http://www.traumaclinic.co.za/
Update on the treatment of
Posttraumatic Stress Disorder
Author: Gerrit van Wyk MA Clin Psych traumaClinic Emergency Counselling Network, Cape
Town
Course outcomes:
When you have completed this course you will have an understanding of:




Different types of treatment of Posttraumatic Stress Disorder.
The pros and cons for the following treatments: Cognitive behavioural therapy, eye
movement desensitisation and reprocessing, psychodynamic therapy, hypnosis,
stress inoculation training, acceptance and commitment therapy, creative therapies,
pharmacotherapy, internet therapy and pharmacotherapy.
A better understanding of comorbid disorders and PTSD.
Proven results and studies regarding the different treatments.
1
CONTENTS
1.
COGNITIVE BEHAVIOURAL THERAPY ....................................................................... 5
2.
EYE MOVEMENT DESENSITISATION AND REPROCESSING ................................... 8
3.
PSYCHODYNAMIC THERAPY...................................................................................... 9
4.
HYPNOSIS .................................................................................................................. 10
5.
STRESS INOCULATION TRAINING ........................................................................... 10
6.
ACCEPTANCE AND COMMITMENT THERAPY ......................................................... 10
7.
CREATIVE THERAPIES .............................................................................................. 11
8.
INTERNET THERAPY ................................................................................................. 12
9.
PHARMACOTHERAPY ............................................................................................... 14
10.
CONCLUSION ......................................................................................................... 17
11.
REVIEW ................................................................................................................... 18
12.
REFERENCES ......................................................................................................... 22
Update on the treatment of Posttraumatic Stress
Disorder
A note on the learning and teaching approach
This course is built on the principles of supported open learning pioneered by the UK Open
University and developed by South African Institute for Distance Education (SAIDE) and The
SACHED Trust. Course participants (Students) are asked to do all the tasks as they appear
in the text in order to take full value from the course. There are three kinds of task:
1.Fact check – to memorise key knowledge items
2.Reflection and analysis – to take time to actively engage with the ideas in the course
3.Assignments – a chance for an extended written task to consolidate your knowledge and
express your views.
OVERVIEW
Appropriate treatment for trauma depends upon a number of factors. Most trauma victims
recover naturally, without any need for psychiatric or psychological intervention at all. Having
supportive family and friends may be sufficient. For those with an adjustment disorder, not
PTSD or depression, stronger reactions are necessary, such as supportive counselling or
psychotherapy. These types of therapy provide support, empathy, and an environment that
is conducive to exploring the meaning of the event and the implications for one’s life and
future. When reactions are more severe and enduring, more specific interventions are
necessary, interventions specific for PTSD. Comorbidity with other conditions, most
commonly depression and other anxiety disorders, may complicate treatment even further.
Unfortunately the bulk of research has focussed on treatment of PTSD, and little attention
has been paid to other trauma related disorders.
Until quite recently PTSD was thought to be intractable to treatment, particularly when it has
become chronic. Pharmacological treatments tended to be with anxiolitics, which were
nothing more than palliative, only giving some relief of symptoms, instead of affecting the
course of the condition. In psychotherapy clinicians have tended to use psychodynamically
based models and supportive counselling with no proven efficacy.
The situation has changed dramatically over the last three decades, however, and today we
have very specific treatments with proven efficacy. One can now confidently say that most
cases of PTSD can benefit lastingly and significantly from treatment, with continuing
research making further strides in improving the techniques.
Fact check 1
Question 1.
Do most trauma victims recover naturally
True/False
Question 2.
Recently pharmacological PTSD treatment has been proven to only give some relief of
symptoms?
True/False
Question 3.
Most commonly OCD and other anxiety disorders complicate treatment further
True/False
Question 4.
All treatment for PTSD has proven to be effective
True/False
Question 5.
Research in PTSD can help in creating effective treatments?
True/False
Reflection and analysis
What research on PTSD could you do in order to benefit the research community as well as
help with treatment? How would you go about this?
1. COGNITIVE BEHAVIOURAL THERAPY
Negative cognitions go hand in hand with the common trauma reactions of re-experiencing,
hyperarousal and avoidance (Foa, 1999). A shocking experience does not only affect
emotions and behaviour, it also challenges ones beliefs, assumptions and attributions.
Usually, however, subsequent everyday life experiences gradually correct these negative
cognitions, and the traumatised person has the opportunity to regain a sense of competence
and safety in the world.
In contrast, those that make use of extensive avoidance and numbing, as is prominent in
persons suffering from PTSD, will also tend to avoid the very experiences that could have
corrected their cognitive distortions. By avoiding anything that reminds one of the trauma
one is not exposed to new experiences that enable one to unlearn the negative cognitions.
Following a serious motor vehicle accident, for example, one is likely to feel nervous in traffic
for a while, but if one avoids driving or travelling one is likely to add negative self perceptions
such as incompetence and inadequacy to the already distressing fear and it becomes very
difficult to regain confidence and a sense of coping after the shock. Under these
