PTS3398 - SECTION 5: TREATMENTS FOR PTSD
PTSD Scenario: Development of a Treatment Strategy
Erin G. is a hospital social worker working at the veterans Administration. She has recently started to see Gerald M, a 44-year-old man coming into treatment with a history of headaches, insomnia, gastrointestinal discomfort, and persistent worry and anxiety severe enough to be affecting his work and family life. During the first session, Gerald reported that he had sustained a broken jaw and hip, as well as a compound fracture of the left leg, in a traffic accident in Iraq 7 years earlier. In the accident, he had been pinned against the steering wheel in severe pain and worried about being exposed to potential enemy fire while the rescue team used the jaws of life to pull him free. The smell of gasoline after the accident contributed his worries for his safety, and he is having a difficult time filling up his gas tank because the smell of gasoline triggers flashbacks at the service station. He was evaluated by a staff psychiatrist, treated with anxiolytic medication and referred for counseling.
When relaying to Erin the series of events that led to his being traumatized, he reported that during the time he had been trapped, he had felt disconnected from the surrounding events, almost like being outside his own body, and ended up losing control of his bowels in the pain and the worry. Shortly after his period of physical rehabilitation, Gerald started to experience a number of difficulties. He became excessively worried about germs and odors, and began to wash himself to the point of leaving cracks in the skin of his fingers, and would avoid garbage cans when he encountered them in public. He became increasingly anxious and self-conscious in public, and began to drink too much in order to “calm his nerves”, although he entered into AA and was able to achieve sobriety. The patient has a good deal of cognitive clarity about the connection between his accident and his symptoms, but seems unable to stop himself from avoiding the triggers. Most embarrassingly, he tells Erin that he has been unable to control his urge to spend almost 20 minutes cleaning himself after a bowel movement.
What would need to be implemented as part of an overall treatment strategy to address of the concerns noted in this scenario?
While there is no single best single treatment regimen for PTSD that will work for all patients, there are a variety of treatment approaches to help manage the symptoms and create therapeutic improvements. An examination of the various treatment approaches reveals a number of common features and attributes that likely contribute to their effectiveness.
Successful treatment for PTSD appears to have some combination of the following treatment components: 1) a psychoeducational component that teaches patients about physiological and psychological aspects of trauma, stress and anxiety management; 2) cognitive components that provide guidance in reframing or reshaping the cognitive meaning of the traumatic experience; 3) an exposure based component, where patients are exposed to some degree of re-experiencing of the trauma, whether by imagining the trauma while remaining removed from real components of the trauma, seeing and/or hearing visual or aural recreations of the trauma on a video based format, or some degree of actual re-exposure to a partial recreation of the trauma utilizing a system of gradually increasing the intensity of exposure; 4) a skill building component, where patients are led through acquisition of new skills for coping with components of the trauma; 5) a kind of relapse prevention based component, where information is gathered concerning what events might trigger a re-experiencing of the trauma and patients prepare a strategy for avoiding, managing or gaining mastery over those triggers.
These features have been organized into a schema for a phased approach to PTSD treatment by PTSD specialist Sherry Falsetti (Falsetti, 2003), with the treatment phases ordered as below:
Psychoeducational phase: Teach about PTSD, trauma, co-morbid problems
Coping Skills Development phase: Teach coping skills, anxiety control skills
Imaginal Exposure phase: Exposure through imagination, rather than direct exposure to trauma creating triggers
Cognitive phase: Education about connection between thoughts and feelings, teach skills in cognitive restructuring,
Behavioral Task Scheduling phase: (systematic desensitization) Exposure first to panic causing cues, then moving up hierarchy of increasingly anxiety producing triggers
Relapse prevention phase: Predict situations of high trigger cues, do preparation work for only taking on manageable triggers, prepare for situations in which baseline stress is higher, decreasing resiliency
Evaluation phase: Evaluate what additional treatment services might be needed.
Since trauma is a common contributor to many diagnosable disorders, it is probably helpful for all clinicians to be aware of these phases and these components of treatment. Additionally, knowledge of PTSD and some familiarity with the best approaches to handling and intervening with trauma is probably a prerequisite for being a clinician operating at the independent level. However, as we have previously referenced, if a clinician does not have adequate education, training and experience in treating PTSD, it is not considered wise to continue treatment in complex PTSD cases where better preparedness is required.
