Treatments for Psychological Trauma:
From Acute PTSD to Chronic Traumatization
James L Spira, Ph.D., MPH, ABPP
Clinical Professor, Department of Psychiatry, UCSD
Clinical Director, Casa Palmera Residential Treatment Facility
Overview
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Part 1: Understanding Trauma and Trauma Tx
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Part 2: Clinical Methods Which Can Be Easily
Used
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Part 3: Applications to Counseling Center
Settings with Non-specialized Staff
Outline, Part 1
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Types of Trauma
Psychophysiology of Trauma
Predispositions to Develop Trauma
Traditional Treatments and Efficacy
Recent Developments in Treatment and
Improved Efficacy
Adapting Methods for Therapy with Students
Types of Trauma
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Recent Single Event
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ASD (dissociative and hypervigilant qualities)
PTSD Acute (hypervigilant and avoidant qualities)
PTSD Chronic ( > 3 mo)
Complex Acute PTSD
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Complex Chronic PTSD/Trauma
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Ongoing Childhood Abuse, by caregiver
Adolescent
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Other co-existing psychological or physical problems
by authority figure
by partner
Delayed PTSD
Types of Trauma
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Childhood chronic abuse
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Not necessarily fitting PTSD Criteria
Involved in personality development
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Understanding of relationship and sexuality
Bonding Difficulty
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Avoidant or anxious attachment
Trusting and intimacy
Borderline Spectrum
Influences interpretation of and coping with new
‘traumatic’ incidents
Types of Trauma
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Delayed PTSD
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Delayed Onset (several months)
Long Delayed (years)
Early chronic trauma influences later susceptibility to
PTSD from a traumatic event
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Example of childhood molestation influencing
susceptibility to later relationship abuse
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Case: 19 y/o SWF; victimized as 12 y/o by father’s business
partner; father did not take appropriate action; but later got her
‘counseling’ from a married 52 y/o Church of Scientology
“counselor” who then started a sexual relationship with her, which
quickly turned controlling with threats
Other cases are similar in getting involved in abusive relationships,
which are seen as normal, or from which the victim can’t find a way
out.
Psychophysiology of Trauma
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Imaging shows:
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Enhanced Reticular Activating System arousal
Enhanced Periaquiductal Grey arousal
Limbic Involvement
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Acute trauma related to
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increased limbic/hippocampal processing
Increased cortisol and glutamate/NMDA receptor changes
Chronic trauma related to decreased limbic morphology
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Possibly due to excessive cortisol and glutamate involvement
Psychophysiology
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Hypothalamic-Pituitary-Adrenal Axis
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Situation interpreted as emergency
Classical Conditioning of paired emotion-episodic memory (amygdalahippocampus)
Continual Reprocessing of Reaction
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Internal recall kept active, since situation could recur
External generalizability of situation to similar elements
Frontal interpretation (serious life threatening problem – deal with it)
 Limbic Reaction (keep brain and body in emergency status)
 Frontal Interpretation (Stay alert in case emergency returns!)
 Limbic Reaction (keep brain and body in emergency status)
 Etc. (focusing on the problem keeps the problem real)
Prevalence
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According to the National Institutes of Mental Health, 5.2
million Americans aged 18-54 have PTSD.
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Untold millions have had traumatic experiences that affect their
lives
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The Veteran's Administration (VA) operates more than 140
specialized programs for the treatment of PTSD through VA
Medical Centers and Clinics. In 2001, more than 77,300
veterans were treated for PTSD by VA specialists.
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National Institute of Mental Health. Reliving Trauma, Post-traumatic Stress
Disorder. Available at: http://www.nimh.nih.gov/publicat/reliving.cfm
Department of Veterans Affairs. Fact Sheet: VA programs for veterans with
Post-Traumatic Stress Disorder (PTSD). Available at:
http://www.va.gov/pressrel/ptsd402.htm
Predisposition to PTSD
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Prior psychological difficulties
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Prior traumatic event
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Prior psychological diagnosis
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(especially Anxiety disorders)
Personality / Coping Style
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Especially which was not coped with well
Especially which was chronic
Especially which involved caregivers
Very reflective and sensitive (hyper-reflective anxious PTSD)
Blunted and non-reflective (angry/repressive type PTSD)
Meaninglessness
Prevalence and Time Course
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A prospective longitudinal study assessed 967 consecutive patients who
attended an emergency clinic shortly after a motor vehicle accident, again at 3
months, and at 1 year.
The prevalence of posttraumatic stress disorder (PTSD)
 23.1% at 3 months
 16.5% at 1 year.