circumstances one is at higher risk of developing PTSD.
Foa and Jaycox (1999) suggest that two particular groups or erroneous cognitions are
associated with later development of PTSD: that the world is extremely dangerous (for
example, that no place is safe and that people are untrustworthy) and that the sufferer is
extremely incompetent (for example, that others would have been able to prevent the trauma
somehow, or dealt with it better, and that the sufferer’s PTSD symptoms are a clear sign of
weakness). It is suggested that negative cognitions may actually be more important in
driving and maintaining PTSD than the trauma itself.
Most studies of PTSD psychotherapy outcomes have explored cognitive-behavioural
therapies. These therapies usually have three components:
-
In exposure therapies, such as systematic desensitisation and flooding, patients
confront their fears, objects, situations, memories and images without being as
overwhelmed as they had anticipated. These experiences of exposure thus serve to
disprove and correct cognitive distortions harboured by the patient.
-
An anxiety management component includes techniques such as controlled
breathing, relaxation, and self-distraction and thought stopping. Patients are taught
these exercises to voluntarily reduce anxiety.
-
Cognitive therapy that identify and challenge dysfunctional and erroneous cognitions
and replace them with more functional and realistic thought patterns.
The clinical practice guidelines of the International Society for Traumatic Stress Studies
(Foa, Keane, Friedman, & Cohen, 2009) suggest that cognitive-behavioural therapy with
prolonged exposure has the best support empirically for the treatment for PTSD. However,
studies have also shown that trauma-focussed cognitive therapy where the focus on
exposure is less, can also be effective (Ehlers, et al., 2003).
Foa and Rothbaum (1998) developed a prolonged exposure therapy programme, consisting
in essence of repeated and prolonged sessions of exposure to the trauma memory,
memories which the patient would normally avoid. At a later stage in vivo exposure sessions
are added, exposure to the places or situation where the trauma actually happened. The
treatment also includes breathing retraining and psycho-education about the common
reactions to trauma.
Exposure therapy comprises repeated presentations of trauma-related stimuli, typically in the
patient’s imagination, coupled with prevention of various avoidance behaviours and
manoeuvres to focus the patient on his/her dread. The memories are processed in as rich
and comprehensive a way as possible, including sensations, thoughts, beliefs, and
especially feelings, which are uncovered and then managed over and over again. Patients
are also taught how to rate subjective units of distress (SUDS), which are then monitored
repeatedly to self-monitor their reduction in negative affect. Foa and Rothbaum usually make
a recording of each of the exposure sessions that the patient is instructed to replay as
homework after each session.
Ideally the result of the repeated exposure is inter- and intra-session extinction of the trauma
conditioned reactions, which can in turn make it possible for the patient to have success
experiences that enhance self-efficacy and symptom reduction. There is general agreement
that non-reinforcing exposure is an optimal and efficient method of providing a corrective
experience that counteracts maladaptive ways of thinking about the meaning and implication
of the trauma, in other words, it enables the patient to discover that the pain is not
unbearable, the arousal and negative affect is manageable, you do not go crazy, and that
others can understand and validate your experience (Litz and Bryant, 2009).
In one study Foa (1999a) compared the efficacy of three treatments: prolonged exposure,
stress inoculation training (consisting of relaxation training, thought stopping, self-guided
dialogue, cognitive restructuring, modelling and role play, see heading 5) and a combination
of the two treatments. All three the treatments reduced PTSD and depressive symptoms
significantly, but exposure therapy alone had greater effect. Other later studies have
suggested a combination of restructuring and exposure therapy does not produce a
significantly better result than exposure therapy on its own.
The evidence supporting the effectiveness of individually administered cognitive-behavioural
therapy for the treatment of PTSD in adults is now quite compelling. Numerous CBT
programs have been shown to work in well-controlled studies meeting high methodological
standards, but the evidence is in favour of exposure therapy and the evidence across a wide
range of traumatised populations is most convincing, according to the ISTSS treatment
guidelines (Foa, Friedman, Keane and Cohen, 2009).
Fact check 2
Question 1.
Persons suffering from PTSD will tend to avoid the very experiences that could have
corrected their cognitive distortions
True/False
Question 2.
Under what circumstances is one at higher risk of developing PTSD?
_________________________
__________________________
Question 3.
What is anxiety management?
________________________________________________________
________________________________________________________
Question 4.
Cognitive therapy that identify and challenge ___________ and
___________cognitions and replace them with more ____________and
____________thought patterns.
Question 5.
What is in vivo therapy?
_______________________________________________________________
Reflection and analysis
Foa and Rothbaum usually make a recording of each of the exposure sessions that the
patient is instructed to replay as homework after each session. Why do you think this was
recommended?
2. EYE MOVEMENT DESENSITISATION AND REPROCESSING
Eye movement desensitisation and reprocessing (EMDR) (Shapiro, 1995) is a new and
somewhat contentious treatment modality that has caught the imagination of many
therapists. It evolved not from research, but from personal observations of Shapiro.
EMDR is based on a chance observation by Shapiro that troubling thoughts were resolved
when her eyes followed the waving of leaves during a walk in the park. She argued that the
eye movements from side to side (bilateral eye movements) facilitated cognitive
reprocessing of trauma. At first it was put forward as a single session technique but it has
