The Treatments for PTSD

 

Written and Compiled by Ruwan M Jayatunge M.D. PhD (in progress) 

 

In matters of truth and justice, there is no difference between large and small problems, for issues concerning the treatment of people are all the same., Albert Einstein

 

For treatment, procedures for PTSD in Sri Lanka medications and psychotherapy are widely used. Some prefer to use indigenous treatment measures.

 

The victims of PTSD have psychological as well as physical (somatic) symptoms. Since there is no magic bullet for PTSD, the treatment measures generally take fairly a long time. Connecting with the patient is highly important and the therapeutic relationship plays a vital role. Therapeutic relationships with the patients the often the foundation of effective treatment. Therefore, therapists should maintain a good rapport with the patients. 

 

Phases of Treatment for PTSD

 

1)      Support and stabilization

2)      Trauma Education

3)      Stress management

4)      Trauma focus- confronting the memories

5)      Relapse prevention 

6)      Follow-up and maintenance

 

Medication

Drug therapy is an essential component of PTSD treatment. Serotonin Reuptake Inhibitors like fluoxetine paroxetine are often used to combat depression and anxiety.  These drugs provide symptomatic relief. Sometimes Antipsychotics ( typical and atypical) are prescribed to relieve severe anxiety, agitation, delusions, hallucinations, and disordered thought. Drug therapy combined with psychological therapies gives effective results.

 

Psychotherapy

According to Stedman's Medical Dictionary psychotherapy psychotherapy is a treatment of emotional, behavioral, personality, and psychiatric disorders based primarily upon verbal or nonverbal communication with the patient, in contrast to treatments utilizing chemical and physical measures. There are a number of psychotherapies that can be used to treat PTSD.

 

 

Cognitive Behavior Therapy

CBT or Cognitive Behavior Therapy is an approach that focuses on improving mood by modifying dysfunctional thinking and behaviour. The goal of CBT is to guide the person's thoughts in a more rational direction and help the person stop avoiding situations that once caused anxiety. It teaches people to react differently to the situations that trigger their anxiety symptoms. Therapy may include systematic desensitization or real-life exposure to the fired situation.

 

CBT for PTSD typically begins with an introduction to how thoughts affect emotions and behavior. Early treatment, new skills to identify and clarify patterns of thinking are taught using techniques such as recording thoughts about significant events, identifying distressing trauma-related thoughts, and converting such dysfunctional thought patterns into more accurate thoughts.

 

 CBT   generally includes directly discussing the traumatic event (exposure), anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma-related thoughts. CBT is often accompanied by psycho-education or education about PTSD symptoms and their effects. CBT   helps victims restructure their thoughts and feelings. Through CBT the victims can live without feeling threatened.

 

Exposure Therapy

Exposure Therapy is one form of cognitive behavior therapy unique to trauma. Treatment, which uses careful repeated, detailed imaging of the trauma (exposure) in a safe controlled context, to help the survivor face and gain, control of fear and distress that was overwhelmed by the trauma. Intrusive thoughts, flashbacks, and avoidances are best treated by exposure therapy.

Anger Management

Anger and rage are widespread emotions in individuals experiencing combat trauma. Combat veterans experience more anger and hostility than their civilian counterparts. Treatment of the anger component is a necessary ingredient in trauma recuperation work. In anger management combatants learn constructive ways to manage their anger.

 

Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing (EMDR) is a non-drug, psychotherapy procedure.  EMDR was discovered (in 1987) and developed by Francine Shapiro, Ph.D. - Clinical Psychologist and a senior research fellow at the Mental Research Institute in Palo Alto, California USA.   