Chronic PTSD was related to some objective measures of trauma severity
 perceived threat, and dissociation during the accident,
 to female gender, to previous emotional problems, and to litigation.
Maintaining psychological factors enhanced the accuracy of the prediction
 negative interpretation of intrusions, rumination, thought suppression, and
anger cognitions
The most important predictors of PTSD symptoms at 1 year were:
 Negative interpretation of intrusions, persistent medical problems, and
rumination at 3 months,
Cases of delayed onset related to anger cognitions, injury severity, and prior
emotional problems
Ehlers, A, Mayou, R, Bryant, B (1998) Psychological Predictors of Chronic Posttraumatic
Stress Disorder After Motor Vehicle Accidents Journal of Abnormal Psychology; 107(3)
508-519
Prevalence and Time Course
Gray, MJ, Bolton, EE & Litz, BT (2004). Longitudinal Analysis of PTSD Symptom Course:
Delayed-Onset PTSD in Somalia Peacekeepers; JCCP; 2004, Vol. 72, No. 5,
909–913.
N=1035 sample followed over one year
Sample Type
PTSD Sx Score
Time 1
Time 2
902
Resilient (few Sx)
24
25
47
Acute onset, no remittance
59
57
23
Remitters (acute onset, remitted)
53
35
68
Delayed Onset
34
52
(about 14% of sample developed significant Sx, about ½ was delayed onset)
Typical Treatments
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Medications
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For each type of PTSD
Cognitive Behavioral Therapies
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For each type of PTSD
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Rational vs automatic responses
Individual vs group
Critical Incident Stress Debriefings (CISD)
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Immediately following a disaster to prevent PTSD
Typical Treatments: Medication
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Acute Stress D/O
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Acute PTSD
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Beta Blockade
Benzodiazepine
SSRI, TCA
Chronic PTSD
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SSRI
Anti-Psychotic
Benzodiazepine?
Sleep Support
Typical Treatments:
CBT for Complex PTSD
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121 female rape victims, most of whom had extensive histories of trauma, were
randomly assigned to cognitive-processing therapy, prolonged exposure, or a
delayed-treatment waiting-list condition.
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Both types of treatment were equally effective for treating complex PTSD
symptoms,
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The sample was then divided into two groups depending upon whether they had a
history of child sexual abuse. Both groups improved significantly over the
course of treatment with regard to PTSD, depression, and the symptoms of
complex PTSD as measured by the Trauma Symptom Inventory. Improvements
were maintained for at least 9 months.
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These findings indicate that cognitive-behavioral and exposure therapies are
effective for patients with complex trauma histories and symptoms patterns.
Resick PA. Nishith P. Griffin MG. (2003) How well does cognitive-behavioral therapy
treat symptoms of complex PTSD? An examination of child sexual abuse survivors within
a clinical trial. Cns Spectrums. 8(5):340-55.
Typical Treatments
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Critical Incident Stress Debriefing /
Management (CISD/CISM)
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Makes Clinical Sense
Unlikely to do harm
Likely to be useful as screening assessment
Likely to be useful to normalize therapy for future
Not good evidence of value in reducing PTSD Dx
or Sx in studies and meta analysis, and therefore
not as widely recommended as it once was
Experiential Therapies:
Dissociation
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Relaxation
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Physical (Autonomic) Emphasis
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PSNS retraining
Muscle relaxation
Slow breathing
Biofeedback
Efficacy?
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Alone has limited effects
More effective in combination with other techniques
Experiential Therapies: Dissociation
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Meditation
Attentional retraining
 Attention is enhanced processing:
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Your brain/body support what you attend to:
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Whatever you attend to, you enhance
 (worry, pain, noise, arousal / breath, warmth, work)
H-P-A axis
 (ANS activation; PAG relay; Limbic arousal; frontal
interpretation – for SNS or PSNS)
If you can address a problem, then do so, otherwise focus on
neutral or positive sensations or activity
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Meditation helps reduce background “noise” and enhance
foregrounded signal
ZEN MEDITATION (signal emphasis)
VIPASSANA MEDITATION (noise reduction)
Experiential Therapies:
Controlled Dissociation
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Hypnosis
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Principles
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Methods
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Controlled dissociation (x4)
Hypnotizability
Light trance
 CBT + relaxation + graded exposure
 Bypasses typical conscious resistance (schema)
Deep trance
 Bypasses conscious resistance/habit schema
 Reassociates new emotions with old memories
Efficacy?
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Reportedly high for highly hypnotizable pts
Highly hypnotizable pts may do worse w/o tx, better w/tx
Experiential Therapies:
Dissociation
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EMDR
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Principles
Methods
Efficacy?