developed into a phased process that involves the accessing of trauma memories and
images, evaluating their distressing qualities, and generating alternative cognitions of these
images and memories while performing sets of bilateral eye movements.
Initially this method was regarded with some scepticism by the scientific community, but in
time it has proven its efficacy. An analysis of 34 studies of EMDR (Davidson, 2001)
concluded that EMDR was more effective than non-exposure therapies, but that it was not
any more effective than other exposure therapies. It also concluded that the eye movements
are probably an unimportant aspect in its overall effectiveness and that in essence it shares
the same elements as exposure therapy.
Fact check 3
Question 1.
What does contentious treatment mean?
_________________________________________________________________________
Question 2.
EMDR developed from theory and clinical practice?
True/False
Question 3.
What do the eye movements from side to side (bilateral eye movements) do?
_________________________________________________________________________
Question 4.
EMDR is more effective than other exposure therapies?
True/False
Question 5.
Briefly, what does EMDR do cognitively?
_________________________________________________________________________
Reflection and analysis
In your opinion why was EMDR met with scepticism?
3. PSYCHODYNAMIC THERAPY
Psychodynamic therapy in essence seeks to reengage normal mechanisms of adaptation by
addressing what is unconscious and making it conscious in tolerable doses. In the case of
trauma an understanding is gained progressively of the meaning of a traumatic event, within
the context of the survivor’s personal history and aspirations. This consists of a collaborative
sifting and sorting through wishes, fantasies, fears, defences that were stirred up by the
trauma. Transference and counter-transference are usually central to the psychodynamic
treatment approach, but in this case it may or may not be explicitly addressed. The
therapeutic relationship remains a crucial element of the therapeutic process.
Psychodynamic psychotherapy has a long and rich tradition in the mental health field. Its
roots stretch back more than 100 years. Authors have contributed a considerable volume of
scholarly work on the treatments of PTSD, but very few empirical studies exist in the
literature today. Given that there are a large number of clinicians practicing within this
framework, more scientific research in this area is warranted (Foa, Keane, Friedman, &
Cohen, 2009).
Reflection and analysis
In your opinion why is the therapeutic relationship such a crucial element of the therapeutic
process?
4. HYPNOSIS
Hypnosis is a procedure that establishes through a process of induction a state of altered
consciousness, during which the therapist provides suggestions for alterations in behaviour
and mental processes, including sensations, perceptions, emotions, and thoughts. The
process can bring about a narrow focus of attention, enhanced suggestibility and altered
consciousness (for instance, alterations in time perception, body image, levels of distress).
Individuals differ widely in their responsiveness to hypnotic suggestion and this is positively
related to treatment efficacy.
In the field of trauma, hypnosis is used frequently, but most often not as a standalone
treatment. It is usually used as an adjunct to psychodynamic, cognitive-behavioural, or other
therapies, and it has been shown to significantly enhance therapeutic efficacy in a variety of
clinical conditions. However, the use of hypnosis in clinical practice in most countries
requires considerable professional training and credentialing (Foa, et al. 2009).
5. STRESS INOCULATION TRAINING
Stress inoculation training (SIT) is an anxiety management treatment programme with a
number of components. It usually includes an educational component, muscle relaxation
training, breathing retraining, role playing, covert modelling, guided self-dialogue and thought
stopping. SIT programmes may also include assertiveness training and exposure therapy.
Empirical support for the efficacy of SIT is mixed, with some studies showing significant
reductions in PTSD symptoms, particularly in female sexual assault victims, but the evidence
for war veterans is not as positive (Foa, et al., 2009).
6. ACCEPTANCE AND COMMITMENT THERAPY
ACT is theoretically based on an analysis from the perspective of functional contextualism
(Follette, Palm, & Hall, 2004). The central point of departure in this therapy is that much of
human suffering if brought about by “experiential avoidance”, the attempt to prevent, or
modify unwanted private experiences, or in the case of PTSD the avoidance of
reexperiencing symptoms. Such attempts are generally not effective and, paradoxically, may
result in more of the very thoughts, symptoms and emotions the person was attempting to
avoid. Such failure tends to have a damaging effect on self-attributions and coping, and lead
to increasingly more dysfunctional means to achieve experiential avoidance, like social
isolation or substance abuse. From the ACT perspective the essential problem is the attempt
to control internal experiences, and therapeutic interventions are designed to promote the
person’s acceptance of internal experiences, while acting according to his/her own values
(Cahill, Rothbaum, Resick, & Follette, 2009).
As yet no published studies have evaluated ACT as a treatment for PTSD, but anecdotal
evidence has stimulated interest in this modality of treatment (Foa, et al., 2009).
7. CREATIVE THERAPIES
This heading includes all those therapies that make use of art, music, dance / movement,
drama and poetry. Most of these forms of therapies have some elements in common with
other recognised therapies, such as imaginal exposure, in that the traumatic event is reenacted or expressed in artwork, role play, movement, dance, poetry or music. Elements of
cognitive restructuring are present in role play, acting out the trauma, switching roles, and
modelling options to change the person’s view of the event. Journal writing, storytelling and
other narrative techniques are attempts to identify distorted cognitions and then to reframe
and to reprocess those cognitions. Stress and anxiety management is usually a common
element, and resilience enhancement is implicit in the use of creativity, humour, flexibility