 

 EMDR   is one of the most researched methods of psychotherapy used in the treatment of trauma. The Department of Veterans Affairs Practice Guidelines has placed EMDR in the highest category, recommended for all trauma populations at all times. In addition, the International Society for Traumatic Stress Studies current treatment guidelines have designated EMDR as an effective treatment for PTSD (Chemtob, Tolin, van der Kolk & Pitman, 2000) 

 

EMDR is a complex treatment approach that combines salient elements of the major therapeutic schools such as cognitive, behavioral, psychodynamic, and interactional. It is a specific treatment approach, which helps a person quickly resolve the emotional aftermath of traumatic experiences. EMDR is an information-processing therapy and uses an eight-phase approach. EMDR is helpful in the treatment of PTSD (Posttraumatic Stress Disorder), unresolved grief, phobias, sexual abuse, combat trauma, depression, eating disorders, and substance abuse.  It can also be used to enhance emotional resources such as confidence and self-esteem. Recent studies lend empirical support for the use of cognitive behavioral therapy (CBT) and EMDR in treating combatants with PTSD. EMDR 

 

Eye movement desensitization and reprocessing (EMDR)   has been reported to dramatically increase efficiency in the treatment of traumatic memories (Shapiro, 1989a, 1991a). In a controlled study, Shapiro (1989a) reported very successful brief EMDR treatment of Vietnam veterans and rape victims suffering from PTSD, with gains maintained at a three-year follow-up (Shapiro, 1991a).   EMDR has been given the same status as CBT as an effective treatment for ameliorating symptoms of both acute and chronic PTSD (APA 2004).  In the practice guidelines of the International Society for Traumatic Stress Studies EMDR was listed as an efficacious treatment for PTSD.(FoaE.B Kene T.M & Friedman M.J 2000).

 

The expression of trauma may differ from culture to culture. Every culture has its own way of dealing with traumatic experiences. EMDR is considered to be an effective treatment for PTSD despite cultural differences. A recent study on Sri Lankan combat veterans diagnosed with combat-related PTSD showed significant improvements from pre- to post-treatment following EMDR. (Jayatunge, 2008) 

 

 

Client-Centered Therapy

Client-centered therapy or Rogerian therapy is one of the effective talk therapies.  By retelling the traumatic event to a calm, empathic, compassionate, and nonjudgmental therapist the client achieves a greater sense of self-esteem, develops effective ways of thinking, and coping, and more successfully deals with the intense emotions that emerge during therapy.

 

Carl Rogers emphasized that through client-centered therapy, the process of client self-discovery and actualization occurs in response to the therapist supplying a consistent empathic understanding of the client’s experience, based on the attitude of acceptance and respect. Client-centered therapy is centered upon the expansion of self-awareness, the enhancement of self-esteem, and greater self-reliance. Rogers once stated that individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior; these resources can be tapped if a definable climate of facilitative psychological attitudes can be provided.

 

Rogers' theory provides the conceptual underpinnings to the client-centered and experiential ways of working with traumatized people. Furthermore, Rogers' theory provides an understanding of post-traumatic growth processes and encourages therapists to adopt a more positive psychological perspective to their understanding of how people adjust to traumatic events (Joseph, 2004). However, in extreme trauma (in C PTSD) Client-Centered Therapy was found to be not effective.

 

 

Trauma Focus Group Therapy

Trauma focus therapy groups are typically smaller and more structured involving 5-10 patients. Group composition is controlled in some treatment settings with patients grouped according to the type of trauma they experienced. Traumatic memories are actively re-engaged and patients openly discuss traumatic experiences with a co-facilitator. Group therapy deals with “isolation, alienation, and diminished feelings Also it helps the survivor” feelings in participants. In group settings, the combatants are able to discuss their pent-up feelings and able to realize that they are not isolated and that others have similar experiences and problems.

 

  

Rational Emotive Therapy

The American Psychologist Albert Ellis comes to regard irrational beliefs and illogical thinking as the major cause of most emotional disturbances. In his view, negative events do not by themselves cause depression or anxiety. Rather emotional disorders result when a person perceives the event in an irrational way. So despite the client's irrational beliefs and long-lasting assumptions rational emotive behavior therapists often use confrontation techniques. Most of the people suffering from PTSD have unresolved grief, survival guilt, and irrational beliefs which lead to depression and anxiety. Rational Emotive Therapy can be used to break their illogical thinking pattern through friendly mediation.

