PTSD: treatment

Understanding what is happening in PTSD takes away some of its power over you. It demystifies the condition and checks maladaptive coping strategies – intentional or otherwise. In general, understanding your health condition improves outcomes. Read our article “PTSD – Defined” for more information.

A quick summary:

1. Trauma memory needs elaboration and integration into autobiographical memory.
2. Problematic appraisals (ways of thinking of yourself or the way you relate to various situations) need to be identified and modified.
3. Dysfunctional behaviour and cognitive strategies need to be dropped.
   • Many of the ways in which patients have dealt with trauma memory may have been useful for other, milder stressors but, paradoxically could be maintaining symptoms now;
   • They may directly produce PTSD symptoms;
   • They may prevent change in negative appraisals of the trauma and its consequences;
   • They may prevent the necessary change in the nature of one’s memory of the trauma.

Look after yourself and re-establish social relationships! Looking after yourself can involve sticking to an exercise regimen, not taking on too much work, managing any added stress in your life, looking after your diet, getting back into the activities you enjoy, etc.

If problematic beliefs are stopping you from doing this, then these need to be identified and evaluated.

As the majority of people don’t develop PTSD (See Does everyone who experiences trauma develop PTSD), the first month is an important time to reintegrate into a normal schedule and live a healthy lifestyle (i.e., good diet, good sleep regimen, social engagement). Talking about the trauma before you are ready is not necessary. Treatment for PTSD cannot realistically begin until you no longer feel traumatized.

An analogy for this would be coming up from deep sea diving; it needs to be done in a gradual albeit timely fashion.

• There is a high incidence of sleep disturbances in PTSD. In fact, even after evidence-based treatment for PTSD, insomnia is one of the most common persistent symptoms (Belleville et al., 2011).
• CBT-i is considered first-line therapy for insomnia treatment in PTSD. (Talbot et al., 2014)
• Improving sleep will go along way to make you feel more rested and able to reintegrate into your activities.

What are your life’s aspirations? Now, more than ever, it is helpful to keep them in mind.

A horse is so sensitive that it will take you where you are looking; and normally, you look where you want to go. Like that, keep your eye on where you want to go. Keeping in mind what you would like out of life in the next week, month, year, etc., and visualizing it as if you were experiencing it (e.g., taste, smell, feel, thought, emotions, etc.) will provide you with positive emotions that can provide the leverage you need over PTSD roadblocks.

An example of a practice that many successful people employ is one of a visualization board. Here, you create a detailed movie in your mind of how you envision yourself. This can be made more concrete by using crafts and handing up a collage somewhere in your house. It’s important that this “detailed movie” contains positive things as opposed to the absence of negative things (i.e., symptoms, problems).

• This exercise can give us strength when we face tough times.
• It can keep us on track: “What can I do this week to help me realize my aspirations?”

Some areas to consider in which people commonly have aspirations are:

1. Social interactions
2. Productivity/career
3. Household mx
4. Leisure activities/fun
5. Spiritual/cultural/intellectual activities
6. Exercise/health
7. Daily relaxation

Try filling out the Aspirations Diary so you are clear on where you want to get.

Coping strategies are general strategies people use to help reduce the effects of stress. These are commonly used in the treatment of PTSD as the rehabilitation can in and of itself present one with stress. An analogy would be when one makes an investment, they have to make some budgeting changes and perhaps change their lifestyle a bit until the investment shows returns. These coping strategies are not treatment strategies specific to PTSD.

• Role playing
• Assertiveness training
• Stress management
• Relaxation exercises
• Biofeedback (e.g., using electromyography, heart rate, or respiration rate)
• Exercise
• Mindfulness-Based Stress Reduction

1. The fear memory must be activated. The patient must be helped in evaluating the trauma-related information in a therapeutic manner.
2. New, corrective information must be appreciated that don’t quite fit in to the new fear structure. That is, information was overlooked that changes the perception of either what happened; and/or the consequences of what happened; and/or one’s ability to live life the way they would like. Corrective information means having a decreased fear responses while in the presence of trauma reminders.

Generally, PTSD-specific treatments are started when the patient is ready as the exercises can be challenging, emotionally and physiologically. Ideal candidates will have a stable lifestyle and support network; and will have put into place many of the things mentioned in the section above “WHAT ARE SOME NON-SPECIFIC (GENERIC) TREATMENT STRATEGIES FOR PTSD?”.