and activity. Testimony and de-stigmatisation is also common, particularly in traditional
healing practices in Africa, such as ritual cleansing.
Theoretically the potential advantage that the creative therapies could have over other forms
of therapy, is in the use of non-verbal techniques and symbolism that may provide access to
the implicit, non-verbal aspects of trauma memory that other therapies do not readily
address. By providing a wider range of stimuli, visual, tactile, and other stimuli, creative
therapies may increase the vividness of imaginal exposure, and by using concretised
representations of the trauma in writing, drawing and acting it may decrease avoidance
symptoms. A further value that these therapies may have is for persons who have difficulty
expressing themselves verbally, or difficulty putting their feelings into words, and for these
people the creative therapies offer a more effective means of expressing themselves
(Johnson, Lahad, & Gray, 2009).
Unfortunately creative arts treatments have not been empirically tested, even though there is
a large body of literature consisting mainly of case studies and anecdotal evidence. It has
been reported to be helpful in the reduction of alexitimia (the inability to put feelings into
words), dissociation, anxiety, nightmares, sleep problems, depression, and in improving
body image (Foa, et al., 2009).
Fact check 4
Question 1.
Creative therapies make use of ___________________, ___________________,
___________________, ___________________&___________________
Question 2.
Elements of cognitive restructuring are present in___________________,
___________________, ___________________, & ___________________
Question 3.
What is the benefit of creative therapies for people who have difficulty expressing
themselves verbally, or difficulty putting their feelings into words?
_________________________________________________________________________
_________________________________________________________________________
Question 4.
What age group do you think this form of therapy could help? Or is there none?
_________________________________________________________________________
Question 5.
Give the full definition for alexitimia and where it originated from?
_________________________________________________________________________
8. INTERNET THERAPY
Although cognitive-behaviour therapy has been shown to be effective in helping trauma
survivors, it is not widely available. Cognitive-behaviour therapy requires considerable
professional training and expertise to apply effectively, and on the part of the patient
considerable time and resources to access and afford. Given the proven efficacy of CBT it is
justified to search for ways to make it more accessible, more self-managed and less
dependent on expensive professional time. The internet presents the perfect medium.
At present there are already a number of models using the internet for the treatment of
PTSD and other disorders, like panic disorder, social phobia and depression, as well as selfhelp sites for substance abuse, weight loss, smoking cessation, programmes in the public
domain, very widely subscribed. The response to these programmes has been astounding,
probably because of the ease of use and anonymity that the internet provides. The internet
provides a protected environment where participants can easily control and regulate the
degree of intimacy they want, to share without fearing judgement, rejection or devaluation.
This may be relevant particularly to posttraumatic stress, because traumatic experiences are
often associated with stigmatisation and/or intense feelings of shame and guilt.
Currently the best known and researched model for internet therapy is Interapy (Lange, Van
de Ven, & Schrieken, 2003). The treatment is essentially based on cognitive-behavioural
techniques, and consists of structured writing assignments delivered though internet, without
any face-to-face contact. This makes it accessible from anywhere in the world, across
cultures and languages. Originally developed in Netherlands, studies in various sites have
found substantial, significant and enduring improvements in PTSD symptoms as well as
anxiety, depression and in complicated grief (Lange, Van de Ven, Schrieken, & Emmelkamp,
2001) (Lange, Rietdijk, Hudcovicova, Van de Ven, Schrieken, & Emmelkamp, 2003)
(Wagner, Knaevelsrud, & Maercker, 2004). Another example of a web-based service is DESTRESS (Delivery of Self-training and Education for Stressful Situations) developed
specifically for US military personnel (Litz, Engel, Bryant, & Papa, 2007). The programme
has six components:
1. Self-monitoring of situations that trigger trauma-related distress.
2. Generating a hierarchy of these trigger situations in terms of the degree of threat or
avoidance that the situations cause
3. Training in, and practising of stress management strategies
4. Graded, self-guided, in vivo exposure to items from the personalised hierarchy,
starting with the least threatening.
5. Seven online trauma writing sessions
6. Finally, a review of progress, information about relapse prevention, and the
generation of a personalised plan for dealing with future challenges.
The first study of the efficacy of this programme showed that participants gained significantly
more than a control group that received supportive counselling and it has shown that it is
worth investigating and developing this mode of treatment more widely.
Fact check 5
Question 1.
The internet provides a protected environment where participants can easily control and
regulate the degree of intimacy they want, to share without_______________,
_____________or _____________.
Question 2.
The response to internet programmes has been astounding; this may be particularly relevant
to posttraumatic stress, because traumatic experiences are often associated with
stigmatisation and/or intense feelings of shame and guilt.
True/False
Question 3.
What is the best known and researched model for internet therapy?
_________________________________________________________________________
Question 4.
List the benefits of Internet therapy.
Question 5.
DE-STRESS (Delivery of Self-training and Education for Stressful Situations) has six
components:
One being, generating a hierarchy of these trigger situations in terms of the degree of threat
