Post-Traumatic Stress Disorder

Successful Treatment with Prolonged Exposure Therapy

Post-Traumatic Stress Disorder (PTSD) is a trauma-related disorder caused by exposure to an event involving actual or threatened death, serious injury or sexual violence. These events may include—but are not limited to—acts of violence, combat situations, witnessing domestic violence, natural disasters, car accidents, or stress related to acts of racism. PTSD may develop in individuals who have these experiences or witness others having them. The disorder may also arise in individuals who learn of a traumatic event occurring to a family member or other loved one. Individuals who experience repeated or extreme details of traumatic events in the course of their jobs—such as first responders—are also at increased risk of developing PTSD.

In the aftermath of a traumatic event, people often suffer symptoms such as intrusive memories of the experience, negative emotional states, and anxious arousal. For most people, these symptoms naturally run their course and resolve on their own. Others, however, do not recover naturally and struggle to come to terms with the event. What sets PTSD apart from normal post-traumatic stress is the prolonged duration of symptoms. If a trauma is sufficiently intense, or if a person experiences trauma repeatedly, the symptoms of PTSD are considered to be normal responses.

The symptoms of PTSD fall within four categories:

Reliving the Trauma:

  • Bad dreams
  • Frightening thoughts
  • Intrusive memories of the trauma
  • Flashbacks — reliving the trauma as if it is happening again
  • Intense distress when reminded of the event

Avoidance Symptoms:

  • Staying away from places, events, or objects that are reminders of the experience
  • Efforts to avoid memories, thoughts, or feelings associated with the event
  • Avoidance of external reminders that arouse distressing emotions associated with the trauma

Negative Mood and Cognitions:

  • Feeling emotionally numb
  • Feeling strong guilt, depression, or worry
  • Distorted sense of blame about the event
  • Losing interest in activities that were enjoyable in the past
  • Having trouble remembering the dangerous event
  • Exaggerated negative beliefs about self, others, or the world
  • Social detachment or estrangement from others
  • Inability to feel positive emotions
  • Persistent negative emotions

Hyperarousal Symptoms:

  • Being easily startled
  • Feeling tense or "on edge"
  • Having difficulty sleeping
  • Angry outbursts
  • Physical symptoms of anxiety, like a racing heart or sweating
  • Reckless or self-destructive behavior
  • Poor concentration

Research has validated two primary methods of treatment that lead to major improvements in patients suffering from PTSD: Prolonged Exposure and Cognitive Processing Therapy.

What is Prolonged Exposure?

Prolonged Exposure (PE) is a treatment developed by Dr. Edna Foa and colleagues at the University of Pennsylvania that helps the individual overcome their anxiety and avoidance head on. PE has four elements:

  1. Education on the therapy: The patient is educated on common trauma reactions and PTSD. This process helps them understand their symptoms and the overall goals of their treatment.
  2. Breathing techniques: Often when trauma occurs or someone with PTSD is reliving the trauma, their breathing pattern and speed changes. Learning to control the way their breathing can help people mitigate the immediate stress, lessening its impact.
  3. Real-world application: In many cases, PTSD sufferers will avoid doing things that may be linked to their trauma, for example someone who served overseas and had their convoy bombed may not want to drive, or someone who has experienced sexual assault may avoid any situation that could provide intimacy with another person. Real world therapy helps them to confront the anxiety in a safe way that has no risk of further trauma. Over time this helps reduce the stress and helps them regain control.
  4. Talking through the trauma: This part of the process is talking about the trauma over and over with a therapist, which helps the person with PTSD gain control over the thoughts and feelings associated with the event. This has been the show to reduce stress and eliminate the fear of the memories of the traumatic event.

What is Cognitive Processing Therapy?

Cognitive Processing Therapy (CPT) is a treatment developed by Dr. Patricia Resick and colleagues at the University of Missouri–St. Louis that addresses how traumatic experiences disrupt and distort people’s beliefs about themselves, other people, the world. CPT focuses on beliefs formed or confirmed by the trauma more than on the details of the trauma itself; a recounting of the event may be included as part of the treatment but is not required for it be effective. CPT emphasizes the person’s thoughts about the causes and consequences of the trauma, and how these in turn shape emotions and behaviors. CPT has the following features:

  1. Education on the therapy: The patient is educated on PTSD and how traumatic experiences often affect people. This process helps them understand both their symptoms and the treatment itself.
  2. Identifying and challenging distorted beliefs: People with PTSD often attempt to make sense of the events by altering their beliefs about what happened; other times, they change their beliefs about themselves and the world. Many do both. These “stuck points” often generalize to other situations not related to the original trauma and may be rooted in pre-trauma experiences. Patients learn to separate thoughts from emotions and to see how beliefs shape and determine feelings and behavior. Distorted beliefs, by nature, lead to distorted emotions and unhelpful behaviors.
  3. Cognitive restructuring: CPT involves daily practice identifying stuck points relating to both the original trauma and current stressful experiences, then developing more helpful, balanced beliefs about these events. Patients learn to observe and challenge their own distorted thoughts, as well as identify and resist the unhelpful mental shortcuts that sustain PTSD symptoms. Developing a balanced view of self, others, and the original trauma fosters more positive emotions and effective behaviors.
  4. Five core themes: The final stage of CPT focuses on a series of themes of negative beliefs that were either formed following the trauma or were seemingly confirmed by the event: Safety, Trust, Power/Control, Esteem, and Intimacy. One by one, patients work through these five modules, apply the skills they have acquired to develop more effective ways of relating to themselves and others.