The next section will address the most frequently noted treatment approaches for addressing PTSD. As the reader will see, there will be many places of overlap between different approaches, and the approaches will make use of some or all of the five components of treatment noted above.
In presenting these different treatment models, it is not the intent of this course to describe a preference for one model over another. Rather, it is assumed that one’s knowledge base and skill sets can profit from a full picture of what is being utilized to treat PTSD.
Systemic desensitization was one of the earliest forms of cognitive behavioral approaches used in the treatment of PTSD and other kinds of anxiety based reactions. Developed in the 1950s by South African physician Joseph Wolpe, it was based upon the behaviorist principles of operant and classical conditioning and the concept of extinguishing the elicitation of a fear response to the effects of a stimulus. (Encyclopedia of Mental Disorders)
This was not the only aspect of Systematic Desensitization that was actually involved in treatment. Dr. Wolpe also engaged in skill building around relaxation techniques, as well as what he called “reciprocal inhibition” approaches. For example, he would instruct his patients in the use of assertiveness skills as a vehicle for increasing confidence and decreasing fear and anxiety, under the assumption that a fully assertive person would be less anxious when approaching a challenge that involved stress and conflict. Based upon his observations, the presence of the assertiveness would tend to inhibit the reciprocal anxiety response.
The other important element of Systematic Desensitization was developing a hierarchy of fears. This would allow patients to plan out an approach to facing increasingly stressful amounts and elements of their fears gradually and over time, beginning with easily manageable amounts of fear inducing stimuli and only moving to the next step of the hierarchy when mastery had been achieved over the fear at the previous level. In this manner, they would not be placed in the presence of triggers or stimuli that would lead to a re-traumatizing amount of fear or anxiety.
The patients would employ relaxation approaches to help reduce the impact of the anxiety or fear while confronting fear inducing stimuli, helping in the process of gaining mastery over them. The gradual process of moving up the hierarchy would continue until mastery over the most difficult fears was reached.
While generally viewing himself in the behavioral school of psychology, Dr. Wolpe’s work also contributed to laying the groundwork for the cognitive and relapse prevention elements that became part of the package of components of treatment for PTSD.
Cognitive-Behavioral Therapy (CBT) has been reported to be an effective approach for treating the depressive symptoms of PTSD. While there are different approaches to CBT, the 10-session method has proven to be effective in both individual and group CBT. (Beck & Coffey, 2006)
CBT for depression involves several essential features:
- Identifying and correcting false thoughts associated with depressed feelings (cognitive restructuring). (University of Michigan, Depression Center, n.d.)
- Helping patients to engage more often in enjoyable activities (behavioral activation), and enhancing problem-solving skills. (University of Michigan, Depression Center, n.d.)
The first of these components, cognitive restructuring, involves collaboration between the patient and the therapist to identify and modify habitual errors in thinking that are associated with depression.
Depressed patients often experience distorted thoughts about themselves (e.g. I am stupid), their environment (e.g. my life is terrible), and their future (e.g. there is no sense in going forward, nothing will work out for me).
A complete psychosocial history is gathered from the patient's current experience, past history, and future prospects, and this history is used to counter these distorted thoughts. (University of Michigan, Depression Center, n.d.)
In addition to self-critical thoughts, patients with depression typically do not engage in activities that have been previously enjoyable to them, because they anticipate that such activities will not be worth their effort. As a result, this usually perpetuates a vicious cycle. That is, less activity decreases physical and psychological wellness and feeds physical and psychological illnesses.
When patients are depressed, problems in daily living often seem insurmountable. In the final process, the CBT therapist provides instruction and guidance in specific strategies for solving problems such as. breaking problems down into small, more manageable steps. (University of Michigan, Depression Center, n.d.)
Exposure therapy is focused on having survivors repeatedly re-experience their traumatic event, while receiving emotional support and cognitive restructuring. Two of the more popular approaches used to treat PTSD, Exposure Therapy (ET) and Prolonged Exposure (PE), begin with the cognitive approach and then rely on the patient or client to repeatedly recount, in as vivid detail as possible, all recollection of his or her traumatic experiences. (Everly & Mitchell, n.d)
Both processes force the patient to confront their fears. The goal is to activate the fear structures of the brain, while being coached and led through a guided emotional processing of the fear, often using relaxation skill building to activate the systems of the brain that create states of calm and thereby reduce or eliminate the constant state of hyper-arousal.