or avoidance that the situations cause. Explain this further with an example.
Reflection and analysis
Currently the best known and researched model for internet therapy is Interapy (Lange, Van
de Ven, & Schrieken, 2003). The treatment is essentially based on cognitive-behavioural
techniques, and consists of structured writing assignments delivered through internet,
without any face-to-face contact.
Think of an example that could be a topic for one of those written assignments.
9. PHARMACOTHERAPY
PTSD is a complex disorder associated with far-reaching alterations in a number of
psychobiological systems. Ideally pharmacotherapy for PTSD would select from different
types of medications, chosen because of their actions on specific psychobiological systems.
However, current pharmacotherapy for PTSD only has access to medications that have
been developed for other conditions, such as depression and anxiety, not medications that
can target the specific neurobiological mechanisms underlying the pathophysiology of PTSD
(Friedman, Davidson, & Stein, 2009).
There is a strong rationale for drug treatment in PTSD, nevertheless. Medication is one of
the most feasible treatments for PTSD for the following reasons (Friedman, et al.,2009).
Firstly, it is generally accepted by most patients, in spite of side-effects and high cost of the
newer drugs. Secondly, PTSD is often associated with at least one comorbid condition that
can be effectively treated with medication, such as depression and other anxiety disorders,
and thirdly, PTSD is often associated with disruptive symptoms (impulsivity, mood lability,
irritability, aggressiveness, suicidal behaviour) that can also be controlled to some extent by
medication (Najavits, Ryngala, Back, Bolton, Mueser, & Brady, 2009). Furthermore, while
CBT is the first choice for treatment of PTSD (Foa, et.al.,2009), it demands considerable
manpower and input by very highly skilled and scarce professionals, making it inaccessible
to large numbers of PTSD sufferers, whereas drug therapy may be more accessible.
Research has identified a number of pharmacological agents, mainly among the antidepressants, capable of reducing PTSD symptoms significantly. The best results have been
achieved with selective serotonin reuptake inhibitors (SSRI, sertraline, paroxetine,
fluoxetine), and serotonin-norepinephrine reuptake inhibitors (SNRI, venlafaxine), as well as
some of the other second generation anti-depressants (mirtazapine, nefazodone,
trazodone). These agents are regarded as first line treatments (Friedman, et al., 2009).
Some of the older anti-depressants, monoamine oxidase inhibitors (MAOI) and tricyclic
antidepressants (TCA), have been shown to be effective mainly in reducing reexperiencing
symptoms.
Among other groups of medications, not the anti-depressants, limited results have been
achieved. Anti-adrenergic medications appear to reduce arousal, reexperiencing, and
possibly dissociation, but findings have not been consistent. Some anticonvulsants have
shown promise, but results have been inconclusive, and side-effects are often a problem.
Atypical antipsychotics, like risperidone and olanzapine (not the conventional antipsychotics)
have started a new direction of experimentation. Initial evidence shows that they may be
effective as an augmentation to SSRI treatment when patients have only partly responded to
treatment, or not responded at all (Friedman, et al., 2009).
While benzodiazepines are effective anxiolytics, they are contraindicated for PTSD
treatment. They do not reduce PTSD symptoms and may complicate the symptomatology by
adding psychomotor slowing and depression. The added risk of dependency is also
unacceptable (Friedman, 2009). In fact, there are indications that use of these tranquilisers
shortly after trauma, may increase the likelihood of PTSD (Gelpin, Bonne, Peri, Brandes, &
Shalev, 1996) (Mellman, Bustamante, David, & Fins, 2002), and are thus contraindicated
also as an early intervention after trauma.
Importantly, although the pharmacotherapy of PTSD seems capable of controlling
symptoms, it is not yet able to affect the course of the disorder. At this stage the treatment is
only palliative, in the sense that it can only reduce symptoms and at best aid remission, but
as yet recovery from PTSD is not yet possible with medication. Patients who have
responded well to medication must either remain on medication indefinitely, or run a
significant risk of relapse. Furthermore, patients who have benefited from CBT have a
considerably smaller risk of relapse than patients who were treated with medication only
(Foa, et al., 2009). However, combining SSRI treatment with CBT does not seem to have
particular advantages at this stage, but there are initial indications that patients who have not
responded well to CBT may do better in their therapy if it is combined with certain
pharmacological agents, such as D-cycloserine (Friedman & Davidson, 2007).
New areas of investigation in pharmacotherapy are steering away from symptom reduction
and attempt to address the mechanisms involved with the biology of memory, particularly
fear memory, the prevention of PTSD, and combined treatments, more specifically
medication that facilitate CBT.
Fact check 6
Question 1.
PTSD only has access to medications that have been developed for other conditions,
such as ______________ and ____________ not medications that can target the specific
neurobiological mechanisms underlying the pathophysiology of PTSD.
Question 2.
Pharmacotherapy is the preferred treatment choice, above CBT, of PTSD
True/False
Question 3.
Although the pharmacotherapy of PTSD seems capable of controlling symptoms, it is not yet
able to affect the course of the disorder?
True/False
Question 4.
Patients who have benefited from CBT have a considerably smaller risk of relapse than
patients who were treated with medication only?
True/False
Question 5.
Patients who have responded well to medication must either _____________________,
or ___________________________.
Reflection and analysis
In your professional opinion, if you had a client suffering from PTSD, with the comorbid
condition of depression, what would your treatment be?
10. CONCLUSION
The NICE treatment guidelines (National Institute for Health and Clinical Excellence, 2005)
offer a useful summary of our knowledge with practical guidelines for the treatment of PTSD:
















