide attempt nightmares (OR = 0.96; 95% CI, 0.85–1.09) nor sleep-related breathing disorders (OR = 0.87, 95% CI = 0.79–0.94). Additionally, sleep medicine visits 180 days prior to index date were associated with decreased likelihood of suicide attempt for individuals with sleep disorders (OR = 0.86; 95% CI, 0.79–0.94).ConclusionInsomnia is associated with suicide attempt among veterans. Sleep medicine visits were associated with a reduced risk of suicide attempt in sleep disordered patients. The assessment and treatment of sleep disorders should be considered in context of strategies to augment suicide prevention efforts.     

Post-traumatic stress disorder and sleep-what a nightmare!

According to DSM IV criteria, sleep disturbances are incorporated in the definition of post-traumatic stress disorder (PTSD). These include the re-experiencing symptoms (nightmares, criteria B) and a hyperarousal state (difficulty initiating and maintaining sleep, criteria D). PTSD patients commonly complain of sleep disturbances. Moreover, insomnia, restless sleep and trauma-related dreams might be the primary complaint of some patients. However, although subjective sleep disturbances are considered characteristic of PTSD, sleep laboratory studies have provided inconsistent evidence of objective sleep disorders. A variety of sleep architectures and sleep patterns has been reported in PTSD. However, only a few studies have controlled for comorbidities. Thus, uncertainty exists to what extent the sustained complaints of sleep disturbances in chronic PTSD are specifically related to the impact of exposure to traumatic stress, or rather are a consequence of comorbid disorders. Specific changes in REM sleep suggest a pathophysiologic role of REM sleep abnormality in PTSD (e.g. anxiety dreams, increased REM density, exaggerated startle response, decreased dream recall and elevated awakening thresholds from REM sleep). However, again, studies have failed to show consistent changes in percentage of REM sleep or in REM latency. There might be a coexistence of pressure to REM along with inhibitory forces of REM that result in high variability of REM parameters across patients. Alternatively, changes in REM sleep might reflect the effect of comorbid psychiatric disorders that results in inconsistent findings between patients. The current review tries to address these issues based on recent studies carried out in this field.     

The impact of comorbid posttraumatic stress disorder on short-term clinical outcome in hospitalized patients with depression

OBJECTIVE: Posttraumatic stress disorder (PTSD) is often comorbid with other psychiatric disorders but often goes unrecognized. The effects of PTSD comorbidity are unclear, especially in patients with severe mental illness. The authors assessed short-term clinical outcome in severely depressed psychiatric inpatients with and without comorbid PTSD. METHOD: From patients hospitalized between 1995 and 2000, all patients with depression and comorbid PTSD (N=587) were selected and matched with depressed patients without PTSD (N=587). Clinical outcome was assessed with a semistructured, physician-administered battery. Differences between the two groups were examined, with overall burden of psychiatric illness entered as a covariate in the analyses. RESULTS: Relative to depressed patients without PTSD, depressed patients with PTSD had, at discharge, greater psychiatric symptom severity and higher levels of depression and hostility. Depressed patients with comorbid PTSD also had a significantly higher rate of being discharged against medical advice (odds ratio=6.10, 95% CI 2.96-12.57). CONCLUSIONS: PTSD comorbidity correlates with poorer short-term clinical outcome and greater likelihood of discharge against medical advice in severely depressed psychiatric inpatients. Better recognition of PTSD comorbidity may improve overall care of these patients.     

Does olanzapine have antidepressant properties? A retrospective preliminary study

Objective: Mood‐stabilizing agents are ideally conceptualized as possessing antimanic and antidepressant properties. While research on olanzapine's antimanic effects is growing, data on its possible antidepressant properties are limited. We sought to determine if olanzapine is effective in the add‐on treatment of major affective disorders, particularly depressive symptoms, in a naturalistic setting.