Prolonged Exposure (PE), combined with CBT, seems to be the more effective when treating combat veterans with PTSD that arose while serving in a combat theatre. The development of Virtual Reality tools over the past couple of decades has been an extremely helpful addition to treatment approaches used for PTSD, and is incorporated into the PE model. (Rizzo, et al, 2009)
Unlike traditional (ET), in which the patient recounts the trauma in painful detail, the Virtual Reality model used in PE allows the clinician to gradually introduce and control real time “triggers”, with a model in which more realistic expressions of the original traumatic situation can be presented, while still maintaining some emotional distance by the knowledge that the experience is artificially created.
Examples of Virtual Reality models for Exposure Therapy. (Rizzo, et al, 2009)
Virtual PE may have promising potential for good outcomes and may prove effective with other traumatic scenarios such as hurricanes, tornadoes, and motor vehicles accidents.
Cognitive-Processing Therapy (CPT) is a 12-session, specific form of CBT for PTSD that has a primary focus on cognitive interventions. (Monson et al 2006) Cognitive Processing Therapy addresses the intense feeling of anger, humiliation, shame, guilt, and disgust that is often symptomatic of survivors of trauma.
“Cognitive Processing therapy draws up information sensory of PTSD that proposes that information about a traumatic event is stored in the brain in ‘fear networks.’” Shultz, 1999) That is, for some, the fear of the memory itself blocks an individual from moving forward.
The important first session is psycho educational, in which the symptoms of PTSD are explained, and patients are asked to write an “impact statement.” The impact statement includes writing about the meaning of the traumatic event and beliefs surrounding that meaning. (Monson et al., 2006)
In the following examples, a patient may write their false beliefs:
“I was raped, and I must have asked for it, because rape only happens to women who wear short skirts and makeup.”
“I was raped and rape only happens to bad people.”
“Maybe it wasn't rape, and I did something to lead him on…”
“My house was demolished by a hurricane, and I was being punished by God.”
“My buddy was blown to pieces in combat, and I should have saved him, it should have been me. He was being punished for something that I did.
“I didn’t resist, and it takes extreme force to rape someone.”
“I must be gay, because I got an erection when he sodomized me.”
The second session is used to discuss the beliefs surround the trauma and to get past the “stuck” point. This is the time for the clinician to help the client understand the ideology of their beliefs and to confront them with truths or help the patient confront the conflict between their beliefs and actual beliefs.
For example, the clinician may help the client to understand that rape does not discriminate among the good and the bad. For the service member who was in combat, the clinician may explore their training and help the client understand that, under the circumstances, a person must make split-second decisions.
The third session requires the client to write a detailed explanation of the most traumatic event in their life and to read it every day before the fourth session. (Monson et al., 2006)
Cognitive Processing Therapy attempts to draw out the underlying beliefs that add to the traumatic event itself. (Monson et al., 2006)
The fourth and fifth sessions are used to recall and better understand traumatic events. These sessions are also used to experience the natural emotions that the patient may have originally suppressed. (Monson et al., 2006)
In sessions, five, six, and seven, patients are taught to challenge their own beliefs. The clinician will ask them to describe their beliefs surrounding their trauma and challenge them to prove it. The last five sessions of CPT focus on over-generalized beliefs in five areas, (Monson et al., 2006):
An example of an over-generalized belief may include their beliefs on intimacy—that everyone should be in a romantic relationship, and if they are not, then there is something wrong with them.
In another example, the patient may believe that they should always be in control of their emotions, and if they are not, then they are weak.
EMDR (Eye Movement Desensitization and Reprocessing)
EMDR is a treatment approach developed by Francine Shapiro, a methodology which combines some of the aspects of exposure therapy with rapid eye movements that are created by having the patient track an object or light source with his/her eyes. In the period after this approach entered the practice of psychotherapy, it was hailed as an innovative and rapidly working method of reprocessing trauma and reducing the symptoms of PTSD.
