On the treatment of PTSD

Theme: Therapy

 

The diagnostic criteria of post-traumatic stress disorder were outlined for the first time in 1980 when DSM-3 was published. The disorder has however a long history, with important contributions during and after the great wars WW1 and WW2, including the Holocaust. After the acceptance of the diagnosis, many pointed out that there seemed to exist a more severe type of the disorder, DESNOS; to begin with only a category for the cases that were difficult to place into existing categories (simply meaning Disorders of Excessive Stress Not Otherwise Specified). Judith Lewis Herman, a researcher in social work, formulated the need for such a category with the words “what men experience on the battlefield; women and children experience in the home”. She coined the term complex PTSD for the effects of prolonged and early trauma.



Single trauma PTSD or complex PTSD, does it matter?


In the meantime, research has proven that early and/or prolonged trauma can have effects that go beyond the classical symptom cluster of PTSD with re-experiencing, avoidance (including memory loss?), and arousal. This new symptom cluster specifies Disorder of Self-Organisation (DSO), defined as symptoms of emotional dysregulation, interpersonal difficulties, and negative self-concept. In DSM-5, these symptoms were added to the PTSD criteria, whereas in ICD-11, complex PTSD was added as a new diagnosis with classical PTSD + DSO. Persons fulfilling the criteria for PTSD with additional symptoms of DSO should be diagnosed with complex PTSD. Population studies with statistical analysis of questionnaires have confirmed that “single trauma PTSD” and complex PTSD exist as separate and well-defined entities on the population level.


In the DSM-5, another change apart from the inclusion of DSO in the criteria for PTSD was that a dissociative subtype of PTSD was included.


C-PTSD thus includes the three core elements of PTSD as well as three additional elements called disturbances in self-organisation that are pervasive and occur across various contexts: emotion regulation difficulties (for example problems calming down), negative self-concept (for example beliefs about the self as worthless or a failure) and relationship difficulties (for example avoidance of relationships). Complex PTSD is measured by The International Trauma Questionnaire for self-report, a structured interview is also under development. The most obvious dividing line between classical (or single trauma) PTSD and complex PTSD (C-PTSD) is the higher presence of prolonged trauma and/or childhood trauma in the latter group.


The importance of the diagnosis C-PTSD, according to the proponents, is that the disturbed self-organisation should be taken into consideration, otherwise the risk of treatment interruption is too high. One way of doing this would be to try to help with these difficulties before the treatment of PTSD proper. There are several examples of such treatment strategies, but the number of controlled studies is small. The best example is skills training in affective and interpersonal regulation (STAIR), a stepped treatment protocol for traumatised youth developed by Marylene Cloitre from the National Center for PTSD in the USA, which has been adapted to various other groups as well. Other strategies which might or might not include a focus on DSO are psychoeducative treatment programs, often in group teaching. Apart from information about PTSD, discussion of living with the symptoms for patients and relatives, information about co-morbidity and its treatment, there will often be an emphasis on self-help methods to regulate arousal (such as breathing techniques), learning about the affects and how to deal with strong affects, etc. The negative self-aspects can also be dealt with in a group format since it might be easier to empathise with others than self for people with low perceived self-worth.


General aspects on diagnosis and treatment of PTSD


The assessment of PTSD builds on screening and structured diagnosis. It is important to keep in mind that a screening questionnaire is not diagnostic. From population studies it is well known that screening questionnaires overestimate the number of actual cases; on the individual level, there is problems with over-rating as well as under-rating. Simply asking about difficulties concentrating and problems sleeping might be a good way of finding possible PTSD cases without being perceived as intrusive.


A structured diagnosis is necessary when there is a suspicion of actual PTSD. MINI includes an example of a relatively short and practical interview. On the other hand, for research purposes, or in order to really understand what it implies to suffer from PTSD, the Clinician Assessment for Posttraumatic Stress (CAPS) has been developed. In CAPS, both the frequency and the intensity of each symptom are assessed by prompting questions. In this way, CAPS should be more sensitive to change, a requirement for research in treatment effects.