Imaginal Exposure

This is a technique that is about helping one habituate to the memory of the trauma. It allows one to think about it, visualize it, verbalize it and tolerate distressing information about it. In the process, often patients are able to integrate important information that was overlooked or ignored. One can audio record an account of the trauma and listen to it repeatedly to help in processing the trauma. Patients often will eventually learn that they can think about the trauma without reliving it or getting anxious. They will remember that the trauma happened in the past and they are just as capable as they were before; they can control the memories rather than the memories controlling them. Practicing this technique serves as an opportunity to correct unhelpful beliefs that may have developed as a result of the trauma.

The process involves recalling the memory with one’s eyes closed and then imagining that the trauma is happening right now. Tap into the feelings that go with the memory. Describe the trauma in the present tense and give as many details as you can including the events that happened, your thoughts and feelings. Every once in a while, rate how distressed you feel without losing touch of the memory.

Remember,

1. Memories and many of the situations that trigger PTSD symptoms (e.g., loud noises) are note dangerous;
2. Anxiety/distress decreases after repeated and prolonged exposure;
3. Exposure reduces PTSD symptoms.

 

Prolonged Exposure

We have discussed how one has to face PTSD in order to process and integrate memories. We have also discussed many of the symptoms (emotional, cognitive, physical) that happen after PTSD; and that many people avoid cues that trigger these symptoms. Prolonged Exposure therapy is not concerned with talking about the therapy or thinking about how you are thinking as a result of the trauma. Prolonged Exposure is a behavioural therapy. Here, we systematically desensitize patients to things to which they are afraid like reminders of the trauma, situations they avoid, situations that are viewed as dangerous and situations that help return the survivors to living the lives they are wishing to lead. So just like when skiing down a hill, one starts with the bunny hill and slowly works up to higher heights. Like that, a hierarchy of fears are developed and then patients systematically confront each level until it no longer terrifies them.

The premise to the exercise is fairly simple:

1. The patients must put themselves in the situation that triggers fear.
2. They have to stay their course (usually 30-40 minutes immersed in the situation) until they learn from their own experience that it isn’t as bad as they feared. That is, the anxiety has to subjectively drop by 50%. Eventually acute stress responses do tire out and there is a calm that is restored, it’s a matter of hanging in there until this happens. Some people inadvertently switch to “avoidance mode” and not fully engage in the challenge for that level; this will be counterproductive and be a common reason for a plateauing of progress.
3. Patients need to compare this experimental exposure to the traumatic one to separate fear from the trauma in their minds. What are the similarities and differences between then and now? Is there anything new noticed/experienced that changes beliefs you had regarding this activity? Do you need to avoid it? What’s the worst that could happen in doing this activity nowadays?

 

Gradual Exposure

This is similar to Prolonged Exposure in that it’s a behavioural a therapy and it is based on a hierarchy of fears where a patient has to progressively pass one level to get to the next. However, the approach is different. Where Prolonged Exposure elicited fear to habituate the patient to the stimulus, gradual exposure has the patient as calm as can be and slowly introduces them to a situation on the fear hierarchy with the focus on remaining calm using relaxation strategies. There is a procedure which is followed to help guide the patient up the hierarchy.

Background

Our Youtube Channel has videos introducing you to this line of therapy designed for PTSD. CPT is basically a structured 12-step CBT program that is focused on identifying your thinking in situations where you get stuck, choked up or in a rut, and evaluating from where they come. Then on the touchstone of reason, thoughts underlying these stuck points are tested to see if they actually hold water.

CPT is a standardized application of CBT that consists of a manual, worksheets, and analysis. A common strategy used in working through these stuck points is to write down an account of the trauma. Adding language especially helps when the patient continues to ‘re-experience’ the trauma through sensory impressions (e.g., a pattern of lighting, sounds) – rather than thoughts (e.g., “I’m terrified!”) triggering the symptoms of hyperarousal. Adding language to these situations helps contextualize the experience and slow down – and possibly stop – the automatic reaction the occurs in the face of these stimuli. This is because it changes the way the trauma is encoded in the memory. So, instead of the patient left with the experience of hyperarousal symptoms in the “here-and-now”, the experience is contextualized as having occurred at a different time under a different set of circumstances. Keep in mind that often these stuck points are natural feelings, e.g., “feeling like you’re going to die”. They are not secondary emotions, e.g., “I blame myself for what happened”, which are emotions that trick yourself into a distraction so you don’t have to go where you (consciously or subconsciously) don’t want to go. We are trying to get to the root – the “stuck points” – so that they are processed and then integrated.