PTSD can develop in people of any age following a stressful event or situation of an
exceptionally threatening or catastrophic nature.
PTSD does not usually develop following generally upsetting situations such as
divorce, loss of job, or failing an exam.
Effective treatment can only take place if the disorder is recognised.
Treatment for PTSD should not start until 4 weeks after the trauma, although support
and information can be offered within these early weeks.
Symptoms often develop immediately after the traumatic event but the onset of
symptoms may be delayed in some people.
PTSD is treatable even when problems present many years after the event.
Drugs should not be offered as routine first-line treatment for adult PTSD sufferers.
When symptoms are present 8-12 sessions of trauma-focussed CBT or EMDR
should be offered, regardless of the time elapsed since the trauma.
It should be ensured that psychological treatment is regular and continuous (at least
once a week) and is delivered by the same person.
Consideration should be given to extending trauma-focussed psychological treatment
beyond 12 sessions in the following situations: After multiple traumatic events; after
traumatic bereavement; where chronic disability results from the trauma; when
significant co-morbid disorders or social problems are present.
Non-trauma-focussed interventions such as relaxation or non-directive therapy
should not be routinely offered.
Children and young people should be offered trauma-focussed CBT adapted as
needed to suit their age, circumstances and level of development. For example
Classroom Based Interventions (CBI) as developed by Macy et al. (2003) and Tol et
al. (2008).
Families should be involved in the treatment of children and young people where
appropriate.
PTSD sufferers should be given information about effective treatment and their
preferences taken into account.
The impact of the traumatic event on all family members should be assessed and
appropriate support provided.
There are complex sequelae from long-term trauma, for example personality disorder
or dissociative disorder, and work with complex trauma is long-term rather than time
limited.
Finally, Foa, Friedman, Keane and Cohen (2009) comment in their conclusion to the ISTSS
treatment guidelines, that a considerable amount of research has proven the efficacy of
CBT, EMDR and pharmacotherapy, but relatively little is known at this stage about other
treatments for PTSD, and precious little is known about combined treatment approaches.
The good news is, however, that there has been rapid growth of rigorous clinical research in
recent years. Many questions are emerging, but more sophisticated research methods have
been developed, so that we can expect answers to some of the important questions about
treatment, in the near future.
11. REVIEW
In this course, you have read about the following topics listed below. Check whether you feel
you understand each section by ticking the relevant box. If you feel you need to do more
work in the area, re-read the section and do the tasks again.
COGNITIVE BEHAVIOURAL THERAPY
(
)
EYE MOVEMENT DESENSITISATION AND REPROCESSING
(
)
PSYCHODYNAMIC THERAPY
(
)
HYPNOSIS
(
)
STRESS INOCULATION TRAINING
(
)
ACCEPTANCE AND COMMITMENT THERAPY
(
)
CREATIVE THERAPIES
(
)
INTERNET THERAPY
(
)
PHARMACOTHERAPY
(
)
Though you may feel now that you have mastered all the sections, it is worth trying an
objective practice test before you undertake the multichoice assessment. Write your
responses to the following questions and check the answers in the key on the next page.
End of course self-assessment questions
1. For each of the different therapies listed give at least one pro and con. Try to use the text
as much as possible. In some cases, however, you will need to think of some yourself, be
creative.

