Post traumatic stress disorder medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Medical Therapy

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Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling for PTSD includes education about the condition and provision of safety and support.[1] Cognitive therapy shows good results,[2] and group therapy may be helpful in reducing isolation and social stigma.[3] The psychotherapy programs with the strongest demonstrated efficacy are all cognitive behavioral programs and include variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and combinations of these procedures.[4] Exposure involves assisting trauma survivors to therapeutically confront distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders.

### Prolonged Exposure

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Exposure therapy is a very effective treatment designed to help a traumatized person learn to confront safe but feared memories and situations through gradual  prolonged exposure (PE). Over time, prolonged exposure therapy reduces the debilitating anxiety and avoidance centered on the feared memories and situations, allowing the person to lead a more normal life. With prolonged exposure, the patient is instructed to revisit the traumatic event by imagining that it is currently happening. The person provides detailed descriptions of all thoughts, physical sensations, and emotional reactions to the memory. This is repeated several times over the course of therapy, and it is taped to be listened to later as homework.

PTSD patients are also exposed to real life situations and objects that trigger anxiety and avoidance. Each person, place, situation and activity that triggers anxiety and avoidance is identified and evaluated for safety and relevance to the patient's normal functioning. These things are then repeatedly confronted until the anxiety and avoidance centered on them goes away. Therapy starts small and works its way to more feared and challenging situations.

### CISM

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Early intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However recent studies regarding CISM seem to indicate iatrogenic effects.[5][6] Six studies have formally looked at the effect of CISM, four finding that although patients and providers thought it was helpful, there was no benefit for preventing PTSD. Two other studies have indicated that CISM actually made things worse. Some benefit was found from being connected early to Cognitive Behavioral Therapy, or for some medications such as propranolol. Effects of all these prevention strategies was modest. [7]

### EMDR

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One psychotherapeutic method, specifically targeted at the disorder PTSD, is Eye Movement Desensitization and Reprocessing (EMDR).[8] According to some studies, this may be the most effective psychotherapeutic treatment for PTSD,[9], but this research is largely supported by those with the copyright for EMDR. Most reviews find that EMDR, Cognitive Behavioral Therapy, Exposure Therapy, and Psychodynamic Therapy are all equally effective.[10] Other forms of talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche.[11] Some have shown that a technique of "rewriting" the content of nightmares through imagery rehearsal so that they have a resolution can not only reduce the nightmares but also other symptoms.

### Pharmacological Regimes

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Propranolol, a beta blocker which appears to inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events.[12]

### Combination therapies

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PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and medications such as antidepressants (i.e. SSRI's such as fluoxetine and sertraline, SNRI's such as venlafaxine, and NaSSA's such as mirtazapine) or atypical antipsychotic drugs (such as quetiapine and olanzapine). Recently the anticonvulsant lamotrigine has been reported to be useful in treating some people with PTSD.[13][14][15] The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions.[16]

### Other Psychotherapeutic Methods

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Relationship based treatments are also often used.[17] These, and other approaches, use attachment theory and an attachment model of treatment. In these cases, the treatment of complex trauma often requires a multi-modal approach.

Recently, the use of Virtual reality and Integrated reality experiences applied as a new type of exposure therapy methods to come types of PTSD (specifically military related patients) has been gaining recognition. The first published reports of this were with the Virtual Vietnam project at Emory University. Now, some of this work is done at the CAREN VR LAB at the SHEBA rehabilitation hospital in Israel, at the Brooke Army Medical Center, and at the largest such program is at Naval Medical Center San Diego and nearby Camp Pendleton Marine Base. The ideas behind this methods is based on introducing PTSD causes in a gradual manner, inside a safe environment, the hope is that training in VR in this manner will reduce stress and transfer to daily reality.

Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD[18], but this is not a widely accepted method.[19]

## References

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1. ↑ Foa 1997
2. ↑ Resick 2002
3. ↑ Foy 2002
4. ↑ Cahill, S. P., & Foa, E. B. (2004). A glass half empty or half full? Where we are and directions for future research in the treatment of PTSD. In S. Taylor (Ed.),Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (pp. 267-313) New York: Springer.
5. ↑ Carlier, Lamberts, van Uchelen & Gersons 1998
6. ↑ Mayou, Ehlers & Hobbs 2000
7. ↑ Feldner et al. Behav Modif. 2007 Jan;31(1):80-116.
8. ↑ Devilly, G. J., & Spence, S. H. (1999). "The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder". Journal of Anxiety Disorders, 13, 131–157.
9. ↑ Efficacy of EMDR, copyright 2005, EMDR Institute, Inc
10. ↑ National Center for PTSD Treatment Guidlines
11. ↑ Forbes, D. et al. (2001) "Brief report: treatment of combat-related nightmares using imagery rehearsal: a pilot study", Journal of Traumatic Stress 14 (2): 433-442
12. ↑ Pitman RK, Sanders KM, Zusman RM; et al. (2002). "Pilot study of secondary prevention of posttraumatic stress disorder with propranolol". Biol. Psychiatry. 51 (2): 189–92. PMID 11822998.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
13. ↑ "Lamotrigine FAQ". Retrieved 2007-05-01.
14. ↑ SSRIs versus Non-SSRIs in Post-traumatic Stress Disorder, Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine
15. ↑ A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder, Biol Psychiatry 1999 May 1;45(9):1226-9
16. ↑ MAPS FDA and IRB approved MDMA/PTSD protocol
17. ↑ Johnson S. (2002) Emotionally Focused Couples Therapy with Trauma Survivors. NY: Guilford
18. ↑ Maps.org newsletter
19. ↑ National Center for PTSD Treatment Guidlines

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