Treatment Recommendations for PTSD

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By Jeannie Singleton, MSW, LSW

In the first article of this series (Burn Support Magazine, Issue 2, 2016), we discussed and identified the signs and symptoms that are evaluated for a diagnosis of posttraumatic stress disorder, or PTSD. It is important to note that after experiencing a trauma most people will exhibit behaviors associated with PTSD, but that does not necessarily mean they have a true diagnosis. Diagnostic criteria for PTSD require that an individual must be both experiencing and impacted by the symptoms for a minimum of 90 days.

Clinical practice guidelines for PTSD come from a variety of sources, such as the Institute for Medicine, International Society for Traumatic Stress Studies, U.S. Department of Veterans Affairs, and Department of Defense. Due to the increase in the number of individuals being diagnosed with PTSD, a significant amount of research into the various clinical treatments for PTSD is currently being offered.

Effective Treatment Modalities

Although more research is still needed on a variety of the treatments, a clear body of evidence supports effectiveness from specific treatment modalities. The following 4 psychotherapies used for PTSD treatment indicate strong empirical (observational) evidence of effectiveness:

Prolonged Exposure (PE) Therapy

PE therapy, which generally consists of 9 to 12 sessions, each lasting 90 minutes, includes the following 4 primary components:

  • Breathing retraining
  • Education about common reactions to trauma
  • Imaginal exposure activities
  • In vivo exposure activities

Two primary factors maintain symptoms of PTSD: unhelpful thoughts and avoidance. Therefore, individuals engaging in PE treatment are required to participate in imaginal exposure (re-visiting/telling the trauma memory), which involves recording the trauma story to include sensory details, thoughts, and feelings and then listening to the imaginal exposure recording daily as homework. Although this is often one of the most difficult parts of treatment for individuals to engage in, it is also one of the most critical steps because it allows individuals to learn that memories are not dangerous, it provides an opportunity to process and organize thoughts, and it enables them to gain confidence and control as they move along in their treatment.

In addition to the imaginal exposure, individuals in PE treatment must also participate in “in vivo” exposure exercises, or those that approximate real-life conditions. The therapist and patient work together to develop a list of avoided situations, including pleasurable activities and those related to the trauma, rate these activities in a hierarchy of avoidance, and then slowly and systematically engage in these activities, staying for 45 minutes or until their stress level reduces by 50%. For example, if an individual was assaulted in a parking lot of a large store and experiences fight-or-flight responses whenever he or she is in a store parking lot, the in vivo exposure activity for the first exposure may consist of going to a large, open parking lot and remaining in the car while parked. In the second exposure, the individual would move out of the car and remain standing in the parking lot, and during the third exposure the individual would walk around the parking lot. By engaging in in vivo exercises, individuals can confront safe but avoided situations, which will eventually result in the development of an awareness that the anxiety is temporary. In addition, successful completion of in vivo exercises provides the opportunity for individuals to improve their confidence in their ability to discriminate between trauma reminders vs truly dangerous situations in which the fight-or-flight response would be appropriate.

Cognitive Processing Therapy (CPT)

The theory behind CPT is that trauma is actually newand- important information that needs to be processed, and that not processing it (avoidance) keeps an individual “stuck,” which results in an inability to accommodate this new information and the development of PTSD symptoms. CPT can be conducted individually or in a group setting and generally consists of the patient(s) learning self-guided cognitive restructuring over 12 sessions. During these sessions, an individual is able to identify trauma-related distorted thoughts or “stuck points.” Once these stuck points are identified, he or she can then evaluate and challenge stuck points and replace them with more balanced thoughts. CPT is a very structured form of treatment, rather than the freeflowing “talk story” type of treatment. CPT treatment specifically focuses on issues in 5 core areas:

  • Safety
  • Trust
  • Power/control
  • Esteem
  • Intimacy

CPT includes a component that requires the individual to write a trauma account, as well as a stuck-point list, and complete session-specific worksheets as homework. The written worksheets are key to helping individuals identify old and new thoughts and determine whether or not these thoughts are realistic (see sample below).