In the intervening years, however, evidence from well controlled studies has cast doubt on the effectiveness of the part of EMDR that differentiates it from other cognitive reprocessing approaches: the use of eye movements. (Lilienfield, S. 2007) EMDR has been used with apparently equal effectiveness on blind patients, with sounds substituting for the use of visual tracking, suggesting that mechanisms other than the movement of the eyes are responsible for its treatment efficacy. In one of the best known critiques of EMDR, Richard McNally summarizes the weight of the research thusly: “What is effective in EMDR is not new, and what is new is not effective.” (McNally, 1999)
SIT (Stress Inoculation Therapy)
Stress Inoculation therapy is a structured cognitive and educational approach to increasing the capacity to manage one’s reactions to stressors. It bears some similarities to relapse prevention approaches drawn from the field of addictions. Like relapse prevention, it is a pro-active strategy for anticipating emotional/behavioral challenges and planning and preparing solutions that can be used to modulate and mitigate one’s reactions when stress is encountered. (Meichenbaum, 1988)
SIT was not designed specifically for PTSD, but it can be a very useful adjunctive approach to other kinds of therapy for PTSD. This is because: 1) it can help the patient increase a sense of control over the emergence of traumatic triggers and 2) it can help to structure strategies that help the patient avoid re-traumatizing events.
At its heart, SIT is about improving the patient’s resiliency and increasing a sense of mastery in the management of stress and anxiety. The goals – and approaches – are very similar in nature to systematic desensitization, with a flavor of the CENAPS model of relapse prevention as a supportive addition.
SIT consists of three phases: education (on stress and anxiety), skill building (e.g., good breathing approaches, thought stopping, guided self-dialogue, rehearsal and role playing) and application (integrating and applying the skills they have developed). (Falsetti, 2003)
The approaches which approximate what is used in relapse prevention for substance abuse include the following: 1. Assess the probability of the feared event, 2. Manage escape and avoidance behavior with thought stopping and other anxiety reduction techniques, 3. Control self-criticism with guided self-dialogue, 4. Engage in the feared behavior, 5. Self-reinforce for using skills. (Falsetti, 2003)
Some of the key stress for stress reduction and management are shown below:
KEY STRESS REDUCING SKILLS
- Provides deep seated and positive sense of competence for handling challenging tasks
-Reduces time spent handling tasks, thus time spent in response mode
-Time management is a specific kind of organizational skill
- Reduces stress in your interactions with other people
- Improves ability to develop and maintain sources of support and nurturance
-Different sets of skills needed for a variety of situations: negotiation, conflict management, asking for what you want, assertiveness, relationship building
- Involves psychological components, as well as communication skill components: confidence, self-respect, anxiety management
-Assertiveness skills include setting good boundaries with other people, asking for what you want, standing up for yourself in conflict, not allowing others to take advantage of you
-Confidence in your assertiveness capacities decreases your anxiety in a wide variety of interpersonal situations
- Positive thinking to improve your sense of your own resources for handling challenges
- Thought stopping to redirect negative thinking
- Self-affirmations to decrease self-esteem challenges
- Focused self-talk to aid perceptual/evaluatory skills
- Involve a capacity to clearly see the level of stress response that will be required to handle a challenge, opportunity or threat
-The primary point of entry into improving these skills sets will be cognitive and conscious in nature, however, cognitive/behavioral techniques, and experiential therapy approaches, such as body work, systematic desensitization and bio-feedback, can target perceptual/evaluatory problems at deeper levels of the brain
-Are essential for decreasing ergotrophic over-response
- Deep breathing, visualization, meditation or prayer
- Systematic desensitization, bio-feedback, body work all work to develop stronger trophotrophic responses
- Repeated use of relaxation skills develops ability to turn on your body's trophotrophic responses at will
-The more practiced you become, the more quickly you can turn on the relaxation response
ACT (Acceptance and Commitment Therapy)
Acceptance and Commitment Therapy (ACT) is an intervention approach that combines acceptance and mindfulness strategies drawn from sources such as Dialectical Behavioral Therapy (DBT), with commitment and behavioral change strategies. The defined goal is to increase psychological flexibility, which leads to an increase in resiliency.
The client is presented with exercises that employ metaphors, paradox, and experiential components designed to help them “make healthy contact with thoughts, feelings, memories, and physical sensations that have been feared and avoided”.
An increase in psychological flexibility and resiliency is created through the use of six core ACT processes.
- Acceptance (of the feelings, pain, distress, etc.)
- Cognitive Defusion (alter the functions – of the feelings, distress, etc.)