Subjects with PTSD can vary a great deal in their clinical picture or phenotype. An explanation for this is that there are many genetic variations that can influence the individual picture (phenotype), while the main features of the illness remain.


Another important feature of PTSD is the prevalent co-morbidity, the majority of cases have one or more co-morbid diagnoses. Depression, anxiety disorders, and drug or alcohol abuse are the most common diagnoses of concern, and sometimes have to be dealt with before treatment of PTSD is possible. However, often PTSD is what drives the total illness burden; for instance, co-morbid depression in PTSD can be more difficult to treat.


The trauma history can be elicited in two ways, a simple one is the Life Event Checklist (LEC) which ascertains that no important types of traumatic experiences are undisclosed. Another way, which might be more time-consuming is telling the trauma story, something which can be strongly avoided because of fear of overwhelming affects. Telling the trauma history to another person who is willing to listen can however be a very healing experience.


Listening to the trauma history is the oldest and simplest psychotherapy for PTSD, and it implies a great deal of exposure therapy, which is today seen as the most important treatment modality for PTSD. Before going into the details of psychotherapy, let us deal with the pharmacology issues.


Pharmacological treatment of PTSD; the treatment of comorbidity and nightmares


From early on in the history of PTSD treatment, it was clear that the sleeping problems and the co-morbidity were important. Most often it is disordered sleep or depression that motivates drug treatment. The sleeping disorder is often caused by the fear of nightmares, leading to avoidance of sleep. Most often trazodone (in the U.S.) was used because of the favourable effects on sleep, but also tricyclics. Today the SSRIs and venlafaxine prevail, a logical choice for depression, but as primary or only treatment for PTSD, there is no doubt that the clinical effect on PTSD proper is limited. Following up antidepressants in PTSD is important, for instance venlafaxine might be beneficial for depression but could sometimes increase the risk for suicide or aggressivity.


Combinations of psychotherapy (exposure-based) and pharmacological treatment are much more effective than pharmacological treatment alone.


There are two things I would like to mention before we leave pharmacology; apart from being my own clinical experience they also serve to demonstrate that in the single case pharmacology still can be a part of the treatment.


When I first got to see many PTSD patients they were typically refugees with short contact because of their life situations. Often, they were depressed and suicidal. At the time mianserin had been taken out of the market, the reason seemed to be fear of side effects. However, mianserin was reintroduced when it turned out that it was involved in very few completed suicides, relative to the prescription rate. I used mianserin in a small number of cases that I followed closely, and it turned out they were doing very well, and after ten such cases followed many more. I prescribed it to patients with PTSD for many years when depression and sleeping problems were at the forefront of the clinical picture.


When mirtazapine was introduced, many believed that it was similar, but in my experience it did not do the same in PTSD patients, especially when dysphoric affects were the problem. It is regrettable that there exist no controlled studies of miansering in PTSD, but on the other hand I saw no reason to change my prescription pattern unless there were side effects in individual cases. Chemically and pharmacologically, mirtazapine and mianserin have been reported to be clearly different with regard to α1-receptor activity and NA reuptake.


Another situation where pharmacology can be of importance is when PTSD nightmares are treatment-resistant, despite adequate psychological treatment. The lack of sleep is often caused by fear of the nightmares that can start directly at sleep onset because of REM deprivation. A psychiatrist working for Veterans administration in the US has carried out many studies of prazosin for nightmares in PTSD, based on the observation of beneficial effects. Prazosin was used during the 80-ties for hypertension, a common co-morbidity in chronic PTSD. Prazosin is not registered in Sweden but if nightmares are resistant to therapy it has not been a problem to get permission from the authorities with a relevant reference. Sometimes other α-1 agonists have been suggested but the metastudies published do not support it, nor my personal experience. Studies have shown that prazosin is more fat-soluble than the blockers recommended for prostate problems. While there is limited support for prazosin as a routine treatment for PTSD, it is obvious that it can have a tremendous effect in selected cases.


