What is the best treatment for post-traumatic stress disorder (PTSD) with flashbacks, anxiety, and panic attacks in a patient with a history of seizure disorder who is reluctant to take daily medication?

Treatment for PTSD with Flashbacks, Anxiety, and Panic Attacks in a Patient with Seizure Disorder

For patients with PTSD who have comorbid seizure disorder and do not want daily medication, trauma-focused cognitive behavioral therapy (CBT), particularly Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) is the best treatment approach. 1

First-Line Treatment: Trauma-Focused Psychotherapy

Evidence-Based Psychotherapy Options

• Cognitive Behavioral Therapy (CBT) approaches have demonstrated superior outcomes compared to medication alone 1:
  • Prolonged Exposure (PE): Particularly effective for PTSD with flashbacks, with evidence showing 81.25% of patients experiencing reduction in symptoms 2
  • Cognitive Processing Therapy (CPT): Helps restructure trauma-related thoughts
  • Eye Movement Desensitization and Reprocessing (EMDR): Consists of 8 phases to process traumatic memories using bilateral stimulation 1

Benefits for Seizure Disorder Patients

• Trauma-focused psychotherapy is particularly appropriate for patients with seizure disorders as:
  • It avoids potential medication interactions with anti-seizure medications
  • Eliminates concerns about lowering seizure threshold (which some medications might do)
  • There is evidence that PTSD and trauma are associated with higher risk of psychogenic non-epileptic seizures 3, 4
  • Past trauma is associated with experiencing epileptic seizures as traumatic events 5

Adjunctive Treatments for Specific Symptoms

For Acute Anxiety/Panic Attacks

• As-needed (PRN) medications may be appropriate for patients who don't want daily medication:
  • Consider low-dose benzodiazepines only for acute management, with caution due to:
    • Risk of worsening PTSD outcomes long-term 1
    • Potential for abuse, especially concerning with anxiety disorders 1
    • If needed for acute management, use short-acting benzodiazepines (lorazepam, oxazepam) which are safer in patients with hepatic dysfunction 1

For Sleep Disturbances/Nightmares

• Prazosin (1-15 mg at bedtime) can be used specifically for PTSD-related nightmares on an as-needed basis 1
  • Has Level A recommendation for PTSD-related nightmares
  • Does not require daily use

Monitoring and Follow-Up

Symptom Monitoring

• Use standardized measures such as the PTSD Checklist for DSM-5 (PCL-5) to track progress 1
• Monitor for seizure activity and potential relationship between PTSD symptoms and seizure triggers
• Assess for development of psychogenic non-epileptic seizures, which are common in patients with PTSD 3

Treatment Duration

• Effective psychotherapy typically requires 8-15 weekly sessions 2
• Follow-up should continue to ensure maintenance of gains
• Studies show that gains made in seizure control through PE therapy can be maintained over time 2

Important Considerations and Pitfalls

Trauma-Seizure Relationship

• Be aware that many patients with PTSD and seizures attribute their seizures to traumatic brain injury (TBI), even when the connection is unclear 3, 4
• PTSD may moderate the development of psychogenic non-epileptic seizures in patients with mild TBI history 4

Contraindications

• Avoid psychological debriefing immediately after traumatic events as it may increase risk of PTSD symptoms 6
• Avoid daily benzodiazepines which can worsen PTSD outcomes and have abuse potential 1

When to Consider Medication

• If psychotherapy alone is insufficient, consider discussing with the patient:
  • Prazosin for nightmares (as-needed)
  • SSRIs like sertraline (50-200 mg/day) have FDA approval for PTSD 7 and could be considered if the patient reconsiders their stance on daily medication

Trauma-focused psychotherapy remains the gold standard for treating PTSD in patients with seizure disorder who prefer to avoid daily medication, with strong evidence supporting its efficacy and safety in this population.