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Meta analyses and comparative studies show it may be
effective in PTSD, but is not more effective than other
therapies
May be only exposure therapy with ritual
Experiential Therapies: EMDR
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The authors examined the efficacy, speed, and incidence of
symptom worsening for 3 treatments of posttraumatic stress disorder
(PTSD): prolonged exposure, relaxation training, or eye movement
desensitization and reprocessing (EMDR) N = 60. Treatments did
not differ in attrition, in the incidence of symptom worsening, or in
their effects on numbing and hyperarousalsymptoms.
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Compared with EMDR and relaxation training, exposure
therapy (a) produced significantly larger reductions in
avoidance and reexperiencing symptoms, (b) tended to be faster
at reducing avoidance, and (c) tended to yield a greater
proportion of participants who no longer met criteria for PTSD
after treatment. EMDR and relaxation did not differ from one
another in speed or efficacy.
Taylor, S. Thordarson, D. Maxfield, L. Fedoroff, I. Lovell, K. Ogrodniczuk, J. (2003).
Comparative Efficacy, Speed, and Adverse Effects of Three PTSD Treatments: Exposure
Therapy, EMDR, and Relaxation Training Journal of Consulting and Clinical Psychology;
71(2) 330-338
Experiential Therapies: EMDR
Meta Analyses: Eye movement desensitization and reprocessing (EMDR), a
controversial treatment suggested for posttraumatic stress disorder (PTSD) and
other conditions, was evaluated in a meta-analysis of 34 studies that
examined EMDR with a variety of populations and measures.
Process and outcome measures were examined separately, and EMDR showed an
effect on both when compared with no treatment and with therapies not using
exposure to anxiety-provoking stimuli and in pre-post EMDR comparisons.
However, no significant effect was found when EMDR was compared with other
exposure techniques.
No incremental effect of eye movements was noted when EMDR was
compared with the same procedure without them.
R. J. DeRubeis and P. Crits-Christoph (1998) noted that EMDR is a potentially
effective treatment for noncombat PTSD, but studies that examined such patient
groups did not give clear support to this.
In sum, EMDR appears to be no more effective than other exposure
techniques, and evidence suggests that the eye movements integral to the
treatment, and to its name, are unnecessary.
Davidson, P. Parker, K. (2001) Eye Movement Desensitization and Reprocessing (EMDR): A MetaAnalysis. JCCP 69(2); 305-316.
Experiential Therapies: Exposure
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In the 1980’s, Terence Keane and colleagues found that exposure
therapy was effective in treating the PTSD symptoms of Vietnam War
veterans.
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In the 90s, research by Edna Foa and her colleagues showed that
exposure therapy was perhaps the most effective Tx for reducing
PTSD symptoms of rape victims, including persistent fear.
Improvements were seen immediately after exposure therapy, and
sustained during a three-month follow-up.
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Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). The treatment of posttraumatic stress disorder in
rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical
Psychology, 59, 715-723.
Foa, E. B., Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual
Review of Psychology, 48, 449-480.
Keane, T. M. & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of a posttraumatic stress disorder. Journal of
Consulting and Clinical Psychology, 50, 138-140.
Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduced symptoms
of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260
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Experiential Therapies: Exposure
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Flooding
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Sudden and total immersion into arousing environment
(not recommended for PTSD due to potential for retraumatizing)
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Graded Exposure
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Discussion (CISD)
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Procedure
Efficacy with different populations
Imagery
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Gradually increasing immersion into arousing environment, as the patient is
able to tolerate.
Re-associate previously traumatic cognitions with comfortable or neurtral
affect
Using internal visual images for those with imagery capacity (-20%)
Virtual Reality
VR Assisted Graded Exposure
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VR assisted GRADED EXPOSURE with
biofeedback/attentional retraining
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Combining the best of high tech and low tech
VR assisted GRADED
EXPOSURE
VR assisted GRADED
EXPOSURE
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With Medication that soothes limbic arousal
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Does de-arousing medication:
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Allow greater mental and physical relaxation
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allow greater exposure
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Yes
Yes
Prevent generalizability post treatment?
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Doesn’t seem to; instead, it extends long term outcome at least in
one small, well conducted study using DCS
(Ressler et al (Nov 2004); Cognitive Enhancers as Adjuncts to
Psychotherapy. Arch Gen Psychiatry, 61 1136-1144)
Meta Analyses
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Van Etten and Taylor analyzed 61 treatment trials that included
pharmacotherapy and modalities such as behavior therapy (particularly
exposure therapy), eye movement desensitization and reprocessing (EMDR),
relaxation training, hypnotherapy, and dynamic psychotherapy. Overall, this
meta-analysis found that exposure therapy was more efficacious than any
other type of treatment for PTSD when measured by clinician rated
measures.