A final remark on pharmacology in PTSD is that benzodiazepines should be avoided, which is stated in several treatment guidelines.


Some important psychological treatments for PTSD


Whereas routine pharmacological treatment for PTSD proper has modest effects, there are several psychological treatment modalities with high effects.


The psychological treatment of PTSD has a long history. Suffice to say that there have been great controversies. In the first years of the PTSD diagnosis when psychological treatments of the exposure type were introduced, there was a discussion about whether exposure treatment could be harmful. “There was too much flooding and too little mopping up”, according to one paper that reported a number of cases where exposure therapy had implied problems.


In 1988, a letter was published in the American J of Psychiatry by Francine Shapiro who reported that horizontal eye movements seemed to exert a calming effect during confrontation with disturbing memories. When I showed it to a colleague he remarked; “It is obvious that this woman suffers from wishful thinking, this is impossible”. This reaction was common and still is thirty years later; despite EMDR is an effective treatment for PTSD (7). Recently, I read the following in a review of a submitted paper “Since we know that eye movements have no effect…”. A colleague, who has been involved in attempts at pharmacologically changing traumatic memories, told me that EMDR was built upon a misunderstanding. We now know that horizontal eye movements in ten-second periods enhance the extinction of learned fear via amygdala deactivation. Previous research has shown that the eye movements during EMDR sessions are associated with activation of the parasympathetic system.


The difference between today and 1990 is that there is a lot of research on different treatment methods for PTSD, and we know that many of them are very efficient. The majority of outcome studies build on comparisons and are reported as double-blind controlled studies. However, there is an important difference between the pharmacological placebo-controlled study and psychological treatments; it is almost impossible to make a blind assessment, so the assessor will almost inevitably understand which treatment condition the subject has got. In this way, it is difficult to eliminate the influence of bias. Such is the quality of studies that made the Swedish Board of Social Affairs and Welfare decide that the 22 studies of prolonged exposure (PE) should outweigh the 21 studies of EMDR that were recently assessed in a study of dropout in treatments for PTSD, where the dropout rate for PE was 22% and 18% for EMDR.


With the advent of C-PTSD as a diagnosis we have a further problem; many of the sufferers of C-PTSD belong to the group that would normally be excluded from treatment studies despite the higher prevalence and illness burden. Hopefully, there will be many studies to clarify which treatment serves sufferers from C-PTSD best.


One source of the conflicts between different treatment traditions might stem from a normal emotional reaction to the patients with PTSD. The conditions that the patient has experienced cause fear, guilt, and often much compassion in the therapists. Thus we want to do really good work and be objective. We also are afraid to cause further harm, and easily project these feelings unto others.


Is it possible to treat PTSD without talking about the traumatic experiences? Many have tried, and it is very common that both the therapist and the client avoid the trauma. There is a CBT method that have accepted the premises; the idea here is that the problem in PTSD is not the trauma but the cognitive distortions caused by the trauma, the method that deals with these distortions is called cognitive processing therapy. It has some effect but is not as effective as other treatments. However, understanding the cognitive distortions might offer a good understanding of the patient.


Trauma-focused therapies for PTSD


Prolonged exposure (PE)


The theory behind prolonged exposure is that the memory of a traumatic event acts as an unconditioned stimulus (UCS), however, the circumstances around the memory will become a conditioned stimulus (CS). That implies that the place and other specifics of the event can start to live their own life. Certain colours, smells, sounds, looks of people, and even memories can then become triggers, CS. These can lead to fear and discomfort, and this, in turn, can lead to avoidance. According to this theory, avoidance (the relief = reward of avoiding) is what explains the chronicity of PTSD once it has developed. Avoidance is used to explain everything, even lack of semantic memories is conceptualised as a special form of avoidance (maybe the fragmented memories of trauma are better explained by hippocampal dysfunction which is reversible after improvement).