- Being Present (mindfulness, non-judgmental experiencing of events)
- Self as Context (awareness of one’s own experiences without attachment to them)
- Values (selection of non-avoidant values that promote growth)
- Committed Action (choose patterns of purposeful action)
The first four processes target an increase in psychological flexibility, while the last two seek to incorporate this into structures that form a commitment to more growth oriented values and actions. From a systematic desensitization standpoint, this is another take on the concepts of a willingness to expose one’s self to the distressing affective states – with mindful acceptance of the feelings – and cognitive efforts to restructure the meaning, while committing to active attempts to move one’s life forward.
In other words, it is essentially a more complex rendering of the central principles of systematic desensitization, with a slightly more philosophical central motif.
Multiple Channel Exposure Therapy (MCET)
MCET is a 12-week group model that combines elements of Cognitive Processing Therapy with cognitive-behavioral treatment to target the physiological, cognitive, and behavioral symptoms of panic disorder. It has been shown to be useful for patients who experience panic attacks along with other symptoms of PTSD. (Falsetti, 2003)
As many of the other treatment approaches we have been examining, MCET includes a psychoeducation component, where patients are educated about trauma, PTSD and panic, a cognitive component where patients work on examining the reality behind their worries, elements of exposure therapy, where patients both write about their trauma and work to develop a hierarchy of feared activities, which is then used to increase mastery of the feared elements.
The one unique component that is mentioned in the literature is the use of what is called “Interoceptive Exposure”, where patients are given exercises that can bring on feelings of panic, such as head shaking.
While group or talk therapy treatments for PTSD have not been extensively studied as individuals treatment approaches, many patients have stated that it sometimes helps their symptoms of coping. (Glynn, n.d.)
Three main types of groups are usually available:
- Introductory psycho educational or skills groups
- Intensive therapy groups, which may focus differentially on processing the traumatic event (trauma-focus group treatment)
- Coping with current situations (present-centered group treatment) (Glynn, n.d.)
Why group therapy helps some and not others is not clear. Perhaps sharing thoughts and fears with others is therapeutic within itself, where the communal sharing of the traumatic experience reduces the feelings of aloneness and isolation. In other words, normalizing the symptoms is healing or therapeutic for some patients.
However, since PTSD is a often a disorder with Personality Avoidance features, many survivors - especially those recently traumatized - may require extra support to engage fully in groups. (Glynn, n.d.)
Additional and Adjunctive Approaches
In addition to the psychotherapeutic approaches noted above, a number of other adjunctive elements of treatment have been examined for efficacy in the treatment of PTSD.
One trial showed that acupuncture was as effective as group cognitive behavioral treatment and both were more effective than the waitlist condition. (Hollifield, 2007) This single research study should not be construed as a solid endorsement of acupuncture as a first line of intervention for PTSD, but it does suggest that further study is warranted.
Physical exercise is important in order to maintain good health. For patients with PTSD it may provide additional therapeutic benefits, since increased movement of the body may help reduce depression. The Mayo Clinic reports that exercise increases our endorphins or the "feel good" chemicals in our bodies. There may also be some cortisol reducing effects of exercise, so that some of the destructive physiological effects of excessive stress may be reduced through a regular exercise program. (Melin, 2008)
People with severe PTSD symptoms who have lost interest in social activities may have little or no physical exercise in their daily schedule. The absence of physical activity may have physiological effects that contribute to an increase in their depression. Clinicians should consistently evaluate the level of exercise engaged in by their patients, and include education about the benefits of exercise as part of the psychoeducational elements of their treatment approaches.
Some of the main biological disturbances in PTSD include an imbalance of the naturally occurring stress hormones in the body, thus increasing the anxiety level through purely chemical processes that occur in the brain. (Jeffreys, 2008)
The medications prescribed for treating PTSD symptoms act upon the neurotransmitters related to the fear and anxiety circuitry of the brain, including serotonin, norepinephrine, GABA, glutamate, and dopamine among many others.
Medications are used in treatment to address the biological or physical symptoms of PTSD. At the same time, medications may have added benefits for psychological and social symptoms as well. (Jeffreys, 2008)
According to the National Center for PTSD, the three main symptoms medications address are:
- Sleep problems
- Concentration problems
- Increased startled response
- Unwanted thoughts about the traumatic events
Avoiding triggers for traumatic memories (places, conversations, or other reminders), avoidance may generalize to other previously enjoyable activities.