Methods: All charts of patients meeting DSM‐IV criteria for bipolar disorder or unipolar major depressive disorder treated with olanzapine in a private psychiatric practice were reviewed and clinical response was assessed retrospectively using the Clinical Global Impression Scale for Improvement (CGI‐I).

Results: Olanzapine was moderately effective in 6/10 (60%) patients. Side‐effects were present in 8/10 (80%), most commonly weight gain.

Conclusions: Olanzapine appears to be moderately effective in open add‐on treatment in patients with mainly depressive symptoms. Accumulating evidence suggests that olanzapine, and atypical antipsychotics in general, possess mild to moderate adjunctive antidepressant properties.     

An open-label, 12-week clinical and sleep EEG study of nefazodone in chronic combat-related posttraumatic stress disorder

BACKGROUND: We examined the effects of nefazodone on polysomnographic sleep measures and subjective reports of sleep quality and nightmares. as well as other symptoms, in patients with chronic combat-related posttraumatic stress disorder (PTSD) during a 12-week, open-label clinical trial. To our knowledge, this is the first polysomnographic study of treatment in patients with PTSD. METHOD: The subjects were 12 male veterans (mean age = 54 years) who met DSM-IV diagnostic criteria for PTSD (mean duration = 30 years). All but I patient also met DSM-IV criteria for major depressive disorder. Patients were evaluated weekly with clinical ratings in an open-label clinical trial. Polysomnographic recordings for 2 consecutive nights were obtained before treatment and at 2, 4, 8, and 12 weeks. The dose of nefazodone was adjusted according to individual clinical needs. Final mean daily dose was 441 mg. RESULTS: The patients reported significantly fewer nightmares and sleep problems during treatment. Nevertheless, contrary to studies in depressed patients, nefazodone did not significantly affect polysomnographic sleep measures compared with baseline. In addition, the patients showed significant improvement in the Clinical Global Impressions of PTSD symptoms (global score, hyperarousals and intrusions subscales), the Clinician-Administered PTSD Scale (global, hyperarousal, and intrusions subscales), the Hamilton Rating Scale for Depression (HAM-D). and the Beck Depression Inventory (BDI). CONCLUSION: These patients with chronic, treatment-resistant, combat-related PTSD showed significant improvement of subjective symptoms of nightmares and sleep disturbance, as well as depression and PTSD symptoms. in this 12-week open-label clinical trial. Nevertheless, objective polysomnographic sleep measures did not change. Further studies, including double-blind. placebo-controlled trials, are needed to extend these findings and to understand the relationships between the physiology of sleep and symptoms of poor sleep and nightmares.     

Post-traumatic stress disorder: Hypotheses from clinical neuropsychology and psychopharmacology research

Characteristic features of post-traumatic stress disorder (PTSD) include intrusive memories, avoidance, memory and concentration difficulties, and hyperalertness. Neuropsychological investigations of individuals with PTSD have suggested global and specific impairments of performance on standardized tests of memory. The use of the Emotional Stroop test has shown that trauma-related words are a sensitive measure of clinical state in PTSD patients. The Stroop paradigm has also shown that patients with PTSD appear to be characterized by implicit, explicit and autobiographical memory impairment. Available treatments for chronic post-traumatic stress disorder include cognitive-behaviour therapy, psychodynamic therapy and pharmacotherapy. Whereas drug treatment alone can rarely alleviate the suffering in PTSD, it appears to be most useful as an adjunct to psychotherapy. Tricyclic antidepressants are generally thought to be effective in alleviating symptoms, including nightmares, depression, sleep disorders and startle reactions, but are less able to relieve numbing. On the other hand, selective re-uptake blockers may be effective in decreasing numbing. However, rigorous clinical trials with double-blind placebo-controlled designs need to be performed to confirm these results. With new scientific discoveries in the understanding of PTSD, a new generation of pharmacological treatment is likely to emerge. (Int J Psych Clin Pract 2000; 4:3-18)