 

 

Psychoanalytic Psychotherapy

Psychoanalytic or psychodynamic psychotherapy draws on theories and practices of analytical psychology and psychoanalysis. It is a therapeutic process that helps patients understand and resolve their problems by increasing awareness of their inner world and its influence over relationships both past and present. It differs from most other therapies in aiming for deep-seated change in personality and emotional development. (British Psychoanalytic Council)

 

Psychoanalytic Psychotherapy had been used during the WW1. Some of Freud's patients like the soldier of Darden Hill and the officer Norman White were successfully treated with Psychoanalysis. Some of the Sri Lankan combatants who have developed dissociative phenomena were treated with Psychoanalytic therapies.

 

Existential Therapy

Existential Therapy focuses on free will, responsibility for choices, and the search for meaning and purpose through suffering, love, and work. Existential psychotherapy deals with basic issues of existence that may be present within a person. Existential Therapy avoids restrictive models that categorize or label people. Instead, they look for the universals that can be observed trans-culturally. Existential psychotherapy aims at enabling clients to find constructive ways of coming to terms with the challenges of everyday living.  (Reichenberg & Seligman ( 2010) point out that the creation of meaning and purpose is an attempt to deal with the four existential concerns, of death, freedom, isolation, and meaninglessness.

 

The Psychiatrist and the NAZI Holocaust survivor  Viktor Frankl expressed that death is a primary concern because it is inevitable and inescapable. According to Frankl freedom is an existential concern because insinuates that there is no master plan for the universe; therefore, each person is, responsible for creating who he or she is and what he or she does in life. Frankl developed Logotherapy that tries to find for the patient the aim and meaning of his own life as a human being and does not stress the medical aspect of mental health.

 

According to  Viktor Frankl  Logotherapy stems from Existential Psychotherapy, which espouses that humans are driven by the need to create meaning and purpose in their lives.  Logotherapy uses three primary techniques Paradoxical Intention, Dereflection, and Socratic Dialogue. Frankl believed that people can find meaning in readjusting their attitudes and, perceptions of potentially adverse situations into developmental opportunities. Psychological trauma could cause transformation and growth potential by finding meaning and defending against the primary existential concerns. 

 

People with severe emotional traumas are struck by the “Tragic Triad.” which consists of pain, guilt, and suffering. Frankl suggests that people can deal with this triad of existential, angst through changing their attitudes towards how they perceive and ultimately deal with them. Logotherapy helps PTSD sufferers deal with survivor, guilt, depression, affect dysregulation, and an altered worldview following trauma. 

 

 

 

Family and Marital Therapy

Many sufferers of PTSD have disrupted family relations, Spouse abuse, cruelty to children and sexual dysfunctions are evident among the affected personnel. Emotional numbing and constricted affect associated with PTSD interfere with successful marital relationships and parenting. In family and marital therapy, the therapist applies therapeutic principles while engaging the participation of family members. Constructive aspects of the family's relationships are reinforced, while destructive elements are identified and altered. Family members are taught better communication skills and ways of positive coping.

 

 

Cognitive Processing Therapy

Cognitive Processing Therapy (CPT) has been recognized as one of the effective methods that can be used to treat PTSD. Cognitive processing therapy was developed by Dr Patricia Resick - a renowned Psychologist in 1988 and she did a lot of single cases until its first publication in 1992. Many studies have shown the efficacy of Cognitive processing therapy. 

 

Dr Resick defines (CPT) as a manualized therapy that includes common elements from general cognitive-behavioral treatments. It's developed with both cognitive therapy and written trauma accounts.

 

CPT is an evidence-based approach to combat psychological trauma. CPT is recommended for clients with:, PTSD and comorbid diagnoses such as depression and substance abuse. It is generally not recommended for clients with active suicidal behavior, current Psychosis, or victims with severe dissociation with loss of memory of the traumatic event.

