At this point we have covered a lot of information about PTSD to include an introduction, epidemiology/pathogenesis, clinical pearls, and tips on the mental status exam. Now we will move on to the treatment of PTSD, starting with non-pharmacological interventions. Today we will discuss a number of evidence-based psychotherapies in the treatment of PTSD.
If you are new to psychotherapy and need an introduction then check out the following posts: Day #28 and #29.
Today's Content Level: Intermediate
INTRODUCTION
The VA and Department of Defense (DoD) collaboratively develops unbiased evidence-based clinical practice guidelines (CPGs) on a number of topics. I have found their CPG for PTSD to be particularly helpful, and it will be heavily referenced in today's post.
STRONG recommendations:
Use trauma-focused psychotherapy as first-line treatment for PTSD.
Strong evidence for therapies that have a primary component of exposure and/or cognitive restructuring. See "what is trauma-focused therapy" section below.
Trauma-focused therapy is recommended over other pharmacological and non-pharmacologic interventions for the primary treatment of PTSD.
When trauma-focused psychotherapy is not available or not preferred by the patient, then medications or non-trauma focused psychotherapy is recommended (see day #109 for medication management of PTSD).
NICE guidelines advise that treatment should be 12 sessions of trauma‐focused CBT for PTSD resulting from a single event (longer for chronic or recurrent events) and discourage routine prescription of medications.
WEAK recommendations:
Weak evidence for the following non-trauma focused therapies for treatment of PTSD: Stress Inoculation Training (SIT), Present-Centered Therapy (PCT), and Interpersonal Psychotherapy (IPT)
INSUFFICIENT data:
There is insufficient evidence to recommend for OR against Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Seeking Safety, and supportive therapy.
What is trauma focused therapy?
Trauma-focused psychotherapy is often a specialized form of cognitive behavioral therapy (CBT).
It is any therapy that uses cognitive, emotional, or behavioral techniques to facilitate processing a traumatic experience and in which the trauma focus is a central component of the therapeutic process.
Common elements include: education; cognitive interventions to challenge the constant fear of danger; imaginal exposure (narrating the trauma, processing the emotional response, and learning to feel safe); desensitization; relaxation techniques.
The trauma-focused therapies with the strongest evidence from clinical trials include:
Prolonged Exposure (PE)
Cognitive Processing Therapy (CPT)
Eye Movement Desensitization and Reprocessing (EMDR)
Other protocols with sufficient evidence to recommend include:
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Narrative Exposure Therapy (NET)
Written Exposure Therapy (WET)
Brief Eclectic Psychotherapy (BEP)
There are also other psychotherapies that meet the definition of trauma-focused treatment for which there is currently insufficient evidence to recommend for or against their use.
Other modalities sometimes used (not trauma-focused) include supportive therapy, psychodynamic therapy, and couples/family therapy.
TRAUMA-FOCUSED THERAPIES
Prolonged Exposure (PE) 3
Developed by Edna B Foa, Ph.D.
Typically 8-15 sessions.
Most individuals with PTSD use avoidance behaviors in an attempt to minimize distressful reminders of their trauma, even when those reminders are not inherently dangerous, and in doing so they reinforce their fear.
Exposure-based therapies focus on confronting the harmless triggers in order to disrupt the link between trauma-cues and emotional disturbance.
Core components of PE therapy include:
Imaginal exposure: recount the traumatic experience out loud and process the revisiting experience. This process will be repeated throughout treatment.
In vivo exposure: gradually and repeatedly confront situations, places, and objects that are reminders of the trauma that cause distress but are not inherently dangerous.
Also includes processing of the trauma memory +/- breathing retraining.
Developed by Patricia Resick, Ph.D.
Typically 12 sessions.
CPT is a modified form of CBT in which thoughts, feelings, and meanings of the traumatic event are revisited and questioned. In time CPT aims to understand and change distorted beliefs they have about themselves and the traumatic event.
A unique aspect of CPT is it may or may not involve discussing the details of the traumatic incident. CPT-C = no written trauma account. CPT-A = includes written trauma account.
Core components of CPT include:
Psychoeducation: education regarding PTSD, thoughts, emotions, and the cognitive theory of PTSD development and maintenance. A specific focus is on teaching the patient to identify automatic thoughts and maladaptive beliefs ("stuck points") that interfere with recovery.