Avoidant behaviors may resemble Schizoid or Avoidant Personality Disorders, so it is important for the Clinician to examine and discuss the behaviors carefully with their clients before rendering a diagnosis.
SSRI medications are the most commonly used pharmacological treatments for PTSD, and well designed studies note that complete remission of the PTSD symptomatology was observed in approximately 30% of patients pursuant to treatment with sertraline (trade name, Zoloft) or paroxetine (trade name, Paxil). (VA2)
Cautions are indicated when prescribing these medications for patients with co-morbid disorders, e.g., bipolar disorder, as the SSRI medications may trigger reactions in certain clients.
Venlafaxine (trade name, Effexor) also appears to be effective as a first-line treatment for PTSD based upon well-controlled trials. (VA2)
Atypical antipsychotics such as risperidone (trade name, Risperdal), olanzapine (trade name, Zyprexa) and quetiapine (trade name, Seroquel) have also shown some benefits when used adjunctively to SSRI medications. (VA2)
While not reducing the incidence of PTSD, Propranolol (trade name, Inderal) appears to reduce physiological hyperreactivity in PTSD when given following the appearance of symptoms. (VA2)
Benzodiazepines are typically not recommended for use with PTSD, since they are potentially quite addictive and moreover are contraindicated for patients undergoing CBT. (VA2)
Prazosin (Trade name, Minipress) has some research showing some effectiveness in treating nightmares that often accompany PTSD. (Fink, 2006) (Van Liempt, 2006)
The Forget it Pill
There has recently been a fair amount of both hype and controversy surrounding the "Forget Pill", a drug known as Propranolol (trade name, Inderal). Propranolol is a Beta-blocker and has been used for years to treat a variety of conditions such as:
- Hypertension (high blood pressure)
- Angina, and certain types of cardiac arrhythmias or heart problems
- Hyperthyroid conditions
- Tremors (shaking) of a variety of origins. (Stoppler, 2008)
This medication is also used on occasion for the treatment of medication-induced movement disorders or uncontrollable movements caused by antipsychotic drugs and certain anxiety disorders.
Beta-blockers such as Propranolol work with the body to slow down impulses - in effect slowing down the heart rate or pulse.
James McGaugh, a professor of neurobiology at the University of California, Irvine discovered that the use of Propranolol may help people to forget their traumatic experiences. (Schorn, 2007)
McGaugh theorized that we remember things better when our adrenaline is high. That is why we have very clear memories of some things, while other memories are vague. McGaugh’s theory is that if we reduce the stimuli or impulse through medication, then the memories will less firmly stored in memory.
The controversy surrounding the use of Propranolol is related to the worry that the person will lose their identity through the paring away of memories. Since the drug cannot target one specific memory, the patient runs the risk of losing memories indiscriminately, pleasant memories as well as traumatic or unpleasant memories.
In a study on PTSD from combat burn conducted by United States Army Institute of Surgical Research, victims report that the use of Propranolol does not decrease PTSD or PTSD symptoms. However, while not reducing the incidence of PTSD, Propranolol appears to reduce physiological hyper-reactivity in PTSD when given following the appearance of symptoms. (VA2)
With all of that said, there is much research still needed, and so far, the "Forget It" pill does not seem to offer promising results.
Sometimes overlooked in efforts to treat PTSD is the very real need for a safety plan. Clinicians should speak candidly with their client, as well as any family members involved, about the need to address safety concerns. The safety plan may cover instances such as:
- Dissociative state,
- Suicidal or homicidal thoughts,
- Intrusive thoughts while working, and
- How to deal with panic attacks when in a crowd.
There are many ways that a person may create a personalized safety plan. The safety plan need not be elaborate, and educating family members and friends is critical in terms of carrying out the plan.
For example, much like a fire drill, a person whose anger escalates or intensifies into uncontrollable rage may teach their children to leave the house and go to a neighbor for safety.
The safety plan may simply mean carrying emergency hotline numbers in case of suicidal or homicidal thoughts. If a person is afraid that he or she may have uncontrollable symptoms while at an event, the person may plan ahead and perhaps take a separate vehicle so they may leave the event when they are feeling agitated.