Cognitive Behavioural therapy
ProCon-

Eye movement desensitisation and reprocessing
ProCon-

Psychodynamic therapy
ProCon-

Hypnosis
ProCon-

Stress inoculation training
ProCon-

Acceptance and commitment therapy
ProCon-

Creative therapies
ProCon-

Internet therapy
ProCon-

Pharmacotherapy
ProCon-
2. Which terms are NOT commonly used in trauma treatment?
trauma debriefing, serotonin reuptake inhibitors (SSRI), interapy, Gestalt, cognitive
behaviour therapy, introjections, anxiolitics and shock therapy.
Key:
1. Listed are the answers to the pros and cons to the different therapies.

Cognitive Behavioural therapy
Pro- The International Society of Traumatic Stress suggests that cognitivebehavioural therapy with prolonged exposure has the best support empirically for the
treatment for PTSD. However, studies have also shown that trauma-focussed
cognitive therapy where the focus on exposure is less, can also be effective
Con- Numerous CBT programs have been shown to work in well-controlled studies
meeting high methodological standards, but the evidence is in favour of exposure
therapy. This therefore means that not all the components of CBT are as effective as
the other.

Eye movement desensitisation and reprocessing
Pro- Initially this method was regarded with some scepticism by the scientific
community, but in time it has proven its efficacy.
Con- An analysis of 34 studies of EMDR (Davidson, 2001) concluded that EMDR
was more effective than non-exposure therapies, but that it was not any more
effective than other exposure therapies. It also concluded that the eye movements
are probably an unimportant aspect in its overall effectiveness and that in essence it
shares the same elements as exposure therapy.

Psychodynamic therapy
Pro- Psychodynamic psychotherapy has a long and rich tradition in the mental health
field. Its roots stretch back more than 100 years. Authors have contributed a
considerable volume of scholarly work on the treatments of PTSD,
Con- Very few empirical studies exist in the literature today. Given that there are a
large number of clinicians practicing within this framework, more scientific research in
this area is warranted. This therefore means that more research is needed.

Hypnosis
Pro- In the field of trauma, hypnosis is used frequently and it has been shown to
significantly enhance therapeutic efficacy in a variety of clinical conditions.
Con- Most often it is not as effective as a standalone treatment. It is usually used as
an adjunct to psychodynamic, cognitive-behavioural, or other therapies. The use of
hypnosis in clinical practice in most countries requires considerable professional
training and credentialing

Stress inoculation training
Pro- Empirical support for the efficacy of SIT is mixed, with some studies showing
significant reductions in PTSD symptoms, particularly in female sexual assault
victims.
Con- The evidence for war veterans is not as positive.

Acceptance and commitment therapy
Pro- From the ACT perspective the essential problem is the attempt to control
internal experiences, and therapeutic interventions are designed to promote the
person’s acceptance of internal experiences, while acting according to his/her own
values.
Con-As yet no published studies have evaluated ACT as a treatment for PTSD, but
anecdotal evidence has stimulated interest in this modality of treatment.

Creative therapies
Pro-Theoretically the potential advantage that the creative therapies could have over
other forms of therapy is in the use of non-verbal techniques and symbolism that may
provide access to the implicit, non-verbal aspects of trauma memory that other
therapies do not readily address. It has been reported to be helpful in the reduction of
alexitimia (the inability to put feelings into words), dissociation, anxiety, nightmares,
sleep problems, depression, and in improving body image.
Con- Unfortunately creative arts treatments have not been empirically tested, even
though there is a large body of literature consisting mainly of case studies and
anecdotal evidence.
Internet therapy

Pro- The internet provides a protected environment where participants can easily
control and regulate the degree of intimacy they want, to share without fearing
judgement, rejection or devaluation. Studies in various sites have found substantial,
significant and enduring improvements in PTSD symptoms as well as anxiety,
depression and in complicated grief
Con- No face-to-face contact which many clients benefit from.