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

EMDR is based on the concept that the trauma memory needs to be processed because it is currently being stored physiologically and in a memory network of thoughts, images, sensations, and emotions. Eye movements or “dual attention” stimulation (for example, tracking lights, tapping fingers) facilitates information processing, which will relieve distress and change distorted perceptions. The components of EMDR include the following steps:

  1. Patient history and treatment plan
  2. Preparation for treatment
  3. Assessment of the trauma memory, negative and positive cognitions, attitudes and beliefs
  4. Desensitization and reprocessing—Visualizing the memory, rehearsing the negative cognitions while concentrating on the physical sensations of anxiety, and visually tracking the therapist’s finger)
  5. Installation of positive cognitions—Visualizing the memory, rehearsing the positive cognitions, visually tracking the therapist’s finger, reporting on changes in validity of the positive thought)
  6. Body scan—Identifying body tension or discomfort
  7. Closure—Discussing relaxation skills/positive visualization
  8. Ongoing re-evaluation of patient status

Sample CPT Worksheet

Stress Inoculation Training (SIT)

Unlike the treatments described previously, SIT is not a trauma-focused treatment; instead the focus of SIT is on developing tools to manage symptoms. SIT draws on the social learning theory and promotes the idea that fear and anxiety are evoked during a trauma, and stimuli are then associated with this fear. Unless addressed, harmless but similar stimuli will continue to evoke fear after the trauma is over, so the goal of treatment is to teach skills to cope with trauma-related anxiety and enhance an individual’s skills for managing stress. SIT therapy consists of 8 individual treatment sessions with a focus on the development of emotion regulation skills and the improvement of interpersonal skills.

Considerations for Selecting Treatment

When selecting from the evidence-based treatments for PTSD described above, the following considerations should be taken into account:

PE therapy

  • Requires the most time-intensive homework
  • Can be more difficult to schedule for client and/or provider due to length of sessions
  • Is good for individuals who are more isolated/depressed due to behaviorally activating in vivos
  • Is good for a quick emotional reconnection due to emotional intensity of imaginals

CPT

  • Includes homework assignments that are less time-consuming than the assignments in PE treatment
  • Consists of a set 12-session format
  • Easily incorporates issues from daily life, in addition to trauma
  • Can be difficult for less cognitive-minded individuals or those who are more rigid in their thinking

EMDR

  • Involves less-intense trauma processing
  • Requires less homework than PE/CPT
  • May have less buy-in, as some individuals are skeptical about following a finger or light for treatment

SIT

  • Is good for individuals who are not willing to do trauma-focused work, as SIT focuses more on improving coping skills than addressing the trauma

In addition to the above-mentioned factors, consideration should also be given to patient-specific factors, such as

  • Motivation—Is the individual ready/willing?
  • Stability—Is the individual stable for trauma processing? For instance, is the individual currently having active suicidal ideations/homicidal ideations, engaging in selfharm, or having unaddressed substance abuse issues?
  • Trauma variables—Does the individual have clear trauma memory?
  • Most importantly, patient preference—Does he or she prefer one treatment over others?

Additional Promising Treatments

In addition to the therapies described above, other promising treatments include

  • Acceptance and Commitment Therapy (ACT)
  • Cognitive Behavior Conjoint Therapy (CBCT)
  • Imagery Rehearsal Therapy
  • Dialectical Behavior Therapy
  • Skills Training in Affect and Interpersonal Regulation (STAIR) Therapy

Significant Reduction in Symptoms

The good news in all of this is that PTSD is very amenable to treatment and most treatment protocols are fairly short (3-4 months). Reducing avoidance is the core component to effective PTSD treatment. We know that memories cannot be erased or taken away, but the research continues to support that engaging in treatment generally results in a significant reduction in symptoms, especially for individuals with severe and/or chronic PTSD or those who have experienced multiple traumas.

 

Treatment References
PE Therapy
Zoellner LA, Feeney, NC, Bittinger JN, et al. Teaching trauma-focused
exposure therapy for PTSD: critical clinical lessons for novice exposure
therapists. Psychological Trauma: Theory, Research, Practice, and Policy.
2011;3:300-308.
CPT
Sobel AA, Resick PA, Rabalais AE. The effect of cognitive processing
therapy on cognitions: impact statement coding. J Trauma Stress.
2009;22:205-211.
EMDR
EMDR Institute. What is EMDR? Available at: https://www.emdr.com/
what-is-emdr/. Accessed October 27, 2016.
SIT
Vickerman KA, Margolin G. Rape treatment outcome research:
empirical findings and state of the literature. Clin Psychol Review. 2009.

Jeannie Singleton is a licensed medical social worker currently working in the burn center and ICU unit at Straub Medical Center. Her prior experience includes working in child welfare services, adult mental health and substance abuse, and the Veterans Administration. Jeannie received her certification in cognitive processing therapy for PTSD while working with veterans in the traumatic stress recovery program.

 

This story is an excerpt from The Phoenix Society’s® Burn Support Magazine, Issue 3, 2016.  Burn Support Magazine is a tri-annual publication that contains articles on the emotional, psychological, and social aspects of burn recovery.  All Rights Reserved.
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