 

This therapeutic mode is primarily based on Social Cognitive Theory. When a traumatic event occurs it can dramatically alter basic beliefs about the world, the self, and others. In addition, 5 major dimensions that may be disrupted by traumatic events: safety, trust, power and control, esteem, and intimacy. The CPT focuses on how trauma survivors integrate traumatic events into their overall belief system through assimilation or accommodation.

 

The CPT goals are to process natural emotions (other than fear) in clients with PTSD, address the content of the meaning derived from the traumatic memory., accommodation - accepting that the traumatic event occurred, and discover ways to successfully integrate the experience into one’s life.

 

Resick et al. (2002) indicate that the therapy focuses initially on assimilated–distorted beliefs such as denial and self-blame. Then the focus shifts to overgeneralized beliefs about oneself and the world. Beliefs and assumptions held before the trauma are also considered. Clients are taught to challenge their beliefs and assumptions, through Socratic questioning and the use of daily worksheets.

 

Once dysfunctional beliefs are deconstructed, more balanced self-statements, are generated and practiced. The exposure component consists of having clients write detailed accounts of the most traumatic incident(s) that they read to themselves and to the therapists. Clients are encouraged to experience their emotions while writing and reading, and the accounts are then used to determine "stuck points": areas of conflicting beliefs, leaps of, logic, or blind assumptions.

 

Dr Resick hypothesizes that when individuals are confronted with new information that is inconsistent with preexisting schemas (i.e., stored bodies of knowledge), one of two processes occurs: assimilation or accommodation. Accommodation is the modification of existing schemas to incorporate new events and information. In trauma survivors, these processes often involve the themes of agency, safety, trust, power, esteem, and intimacy. Sobel et al.(2009) suggest that accommodation is necessary to integrate a new event, traumatized individuals sometimes over-accommodate trauma-relevant information. They noted that over-accommodation occurs when schema changes are inaccurate and over-generalized.

 

CPT is a highly structured protocol in, which the client learns the skill of recognizing and challenging, dysfunctional cognitions, first about the worst traumatic event and, then later with regard to the meaning of the events for current, beliefs about self and others.

 

Foreword Treatment in Combat-Related PTSD

In war situations, the psychological management of war casualties is highly important. Management of Combat Stress is often a decisive factor in mental health well-being. Experts unanimously agree that treatment of combat stress should begin as soon as possible. The first organized military system for psychological treatment of combat fatigue occurred during the Russo-Japanese War (1904–1906) when physicians were put as close to the front as possible to allow them to perform evaluations of traumatized soldiers. This “forward treatment” recognized the value of caring for psychological casualties as quickly and as close to the action as possible. The point was to keep the traumatized GI near his unit, as it was observed that the farther from the point of battle that a soldier traveled, the less successful doctors were in getting him back in the fight.

  

CISD (Critical Incident Stress Debriefing)

Debriefings take place on the battlefield as soon as possible after the action. Colonel S.L.A. Marshall of the US Army developed the method of conducting interviews with the surviving members of small units in the field soon after the battles. Marshall regarded this finding as one of his two most important contributions to the Army. Several factors affect an individual's response to a critical incident. Advance warning allows the person time to develop coping strategies. The more intimate the person's role, involvement, and proximity to the event, the more potential impact. The severity of the event and any loss are also contributing issues. Currently, there is controversy regarding CISD. Some forms of debriefing may actually make people worse (Mayou & Ehlers, 2006), while other types of treatment have demonstrated good success in helping people get through trauma.

 

CyberTherapy

Cyber therapy is a powerful medium that is effective in treating  PTSD. Through Cyber therapy the traumatic events can be simulated   (under a controlled environment) for desensitization purposes. Cpl. SXDX29 – a known PTSD patient who had an intense fear of witnessing artillery attacks and had frequent nightmares and intrusions. When he was shown simulated artillery attacks with explosions and gunshot sounds in a safe environment he was able to observe it with moderate distress. After that, he was encouraged to do relaxation exercises.   The second time, he was able to watch the screen with a lesser amount of distress. Repeating this cyber simulation several times over 2-4 weeks, reduced his fear and distressful physiological reaction.  Every time  Cpl. SXDX29 watched the simulation he was encouraged and praised for his bravery by the therapist. While watching he was encouraged to repeat (self-talk) " I am a soldier and I have no fear" By the 4th week Cpl. SXDX29 reported that his nightmares were lesser and he was able to sleep longer periods. 

