Always on High Alert: Addressing Hyperarousal in PTSD Treatment

Marked by being easily startled, irritable and hypervigilant, hyperarousal is a cluster of symptoms that afflicts many people with post-traumatic stress disorder.

Along with hallmark symptoms such as flashbacks and frightening thoughts, hyperarousal is a common feature of PTSD, which involves persistent stress following a traumatic event. Challenges treating PTSD in general remain, and hyperarousal specifically can be very difficult to treat, says Dr. Sanjay Mathew, a professor of psychiatry and behavioral sciences at Baylor College of Medicine and staff physician at the Michael E. DeBakey VA Medical Center in Houston.

Mathew and research colleagues at Baylor recently received a grant that will provide more than $1.35 million from the National Institute of Mental Health over two years to study and develop a drug that might mitigate hyperarousal in patients with PTSD.

At present, there are two Food and Drug Administration-approved drugs to treat PTSD, the antidepressants Zoloft and Paxil (generics: sertraline and paroxetine). Though clinicians say these medications can be helpful, neither of the drugs was specifically designed to treat PTSD. "There's a big dearth of effective drug treatments, and that's what the focus of our research is," Mathew says. "Psychotherapies help a lot of people, but still many will have residual symptoms or incomplete resolution."

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Battling Hyperarousal

Often accompanied by depression, PTSD can strain relationships and lead people to withdraw from social situations; hyperarousal, in particular, can make it difficult to concentrate, disrupt sleep and increase the likelihood of angry outbursts. Many people who don't seek treatment in a timely fashion experience worsening of the symptoms, especially with regards to hyperarousal, including sleep problems and anger management, says Dr. Yuval Neria, professor of medical psychology at Columbia University Medical Center and director of Trauma and PTSD at the New York State Psychiatric Institute in New York City.

"About 50 percent of those who develop [and are] diagnosed with PTSD cannot be helped by current therapy or therapy approaches, unfortunately," he adds. But clinicians hasten to advise that anyone who experiences symptoms believed to be PTSD should seek professional help. While starting with talking to a primary care doctor is reasonable, Neria recommends getting a referral to a trauma specialist. That could include a psychiatrist, psychologist or social worker trained in helping people deal with trauma and PTSD. "The first step is really to be assessed and to be diagnosed correctly," Neria says.

Military veterans who get help for PTSD through the VA health system are commonly treated with a combination of medication and psychotherapy. Two approaches considered to be effective in treating PTSD, cognitive processing and prolonged exposure therapy, are used within as well as outside the VA to treat individuals with the disorder.

"Prolonged exposure is essentially exposing the patient to the traumatic stressor in great detail, with the idea that the exposure to the feared stimulus or set of stimuli will over time become less important, and the patient will be able to extinguish their learned fear response," Mathew notes. This could be done through narrative scripts, where a person describes, in much detail, the nature of the trauma, like a sexual assault. "Some people do exposure via video clips, or there's virtual reality-type exposures," he says. For example, Virtual Iraq provides veterans of that war as well as those who served in Afghanistan with virtual reality environments created to treat PTSD. "The best treatment to address hyperarousal symptoms, I think, is prolonged exposure therapy," Neria says.

With cognitive processing therapy, the focus isn't so much on the exposure, but on thinking patterns of individuals with PTSD. "How you process specific events, and the meaning of specific events, and thinking of constructive ways to take a thought and change the associated feeling or behavior," Mathew explains. With cognitive behavioral therapy -- which also involves addressing disruptive thought patterns -- and cognitive processing therapy, "the hyperarousal symptoms -- the sleep disturbances, anger, irritability, the jitteriness and hypervigilance -- often improve for patients," says Dr. Mark Pollack, chairman of the department of psychiatry at Rush University Medical Center in Chicago.

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Letting Your Guard Down

Standard medications used to treat PTSD also help relieve hyperarousal symptoms, Pollack says; and, in general, hyperarousal decreases as patients see overall improvement in their PTSD.

When hyperarousal persists, Pollack says, certain other medications may also be helpful. "Medicines that block some of the stress hormones, the adrenaline rushes that people get with hyperarousal -- drugs like prazosin, for example, or beta blockers like propranolol can be used to decrease some of that arousal," Pollack says. And antiepileptic medications may be used to treat hyperarousal symptoms frequently seen in people with PTSD, such as irritability and outbursts of anger, which often occur with epilepsy as well.

Finding effective treatment is all the more important, experts say, not only given how emotionally and physically draining it is to constantly be in "fight or flight" mode, but because aspects of hyperarousal, like angry outbursts, can alienate loved ones. "PTSD affects the whole family and actually can cut across generations, or [have an] impact on the children of those who are affected," Pollack says.

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And while access issues -- from insurance coverage limitations to availability of mental health care in certain areas -- persist and PTSD treatment continues to evolve, Neria urges those experiencing PTSD symptoms, including hyperarousal, to persevere in their search for relief. "My advice is to not be discouraged," he says. "Examine whether a combination of medication, especially SSRIs, and prolonged exposure [therapy] may be helpful."

Michael Schroeder is a health editor at U.S. News. He covers a wide array of topics ranging from cancer to depression and prevention to overtreatment. He's been reporting on health since 2005. You can follow him on Twitter or email him at