In the Journal of Anxiety Disorders, investigators in the Department of Psychiatry and Behavioral Sciences report that veterans who fall just below the threshold for a diagnosis of post-traumatic stress disorder (PTSD) respond to psychotherapy better than those with full PTSD. The study highlights the need to recognize veterans suffering from an overlooked condition called subclinical PTSD. “The study shows not only that we can treat those experiencing subclinical presentations of PTSD, but also that those with subclinical PTSD may actually respond better to treatment than those with more severe forms of the disease,” said MUSC investigator Kristina Korte, Ph.D., who is the lead author on the article. MUSC co-authors include Ron Acierno, Ph.D., Daniel F. Gros, Ph.D., and Nicholas P. Allan, MS.
Like patients with full PTSD, those with subclinical PTSD have experienced a traumatic event and are regularly re-experiencing it, often in nightmares or flashbacks. Patients with full PTSD also experience hyperarousal (i.e., they are easily startled) and avoid reminders of the event, for example by withdrawing from social interaction or turning to substance abuse. In addition to re-experiencing the event, patients with subclinical PTSD may exhibit either hyperarousal or avoidance, but not both.
Psychologists began noticing this pattern more frequently in the nineties in veterans returning from the first Iraq War, and even more frequently in veterans returning from Iraq and Afghanistan in the past decade. As researchers have learned more about these patients over time, varying and sometimes conflicting symptoms have provided an incomplete picture of the disorder and how to treat it. Further confounding the issue is that those with subclinical PTSD are often excluded from clinical trials testing treatments for PTSD—patients with only some symptoms of PTSD commonly are not included in the healthy control group or in the group with full PTSD. As a result, there is still no standard psychotherapy for treating subclinical PTSD.
The researchers devised an intuitive approach—Why not treat subclinical PTSD patients with one of the standard evidence-based psychotherapy tools already being used in PTSD patients? They enrolled 200 patients with combat-related PTSD symptoms from the Ralph H. Johnson VA Medical Center located adjacent to MUSC, identifying those with either subclinical or full PTSD. For eight weeks, patients received intensive weekly sessions of behavioral activation and therapeutic exposure therapy, designed to lessen their PTSD symptoms by helping them safely re-experience and resolve elements of the original trauma. Psychologists rated the patients’ PTSD symptoms and had patients rate their own symptoms before, during, and after the eight weeks.
The results were encouraging. Those with subclinical or full PTSD each experienced a real drop in PTSD symptoms after treatment. The striking result was in how much those symptoms dropped: 29% in those with subclinical PTSD as compared to 14% in those with full PTSD.
Symptoms of PTSD often worsen over time; as they do, treatments become less effective at reducing symptoms. In this context, subclinical PTSD could be seen as “early-stage” PTSD, in that treatment might be more effective when the disorder is caught early.
“We hope that providing treatment for subclinical PTSD will make managing this common disorder more cost effective,” said Korte. “It could lead to the prevention of more intractable forms of PTSD that can occur when subclinical PTSD goes untreated.”