 

 

Art Therapy

Art therapy is an aesthetic way of achieving catharsis and giving psychological tranquility to the patient. Artistic endeavors have also been a way for many trauma survivors to express their feelings in a positive creative way. This can improve the mood and minimize PTSD-related nightmares. 

 

Josée Leclerc a prominent creative art therapist expresses that art therapy can engage the creative potential of individuals especially those suffering from PTSD. According to Josée Leclerc art therapy is a form of mind-body intervention that can influence physiological and psychological symptoms. He further says that the experience of expressing oneself creatively can reawaken positive emotions and address symptoms of emotional numbing in individuals with PTSD.

 

 

Meditation

Meditation is a synchronized mind-body technique. It is a technique, defined as, 'the maintained focus of attention on a single object, through which the mind is calmed and distracting influences of other internal and external events are reduced. Meditation enhances cognitive functions strengthening attention span. It helps to achieve optimal growth towards a state of total brain functioning. Mediation augments the psycho-physiological functioning of the body and helps to achieve full mental potential.

 

Relaxation training is one of the major techniques proposed by the Psychotherapists to combat anxiety. Simple relaxation or mindfulness breathing (Ananapanasathi Meditation) helps to reduce anxiolytic feelings. Physiologically, breathing is important to the human body. Breathing nourishes the body and its various organs with the supply of oxygen, which is vital for survival. Oxygen is essential for the integrity of the brain, nerves, glands, internal organs, and healthy skin. Breathing plays an important role in cleansing the body of toxins and waste products. Hence systematic and mindful breathing helps to gather more oxygen concentration in the system and reduce anxiety.

 

Metta 'Meditation (Meditation of  'loving-kindness )   projects a profound wish for the happiness of others. It is a universal feeling without any self-interest or egoistic feelings. The systematic practice of Metta 'Meditation helps to reduce deep-rooted angry feelings,  self-loathing, and the urge to seek revenge.

 

Some PTSD patients have morbid fear and fear of dying. Marananusmathi Meditation or progressively and logically thinking about death ( the concept of death and death as a universal phenomenon ) gives the client to move away from fixation and fear of dying.  Marananusmathi Meditation helps the client to understand the concept of impermanence and that suffering is not permanent.  This meditation is done under an instructor and needs assessment before practicing and prolific training.

 

Generally, meditation helps to have exceptional control over thoughts and facilitates to reduction of dysfunctional patterns of thought and perceptions that generate anxiety. In addition, it gives a greater ability to manage negative emotions and helps to gain a greater sense of stability.

 

 

 

Personal communications

 

1)      Personal communication with Dr. Patricia A. Resick- Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System and Boston University, Boston, MA.

 

2)      Personal communication with   Professor James Alcock -Department of Psychology, Glendon College, York University. Canada

 

3)      Personal communication with Nancy Pingel: Program Instructor - Psychosocial Rehabilitation Humber Lakeshore Campus Canada

 

4)       Personal communication with Professor Daya Somasundaram -University of Adelaide Australia

 

5)      Personal communication with Dr Mahasen  De Silva - Board Certified Psychiatrist: Colmary-O'Neil Veterans Affairs Medical Center Kansas USA.

 

6)      Personal communication with Professor Ari Zaretsky MD FRCPC, Psychiatrist-in-Chief, Sunnybrook Health Sciences Centre, Associate Professor, Department of Psychiatry, University of Toronto.

 

7)      Personal communication with Donna Sabella, M.Ed, MSN, Ph.D., RN, Assistant Academic Dean - Health Sciences, The College of Global Studies, Arcadia University.