This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.
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Effective Treatments for PTSD by Rosa Kesner
The majority of people around the world will experience, witness, or learn about a traumatic event in their lifetime, possibly more than once. Most of them will have flashbacks, bad dreams, or frightening thoughts about the event immediately afterward, which is completely normal. Those feelings usually subside over time and are not a lasting problem. Unfortunately, some individuals do not recover on their own and may receive a diagnosis of Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD). ASD is a trauma and stressor-related disorder which has a prevalence rate of about 20% of situations following a traumatic event. It consists of intrusion, dissociative, avoidance, and arousal symptoms, which usually happen immediately after the traumatic event and last no longer than one month.
PTSD is also a trauma and stressor-related disorder which will affect roughly 9% of US adults. It consists of the same symptoms as ASD, but occurs over a longer timespan, with a duration that may vary anywhere from 12 months to 50 years. It also occurs to some individuals after experiencing or learning about a traumatic event. Any person can get PTSD but the highest rates appear in females who have experienced sexual violence, as well as U.S. Latinos, African Americans, and American Indians. Those with PTSD may experience symptoms of intrusion, such as recurrent thoughts and/or dreams, as well as expressing avoidant behavior toward situations which may trigger those intrusive symptoms. They may also feel anxious or alarmed even when there is no presence of danger, as well as feeling detached or emotionally numb. Other symptoms of PTSD are substance abuse and suicidal thoughts. When it comes to treatment, roughly 60% of those suffering from PTSD seek treatment, but 42% of those are only receiving minimally adequate treatment. There is a variety or treatments available for individuals with PTSD, some are better than others, and unfortunately the better ones are not as easily accessible to everyone. This could be one of the reasons some choose to self-medicate and in-turn develop a comorbid substance use disorder.
Psychotherapy and medication are two common treatments used to manage and treat PTSD. Cognitive Behavioral Therapy (CBT) is the most effective and well-supported psychotherapy used to treat PTSD. It consists of the therapist and the individual working together to understand and modify certain thoughts they may have about the trauma which cause them to experience those negative symptoms discussed previously. For example, if a woman with PTSD was having thoughts of guilt due to a sexually violent trauma she experienced, cognitive therapy would help her understand that the event was not her fault, as well as helping her deal with any anxiety or anger caused by the trauma. CBT is made up of several different approaches for treating certain disorders, and differing approaches are used with children, adults, and depending on the type of trauma. Some common names include prolonged exposure (PE) therapy, cognitive processing therapy (CPT), and trauma-focused CBT (TF-CBT). These approaches use techniques such as cognitive restructuring, exposure therapy, and stress inoculation training. Most CBT methods are short-term and last anywhere from 8-12 sessions, meeting about once or twice a week.
Cognitive restructuring consists of the individual learning to recognize and dispute maladaptive thoughts. The first step of cognitive restructuring is to identify the emotion-causing thought. When an individual is feeling a negative emotion they should recognize the thoughts causing those emotions. The second step is identifying and modifying those thoughts. They should recognize if the thought contains any cognitive distortions, evaluate whether or not that thought is constructive or accurate, then try to correctly modify those thoughts.
Exposure therapy involves exposing the individual to the feared object or situation. The first step of exposure therapy is to create a fear hierarchy. This consists of an individual breaking down their fear or anxiety into more controllable stages, listing them from least anxiety provoking to most anxiety provoking. After creating the hierarchy, each stage should be confronted. These will be difficult for the individual but should not feel unbearable. Exposure therapy works by making the individual face the stressful stimuli they were avoiding. Continual exposure to those thoughts, feelings, or situations decrease the control the stimuli have on the anxiety that individual may feel.
Stress inoculation training (SIT) is a form of cognitive restructuring and it consists of teaching the individual how to control or deal with their emotional responses. There are three stages to SIT; those stages are conceptualization, skill acquisition and rehearsal, and application and follow-through. In the conceptualization stage, the therapist assists the individual to recognize their stressors, how they have been responding, and whether or not those responses have been successful. In the skill acquisition and rehearsal stage, the therapist assists the individual to build and perform positive coping statements when they encounter a stressful situation. In the application and follow-through stage, the therapist is less involved in the process and provides more training if needed, while the individual applies the skills they learned to difficult situations they may encounter.
While there are many other types of therapy offered that purport to treat PTSD, many are pseudoscientific and should be avoided. These include critical incident stress management, eye movement desensitization and retraining, emotional freedom technique, and thought field therapy.
The medications most often used are antidepressants such as Sertraline (Zoloft) or Paroxetine (Paxil). These are used to help control PTSD symptoms of anger, emotional numbness, or worry, as well as treating depression. These medications can cause side effects such as dizziness, sleeplessness, headaches, agitation, or sexual problems in both males and females. Benzodiazepines are also used by individuals with PTSD to help them relax or sleep. However, benzodiazepines can cause weight gain and are highly addictive.
Because the symptoms of PTSD can be extremely difficult to cope with, many individuals turn to self-medication for treatment, creating a dual diagnosis of PTSD and substance use disorder. Over 30% of individuals with PTSD have drug dependence, and 50% have alcohol dependence. Many individuals with PTSD feel a tremendous amount of guilt caused by the trauma. Those feelings may be exacerbated due to their addictive behavior which consequently lowers the likelihood of them seeking treatment. Self-medication is a negative coping strategy which only worsens the symptoms of PTSD and damages other aspects on that individual’s life.
Being aware of the high comorbidity rate between PTSD and substance abuse is an important factor for all medical professionals to be aware of when considering which treatment options will have the most successful and effective outcome. Increasing education within the public would possibly reduce the stigma some individuals have regarding PTSD or all mental disorders, making those who do have a mental disorder feel more comfortable about seeking proper treatment.
(If you are a treatment provider and want to learn more about the evidence-based treatment of PTSD, a wonderful resource is the Medical University of South Carolina, which provides training online in both CPT and TF-CBT.)