 

Impact Statements

Impact statements are meant to focus on the meaning of the event; views of oneself, others and the world; and how it has affected themes of safety, trust and intimacy. It is not meant to focus on the details of the event in the way a police officer would write an accident report. Impact Statements can cause patients to experience dissociations and/or dysregulation:

• Dissociation refers to an experience where patients disconnect with their awareness of themselves. They may blank out and not know what’s happening, who they are, etc. Patients may say, “After that, I don’t remember anything, next thing I know, I was home and in bed and I account for the 2 hours between when I called the tow-truck and got home.”
• Dysregulation refers to losing the ability to regulate your emotions.

The goal of the Impact Statement is to get patients connected to their natural feelings associated with the trauma. So, if someone doesn’t know how to write, any technique that gets you there can be attempted – singing, drawing, speaking, etc.

Sample writing assignment

Write down exactly what happened with as many details as possible. Also write down your thoughts and feeling during the event. Use as many pages as you need. Once you have finished writing the account, you should read the account every day until the next session. Don’t be surprised if you feel your reactions almost as strongly as you did at the time of the incident. However, you need to remind yourself that this is a memory and that you are not actually in danger as you recall the event. Please bring your account to the next session.

 

Stuck Points

“Stuck Points” are identified triggers for intrusive memories. It will help serve as a springboard to dive into the memory of the trauma and promotes better discrimination. They can take the form of:

1. Single event or a series of events;
2. Thoughts, images, memories, flashbacks;
3. Emotions;
4. Behaviours;
5. Physiological sensations.

 

Processing the Trauma

The writing assignment serves as a flywheel to processing the trauma using CBT and involves worksheets and analytical conversations with the therapist. Generally, the areas processed include:

• What it really meant to you on emotional, cognitive and lifestyle levels
• Learning to connect the dots between your thoughts and feelings
  • Different feelings may be caused by different thoughts so all the dots have to be connected skillfully
• The difference between the event and the event’s memory
• Potential feelings of guilt and blame
• Why “stuck points” are “stuck points” and do they really need to be?
• Identifying and correcting cognitive distortions (problematic thinking)
• Rebuilding a sense of safety, trust and self-esteem
• Addressing power and control issues

Ultimately, the main goal is to process the memories of the event. Although many patients avoid memories of the event, ultimately, the memories need to be processed and integrated and to not be made to not feel conspicuous like a mustard stain on a white shirt.

The paradox in doing this is that many patients have a hard time remembering details of the trauma (i.e., avoidance strategy) but they have a high incidence of intrusive memories, emotions, sensory impressions spawned by the trauma.

Just talking about the memory in unemotional contexts doesn’t help integrate it, e.g., I had a bad childhood, I was in a car accident, etc.

Also, just dwelling on why something happened can prevent you from accessing the feelings that go along with the memories. See our article on Journaling  (section – “Be Descriptive”) for more information on how we encode memories; all these different aspects to a memory may need to be accessed and processed to successfully integrate them.

 

Why does CPT work?

• We don’t entirely why
• It identifies and addresses problematic thinking commonly seen in PTSD. See “Common things patients do that worsens their lot: Avoidance, Changed Core Beliefs and Secondary Emotions.”
• Links “unconnected” parts of PTSD (i.e., memories, emotions, thoughts, core beliefs, internal culture, coping strategies, etc.) to correct impressions and thoughts.
• It sounds strange at first, but science has shown that every time someone recalls a memory, it’s a chance to change it (Hardt et al., 2013).
• Facilitates discrimination between the then from the now
  • So that when people have that PTSD reminder, they don’t experience it as if it was happening to them again right now.
• Verbalization of visual/sensory cues may make it more difficult to retrieve original sensory impressions from memory
  • Often we don’t have the same degree of horror/terror we had before if we involve language parts of the cortex

Eye Movement Desensitization and Reprocessing (EMDR)

The technique involves the patient imagining a scene from the trauma, focusing on the accompanying thoughts and arousal level, while the therapist moves two fingers or a wand across the patient’s visual field and instructs the patient to track the fingers/wand. The sequence is repeated until anxiety decreases, at which point the patient is instructed to generate a more adaptive thought. An example of a thought initially associated with the traumatic image might include, “I’m going to die,” while the more adaptive thought might end up as, “I made it through. It’s in the past.”