Formal processing of the trauma: patients discuss their traumatic experiences in order to clarify and modify maladaptive beliefs. Patients may write a detailed account of their worst traumatic experience and then read it to the therapist in session (CPT-A). Alternatively, it can be done almost entirely on socratic dialogue without the use of written accounts (CPT-C) and this has been found to be equally effective. Important goals during this phase include increasing acceptance and decreasing guilt and self-blame.
Develop cognitive skills: help the patient learn and reinforce skills they learned during treatment to include the cognitive skills necessary to identify, evaluate, and realistically modify their beliefs about the traumatic event. There is a focus on beliefs around safety, trust, power/control, self-esteem, and intimacy.
Integration and consolidation
Narrative Exposure Therapy (NET)
Typically 4-10 sessions
Similar to prolonged exposure, however simpler to implement and takes a life narrative approach rather than focusing on a single traumatic event.
It has been most frequently used in community settings and with individuals who experienced trauma as result of political, cultural or social forces (such as refugees).
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) 6
TF-CBT is most effective for children and adolescents and is often seen as the standard of care in this population.
Typically 12-15 sessions (can go up to 25)
Used in the treatment of PTSD but also effective for other aspects of trauma to include neglect, depressive/anxiety symptoms, cognitive and behavioral problems, and increasing caregiver support.
Core components include:
Parental involvement (parents receive as much time in the treatment as children)
Psychoeducation
Skill development (relaxation; affect modulation; cognitive processing)
Trauma narrative and processing
Integration and consolidation
Written Exposure Therapy (WET) 7
WET developed by Brian P. Marx, Ph.D and Denise M. Sloan, Ph.D.
The protocol is only 5 sessions, but may add additional sessions if needed.
CPT and PE are effective but the main limitation is a high dropout rate.
WET is not really a new treatment, but rather a treatment approach (imaginal exposure) that is repackaged to be efficient and tolerable.
Core components include:
Psychoeducation: education regarding PTSD, thoughts, emotions, the harms of avoidance, and the treatment rationale.
Imaginal exposure: patients write for 30 minutes about the details of the traumatic experience during the session. This includes details of the events and the thoughts and emotions they experienced. The therapist collects the written account at the end of the session and reads it prior to the next session.
Feedback: the therapist provides feedback about the written narrative including positive feedback and what can be improved. For example the patient may have done a good job detailing the events of the trauma but avoided writing about the emotions and thoughts they experienced.
Developed by Francine Shapiro, Ph.D.
Typically 6-12 sessions
EMDR involves recalling distressing images while the therapist directs the patient in one type of bilateral stimulation such as side-to-side rapid eye movement or hand tapping. The goal is to mindfully decrease the threat-response with directed eye movement.
There are many theories on why this is effective, but it is still not fully understood. The latest research on the eye movements show that they are simply providing a point of focus in the room which creates a dual awareness when processing difficult memories (can help ground the patient and keep the affect in a safe range).
It is, however, a robust trauma focused therapy that involves imaginal exposure (visualization and oral narration), cognitive restructuring, imagery re-scripting, and affect regulation training.
Brief Eclectic Therapy (BEP) 10
Typically 16 sessions
BEP incorporates many elements found in TF-CBT, but also incorporates a psychodynamic approach with an emphasis on the emotions of shame and guilt and the relationship between patient and therapist. An important goal is to explore the meaning of the event.
Core components include:
Psychoeducation about PTSD
Imaginal exposure
Cognitive restructuring
Ritualistic farewell
Other psychotherapies are effective at treating specific symptoms of PTSD. These include:
Insomnia: Cognitive Behavioral Therapy for Insomnia (CBT-i). CBT-i is recommended for insomnia in patients with PTSD unless an underlying medical or environmental cause is identified or severe sleep deprivation warrants the immediate use of medication to prevent harm.
Nightmares: Image Rehearsal Therapy (IRT). IRT helps make nightmares less intense for people with PTSD. Involves creating detailed non-frightening endings for repetitive nightmares, rehearsing them, and monitoring their effectiveness.
Substance use: Co-ocurring substance use disorder (SUD) is common in PTSD and combination of trauma focused psychotherapy and therapy geared towards SUD is more effective than either alone.
CONCLUSION
Nice work today. I hope this was a helpful introduction to trauma-focused psychotherapies for PTSD. Next up will be a discussion of medication options in PTSD.
Resources used today include the articles linked in the body of the article as well as handbooks for Cognitive Processing Therapy for PTSD, Prolonged Exposure Therapy for PTSD, Written Exposure Therapy for PTSD, EMDR Handbook, and Pocket Psychiatry.
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