Who is Affected by PTSD?

Anyone that experiences a traumatic event in their life can suffer from PTSD, men, women, Black, Hispanic, White are all affected by PTSD. Women however are more likely to get PTSD with studies showing that 20 percent of women may suffer PTSD in their lifetime. Compared to men at eight percent, there is a large difference. 60 percent of American adults will suffer some form of trauma over the course of their life. One reason that women are considered higher risk for PTSD is they at higher risk of suffering some form of sexual assault over their lifetime then men, one of the traumatic events that can trigger PTSD.

Does Prolonged Exposure Therapy Work?

Simple answer: Yes. PE and CPT have been shown to be the most effective treatments for PTSD, over medication and other forms of therapy. One of the advantages of these treatments is they can be adapted to an individual's therapy needs and can instill confidence in the sufferer they can again mastery over their PTSD. PE has been shown to improve 80% of PTSD patients who have suffered any number of traumas, including combat, sexual assault, accidents, natural disasters, and child abuse, among others. PE and CPT are both short-term, time-limited treatments, with most people showing improvement or recovery after just 10-12 sessions.

PE and CPT have been developed, studied and modified for decades. The U.S. Department of Veterans Affairs has adopted them as its primary interventions to help soldiers returning from combat and those who have been victims of military sexual trauma, an increasing need as those returning from service re-integrate into society. This can be an especially difficult process for men and women who have spent months—even years—in the high-intensity situations that occur during combat. Both PE and CPT are considered the gold-standard treatments for PTSD.

References

Keane, T.M. (1998). Psychological and behavioral treatment of post-traumatic stress disorder. In P. Nathan & J. Gorman (Eds.), A guide to treatments that work (pp. 398-407). Oxford: Oxford University Press.

Foa, E.B., & Meadows, E.A. (1997). Psychosocial treatments for post-traumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480.

What about EMDR?

EMDR stands for eye movement desensitization and reprocessing therapy. EMDR employs side-to-side eye movements while asking the client to visually track the therapist’s finger across the visual field. While this is happening, the client reports the nature and emotional consequences of a traumatic experience. The client is also asked to generate a more positive appraisal about the trauma and their experience with it. Healing is said to occur after eye movements unlock the pathological condition (Shapiro, 1995).

EMDR certification is widespread across many therapists, and yet research support of its effectiveness has received considerable scrutiny. It is considered by many clinicians who are trained in evidence-based treatments for PTSD to be a novel, or pseudo treatment, aimed at appealing to a potential client’s interest as something new and different (Lohr, Hooke, Gist, & Tolin, 2003). Several independent studies have shown that eye movements, alternative stimulation, or cognitive reprocessing (all components of EMDR) are not necessary components of treatment (Boudewyns & Hyer, 1996; Boudewyns, Stwertka, Hyer, Albrecht & Sperr, 1993; Devilly, Spence & Rapee, 1998; Renfrey & Spates, 1994;. Instead, any measurable change following EMDR is most likely a function of imagery exposure, which is a major component of prolonged exposure therapy (Muris & Merckelbach, 1997).

The above-mentioned research findings form the basis for why BWC does not provide EMDR to our clients. Rather than unnecessarily subject our clients to a sequence of interventions that have been shown to be inefficacious, we commit to provide only the most effective treatment approaches of PTSD at BWC.

References

Boudewyns, P.A., & Hyer, L.A. (1996). Eye movement desensitization and reprocessing (EMDR) as a treatment for post-traumatic stress disorder. Clinical Psychology and Psychotherapy, 3, 185-195.

Boudewyns, P.A., Stwertka, S.A., Hyer, L.A., Albrecht, J.W., & Sperr, E.V. (1993). Eye movement desensitization for PTSD of combat: A treatment outcome pilot study. Behavior Therapist, 16, 29-33.

Devilly, G.J., Spence, S., & Rapee, R. (1998). Statistical and reliable change with eye movement desensitization and reprocessing: Treating trauma within a veteran population. Behavior Therapy, 26, 435-455.

Lohr, J.M., Hooke, W., Gist, R., & Tolin, D.F. (2003). Novel and controversial treatments for trauma-related stress disorders. In S.O. Lillienfeld, S.J. Lynn, & J.M. Lohr (Eds.), Science and Pseudoscience in Clinical Psychology (pp.243-272), New York: Guilford Press.

Muris, P., & Merckelbach, H. (1997). Treating spider phobics with eye movement desensitization and reprocessing: A controlled study. Behavioural and Cognitive Psychotherapy, 25, 39-50.

Renfrey, G., & Spates, C. (1994). Eye movement desensitization: A partial dismantling study. Journal of Behavior Therapy and Experimental Psychiatry, 25, 231-239.

Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.

How Do You Find Out if You Have PTSD?

If someone is really concerned about trauma and its ongoing effects, they should find a properly trained therapist for a through a proper evaluation and diagnosis. Contact us to establish a treatment plan to help deal with PTSD.

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Behavioral Wellness Clinic
912 Lily Creek Road
Suite 201
Louisville, KY 40243

Office: (502) 338-0608
OCD Clinic: (502) 403-7818
Fax: (502) 245-1888
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Clinical Director: Cheri Levinson, PhD
Office Manager: Jasmine Fairfax