Pharmacotherapy
Pro- Medication is one of the most feasible treatments for PTSD for the following
reasons.Firstly, it is generally accepted by most patients, in spite of side-effects and
high cost of the newer drugs. Secondly, PTSD is often associated with at least one
comorbid condition that can be effectively treated with medication, such as
depression and other anxiety disorders, and thirdly, PTSD is often associated with
disruptive symptoms (impulsivity, mood lability, irritability, aggressiveness, suicidal
behaviour) that can also be controlled to some extent by medication. Furthermore,
while CBT is the first choice for treatment of PTSD (Foa, et.al.,2009), it demands
considerable manpower and input by very highly skilled and scarce professionals,
making it inaccessible to large numbers of PTSD sufferers, whereas drug therapy
may be more accessible.
Con- Importantly, although the pharmacotherapy of PTSD seems capable of
controlling symptoms, it is not yet able to affect the course of the disorder. Many
drugs are also very expensive and not always accessible.
2. Which terms are NOT commonly used in trauma management?
trauma debriefing, serotonin reuptake inhibitors (SSRI), interapy, Gestalt, cognitive
behaviour therapy, introjections, anxiolitics and shock therapy.
SUMMARY
The learning outcomes for the course are:
1. To understand the different types of treatment of Posttraumatic Stress Disorder.
2. To know the pros and cons for the following treatments: Cognitive behavioural
therapy, eye movement desensitisation and reprocessing, psychodynamic therapy,
hypnosis, stress inoculation training, acceptance and commitment therapy, creative
therapies, pharmacotherapy, internet therapy and pharmacotherapy.
3. Have a better knowledge of comorbidity disorders with PTSD,
4. and have an understanding of the results and studies regarding the different
treatments.
12. REFERENCES
Cahill, S., Rothbaum, B., Resick, P., & Follette, V. (2009). Cognitive-behavioural therapy for
adults. . In E. Foa, T. Keane, M. Friedman, & J. Cohen, Effective treatments for PTSD:
Practice guidelines from the International Society for Traumatic Stress Studies. (pp. 139223). New York: Guilford Press
Ehlers, A., Clark, D., Hackman, A., McManus, F., Fennel, M., Berbert, C., et.al. (2003). A
randomised controlled trial of cognitive therapy, self-help, and repeated assessment as early
interventions for PTSD. Archives of General Psychiatry, 60, 1024-1032.
Foa, E. & Rothbaum, B. (1998). Treating the trauma of rape. New York: Guiford Press
Foa,E., Ehlers, A., & Clark, D., (1999). Posttraumatic Cognitions Inventory: Development
and validation. Psychological Assessment, 11, 303-314.
Foa, E. & Jaycox, L. (1999). Cognitive-behavioural theory and treatment of PTSD. In
D.Spiegel (Ed.), Efficacy and cost-effectiveness of psychotherapy, (pp.23-61). Washington
DC: American Psychiatric Press.
Foa, E., Dancu, C., Hembree, E., Jaycox, L., Meadows, E., & Street, G. (1999a). A
comparison of exposure therapy, stress innoculation training,, and their combination for
reducing posttraumatic stress disorder in female assault victims. Journal for Consulting
Psychology, 67 , 194-200.
Foa E., Keane, T., Friedman, M., Cohen, J. (Ed.s), (2009). Effective treatments for PTSD:
Practice guidelines from the International Society for Traumatic Stress Studies. New York:
Guilford Press.
Follette, V., Palm, K., & Hall, R. (2004). Acceptance, mindfullness and trauma. In S. Hayes,
V. Follette, M. Linehan, & (Eds.), Mindfulness and acceptance: Expanding the cognitivebehavioural tradition. (pp. 192-208). New York: Guilford Press
Friedman, M., Davidson, J., & Stein, D. (2009). Psychopharmacotherapy for adults. In E.
Foa, T. Kean, M. Friedman, J. Cohen, & (Eds.), Effective Treatments for PTSD: Practice
guidelines from the International Society for Traumatic Stress Studies. (pp. 245-269). New
York: Guilford Press.
Gelpin, E., Bonne, O., Peri, T., Brandes, D., & Shalev, A. (1996). Treatment of recent trauma
survivors with benzodiazepines: A prospective study. Journal Of Clinial Psychiatry, 57, 390394.
Johnson, D., Lahad, M., & Gray, A. (2009). Creative therapies for adults. In E. Foa, T.
Keane, M. Friedman, & J. Cohen, Effective treatments for PTSD: Practice guidelines from
the International Society for Traumatic Stress Studies. (pp. 479-490). New York: Guilford
Press.
Lange, A., Van de Ven, J., & Schrieken, B. (2003). Interapy: Treatment of stress via the
internet. Cognitive Behavioural Therapy, 32 , 110-124
Lange, A., Rietdijk, D., Hudcovicova, M., Van de Ven, J., Schrieken, B., & Emmelkamp, P.
(2003). Interapy: A controlled randomized trial of the standardised treatment of posttraumatic stress through the internet. Journal of Clinical and Consulting Psychology; 71 ,
901-909.
Lange, A., Van de Ven, J., Schrieken, B., & Emmelkamp, P. (2001). Interapy, treatment of
posttraumatic stress through the internet: A controlled trial. Journal of Behaviour Therapy
and Experimental Psychiatry; 32, 73-90
Litz, B., Engel, C., Bryant, R., & Papa, A. (2007). A randomised, controlled proof-of-concept
Litz, B., & Bryant, R. (2009). Early cognitive-behavioral interventions for adults. In E. Foa, T.
Keane, M. Friedman, J. Cohen, & (Eds.), Effective treatments for PTSD: Practice guidelines
from the International Society for Traumatic Stress. (pp. 117-135). New York: Guilford Press.
Macy, R., Behar, L., Paulson, R., Delman, J., Schmid, L., & Smith, S. (2004). Communitybased acute posttraumatic stress management: A description and evaluation of a
psychosocial-intervention continuum. Harvard Review of Psychiatry, 12 , 217-228
Mellman, T., Bustamante, V., David, D., & Fins, A. (2002). Hypnotic medication in the
aftermath of trauma. Journal of Clinical Psychiatry, 63 , 1183-1184
Najavits, L., Ryngala, D., Back, S., E., B., Mueser, K., & K., B. (2009). Treatment of PTSD
and comorbid disorders. In E. Foa, T. Keane, M. Friedman, J. Cohen, & (Eds.), Effective
treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress
Studies. (pp. 508-535). New York: Guilford Press.
NICE, N. I. (2005, March). Posttraumatic stress disorder: The management of PTSD in
adults and children in primary and secondary care. Retrieved March 3, 2009, from National
Institute for Health and Clinical Excellence: http://www.nice.org.uk
Tol, W., Komproe, I., Susanty, D., Jordans, M., Macy, R., & De Jong, J. (2008). SchoolBased Mental Health Intervention For Children Affected by Political Violence in Indonesia: A
Cluster Randomized Trial. JAMA, 300, 6 , 655-662
Wagner, B., Knaevelsrud, C., & Maercker, A. (2004). Internet based cognitive-behavioural
therapy for complicated grief: a randomisedcontrolled trial. Death Studies; 30, 429-453