Specifically, the effect size for all types of psychotherapy interventions
was 1.17 compared with 0.69 for medication. Perhaps more significant, the
mean dropout rate in medication trials was 32% compared with 14% in
psychotherapy trials.
A second meta-analysis of psychotherapeutic treatments found that treatment
benefits for target symptoms of PTSD and for general psychological
symptoms (intrusion, avoidance, hyperarousal, anxiety, and depression) were
significant, with effect sizes ranging from 0.2 to 0.49
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Van Etten ML, Taylor S. Comparative efficacy of treatments for posttraumatic stress disorder: A
meta-analysis. Clinical Psychology and Psychotherapy 1998;5:144–54.
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Sherman JJ. Effects of psychotherapeutic treatments for PTSD. J Trauma Stress 1998;11:413–6
Consensus Panel on PTSD
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Ballenger JC. Davidson JR. Lecrubier Y. Nutt DJ. Foa EB. Kessler
RC. McFarlane AC. Shalev AY.
Title: Consensus statement on posttraumatic stress disorder from the
International Consensus Group on Depression and Anxiety.
Source: Journal of Clinical Psychiatry. 61 Suppl 5:60-6, 2000.
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EVIDENCE: The consensus statement is based on the 6 review
articles that are published in this supplement and the scientific
literature relevant to the issues reviewed in these articles.
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CONCLUSION: Selective serotonin reuptake inhibitors are
generally the most appropriate choice of first-line medication for
PTSD, and effective therapy should be continued for 12 months or
longer. The most appropriate psychotherapy is exposure therapy, and
it should be continued for 6 months, with follow-up therapy as
needed.
Summary
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SSRI & Sleep support along with Experiential
Therapies which focus on development of cognitive
and somatic skills are very beneficial in the treatment
of simple acute PTSD.
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SSRI along with Cognitive and Interpersonal
Therapies in combination with Experiential Therapies
may be necessary in the treatment of complex
chronic PTSD.
Adapting for Counseling Centers
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Assess:
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simple acute vs chronic complex
existing coping skills vs need for medication
support (sleep, unable to engage in or benefit from
therapy)
willingness to develop personal skills to improve
vs needing continued external interpersonal
support and understanding
Adapting for Counseling Centers
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Provide a cognitive frame
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Psychoeducation for how trauma symptoms occur
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Normalize
Explain the psychophysiology
Explain the Sx
Cognitive Therapy for understanding
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Habit stimuli, cog/emot/physiol/behavioral reactions
Optimal / healthy reactions
Skills needed to obtain these optimal reactions
Adapting for Counseling Centers
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Offer interpersonal support if need be:
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Group process (but be careful not to develop a
“sick role attitude”
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Time limited
CBT oriented with interpersonal discussion
Family/couple therapy
Adapting for Counseling Centers
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If complex/chronic
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Address current crisis
Consider dynamic approach
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Discuss early childhood traumas
How these influence current:
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Personality and Beliefs about self, others, world
Interpretations of and reactions to past critical and current events
Discuss optimal / normal interpretations & reactions
Adapting for Counseling Centers
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Introduce Experiential Methods:
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1st: develop skills of being comfortably in the moment
2nd: take a mildly uncomfortable event and practiced
with it:
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Tolerate sustaining attention to it
Distance as necessary to sustain attention to it
Return to being comfortably in the moment
Go back and forth several times to teach basic skill
(optimally with biofeedback monitoring; otherwise minimal
cues and verbal SUDS)
Adapting for Counseling Centers
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Experiential Methods
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3rd – Take more relevant but moderately arousing event,
and repeat step 2 above
4th – Take most relevant and arousing event, and repeat step
2 above
Continue until no major arousal occurs
Note: Each step could take several sessions
This can be done in group as well (but give
warnings not to use very arousing stimuli at first)
Adapting for Counseling Centers
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Typical Session:
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Review Sx since last session
Review practice since last session
Practice meditation (attentional retraining)
If successful, introduce moderate stressor
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If successful, introduce stronger stressor
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Arousal, distance as necessary
Return to meditation (alternate every few minutes)
Arousal, distance as necessary
Return to meditation (alternate, every few minutes)
Debrief and discuss practice times and situations
Adapting for Counseling Centers
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Practice:
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In group
With partners
Adapting for Counseling Centers
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Discuss issues related to implementation in
counseling center context
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Settings/sessions
Non-specialized staff therapists
Difficult students