Exposure therapy is the logical answer to these behaviours, but brief exposure is not enough, according to the reasoning behind PE. During systematic treatment the client is instructed to do homework, to notice triggering situations, rate them with subjective units of distress, etc. In vivo exposure is prescribed as homework, visiting places that remind of the trauma (or where it happened), rehearsing activities that are normally avoided, etc. Imaginal exposure is done in the therapy, and according to the thinking, it should be prolonged as well, to overcome all possible forms of avoidance. The treatment ends when the traumatic experience(s) can be revisited without fear and suffering.


In PE, emphasis is laid on proper preparation and understanding of the rationale on the part of the client. It is also important to impart understanding and empathy during the treatment sessions.

There is no doubt that PE is a very efficient treatment and it should work well in previously well-functioning persons with single trauma(ta). The need for a thorough understanding and capacity for homework is obvious. A higher drop-out rate is reported in metastudies but occurs as well in other trauma-focused methods. Premature treatment without proper preparation and unavoidable deteriorations might involve risks shared with other trauma-focused methods.


Eye Movement Desensitization and Reprocessing (EMDR)


EMDR also might involve a preparatory phase, but since there is no homework involved, this phase can be shorter. There is also an assessment of the clients’ capacity to work with the method. A treatment session usually is structured the following way; the traumatic experience under consideration is described shortly, and then the Subjective Units of Disturbance (Wolpe) are rated; i.e. the degree of negative emotions experienced when focusing on the trauma. Next, the so-called negative cognition is brought up, e.g. the therapist might ask “what does it say about you?”, aiming at understanding possible dysfunctional cognitions, and even rating the strength. There is also a focus on the bodily sensations accompanied by the SUDS and negative cognition.


After establishing these presentations of the trauma (SUDS, negative cognition, and bodily sensations) the eye movements are administered in sets, with breaks so the client can report what is going on, until -ideally- the SUD is zero, the negative cognition is cleared, and the body scan is “clean”. If not, the next session starts where this one ended. It might then have processed spontaneously or will be the starting point for next session. “The safe place” is an exercise that is used to calm down the client if the session is incomplete or there is a need to calm down before leaving the session.


The question of whether eye movements can have any effect that is relevant to the treatment has been subjected to much research with somewhat differing results. During actual EMDR sessions, eye movements were associated with parasympathetic activation (11). Recently a paper (7) was published that demonstrated that eye movement in short sets (10 seconds which is quite brief in the EMDR context) significantly reduces amygdala activity in a fear induction paradigm, with a sizeable effect size. It is concluded that this can explain the higher efficacy of unlearning of fear memory induced by the paradigm, namely aversion induced by electric current. The authors state that maybe the effect of the eye movements is just a way of taxing the working memory so the fear memory is weakened. But anyway, even fMRI neurofeedback to reduce amygdala activity has shown an effect on PTSD (Lanius), so it is a relevant finding.


Maybe less relevant, and unexpected; eye movements in a memorizing task called the Deese-Roediger-McDermott paradigm reduces false recognition compared with subjects that just wait after they are read a series of word and then confronted with words of similar webs of association. The findings have been questioned and further studies should be carried out.


Francine Shapiro has suggested that using EMDR accelerates information processing during the trauma exposure, which might explain the clinical experience of how the client can shift from fear to shame, anger, sadness, and a future perspective during a single treatment session.


In a metastudy of dropout, EMDR seems to have a somewhat smaller dropout rate than PE. In the assessment and protocol of EMDR, there are safeguards to secure that the therapist is well aware of what is going on during the treatment.


Narrative exposure therapy and expressive arts therapy


A different treatment form is called narrative therapy. James Pennebaker once introduced writing about difficult experiences as a form of therapy. Berthold Gersons has developed a form of brief eclectic psychotherapy (BEP) that takes this one step further by operationalizing it, using different techniques. The latest development is Narrative Exposure Therapy (NET) which is manualized.