Most systematic reviews, meta-analyses and clinical practice guidelines have concluded that EMDR is an efficacious treatment for PTSD (Bisson 2014; Foa et al., 1991 & 2009).

 

Interpersonal psychotherapy

Interpersonal psychotherapy focuses on disorder-specific symptoms and impairment in the context of current interpersonal relationships. It has shown to be effective in a clinical trial for the treatment of PTSD (Markowitz et al., 2015).

 

Mindfulness-Based Stress Reduction (MBSR)

MBSR led to modest reduction of PTSD symptoms in a clinical trial. However, there is no evidence that it changes proportion of patients who continued to meet diagnostic criteria for PTSD (Polusny et al., 2015).

 

Acceptance and commitment therapy (ACT)

ACT involves teaching acceptance while at the same time working on behavior change towards value-driven goals. There are not yet any randomized clinical trials supporting the efficacy of ACT in PTSD.

 

Psychodynamic psychotherapy

Psychodynamic therapy in the treatment of PTSD focuses on improving ego strength and capacity for interpersonal relatedness. Evidence is lacking regarding its efficacy but one trial showed that it has similar rates of improvement to hypnosis and systematic desensitization (Brom et al., 1989).

 

Eclectic psychotherapy

Majority of psychotherapists (of different disciplines, e.g., psychiatrists, psychologists, social workers, etc.) practice an eclectic or integrative form of psychotherapy. Eclectic  therapists employ many different techniques including dynamic, cognitive, and behavioral approaches (Palmer et al., 1999). Their efficacy in PTSD hasn’t been studied.

For patients with both TBI and PTSD, a hybrid approach to combining compensatory cognitive training (for TBI) with CPT (for PTSD) was effective (Jak et al., 2019).

American Psychiatric Association. Practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA 2004.

Belleville, Geneviève & Guay, Stéphane & Marchand, André. (2011). Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder. Journal of psychosomatic research. 70. 318-27. 10.1016/j.jpsychores.2010.09.022.

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Foa, Edna & Rothbaum, Barbara & Riggs, David & Murdock, Tamera. (1991). Treatment of Posttraumatic Stress Disorder in Rape Victims: A Comparison Between Cognitive-Behavioral Procedures and Counseling. Journal of consulting and clinical psychology. 59. 715-23. 10.1037/0022-006X.59.5.715.

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Institutes of Medicine. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence, National Academies Press, Washington, DC 2008.

Jak AJ, Jurick S, Crocker LD, Sanderson-Cimino M, Aupperle R, Rodgers CS, Thomas KR, Boyd B, Norman SB, Lang AJ, Keller AV, Schiehser DM, Twamley EW. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2019;90(3):333. Epub 2018 Dec 15.

Markowitz, John & Petkova, Eva & Neria, Yuval & Van Meter, Page & Zhao, Yihong & Hembree, Elizabeth & Lovell, Karina & Biyanova, Tatyana & Marshall, Randall. (2015). Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD. The American journal of psychiatry. 172. appiajp201414070908. 10.1176/appi.ajp.2014.14070908.

National Institute for Clinical Excellence. Post Traumatic Stress Disorder: The management of PTSD in children and adults in primary and secondary care. The Royal College of Psychiatrists and British Psychological Society, 2005.

Polusny, Melissa & Erbes, Christopher & Thuras, Paul & Moran, Amy & Lamberty, Greg & Collins, Rose & Rodman, John & Lim, Kelvin. (2015). Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial. JAMA. 314. 456-465. 10.1001/jama.2015.8361.

Talbot, Lisa & Maguen, Shira & Metzler, Thomas & Schmitz, Martha & Mccaslin-Rodrigo, Shannon & Richards, Anne & Perlis, Michael & Posner, Donn & Weiss, Brandon & Ruoff, Leslie & Varbel, Jonathan & Neylan, Thomas. (2014). Cognitive Behavioral Therapy for Insomnia in Posttraumatic Stress Disorder: A Randomized Controlled Trial. Sleep. 37. 327-41. 10.5665/sleep.3408.

Veterans Health Administration Department of defense (2004). VA/DOD Clinical Practice Guideline for the management of post traumatic stress. Version 1.0. Washington DC: Veterans Health Administration, Department of Defense.