NET has been used in refugee camps, can be scaled up, and the reported dropout rate is small compared with other trauma-focused methods. Maybe the writing method, by allowing a certain avoidance but still helping to establish perspective as well as causing exposure, can explain this. The narrative methods show an effect size of the same order as PE and EMDR. However, there are still questions regarding the quality of some of the studies. NET has been included in a metastudy of treatments that can be applied by lay workers.


Different forms of expressive art therapy use methods that do not require that the client can talk about traumatic experiences. For instance, painting or drawing whatever comes to mind (in PTSD it is most often a trauma), often prompted by induction such as listening to music also implies a type of exposure, that can be easier to tolerate or utilize than PE or EMDR. There is a growing number of Creative Arts Therapy studies published.


Tapping methods (Emotional Freedom Therapy, Trauma Tapping Therapy)


A lay method that is considered an alternative form of treatment, and not so well documented in research, is in use. The treatment is guaranteed to raise your brows when you hear about it the first time. One variety, assumedly the original one, has been dispersed by a Californian engineer named Gary Craig. The method consists of naming the symptom or problem, after accepting the self despite the problem… during the procedure, the verbal naming of the emotions + problem is accompanied by tapping on successive points, the client taps on a point above the eyebrow, lateral to the corner of the eye, under the eye, above and under the lips, on the joint between clavicle and sternum, on the side of the chest, etc. This variety of the method is known as Emotional Freedom Technique (EFT), not to be confused with emotion-focused therapy. The method - deeming from the video examples that circulate- has been used for phobia, panic, etc. There is one comparison study on PTSD, with favourable results. A metastudy has also been published.


Another variety of the treatment is called Trauma Tapping Therapy. It has been taught and dispersed by lay organizations trying to help victims of war and genocide, for instance in Rwanda. In TTT someone else – a lay person - does the tapping till the client can do it him/herself. The EFT varieties have not been included in a meta-study of lay talk-therapies. The reason mentioned is that it is seen as a body-oriented therapy because of the tapping. While we easily assume that tapping on acupuncture points couldn’t have any effect apart from placebo, even here there might be other explanations; the tapping points are close to nerves that when stimulated are likely to impact the amygdala at the same time as the words referring to traumatic experiences are spoken by the client. And in order to use the method, you must also accept yourself with the problem, name it specifically, and commit yourself to coping with it.


What is interesting here is that the methods are used and that they are the poor cousins of the established exposure therapies for PTSD.


What can be concluded from the literature on PTSD treatment is that there is probably no effective treatment today that does not include exposure to the traumatic event. All exposure therapies share a risk of drop-out. Apart from the discussion regarding which method is best, the study of attrition (drop-out) is relevant. It is a requirement that an effective treatment is also safe.


The organisation of the treatment for PTSD


Clients with PTSD are treated in general psychiatry, primary care, private therapists, or specific trauma centers. There are many ways to deliver treatment, the discussion should be which is most sustainable. First of all, traumatized clients rarely have one trauma and one diagnosis. Differential diagnosis is necessary, on the spectrum of straightforward single trauma PTSD without comorbidity, to chronic multi-traumatised cases with childhood abuse leading to C-PTSD or dissociative disorders that require the possibility of hospitalization and expert knowledge.


All subjects diagnosed with PTSD should get access to psychoeducation and an exposure-based treatment carried out by a therapist with adequate competence. They can also relapse, not uncommon after non-specific stress or new traumatic experiences, implying that they might need to come back.


Further, not all patients with severe PTSD respond to treatment. If they cannot be cured, they are guaranteed to fare worse if they do not have adequate follow-up (medication, psychoeducation, social support).


It is also important to think about the working conditions needed by the therapist in terms of adequate education and supervision, medical support, need for consultations, etc. There is a literature on burnout or exhaustion, and no doubt it is preferable to work in a situation where you can share the burden with others that can help with the most difficult cases.