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Monday, September 1, 2014

How Do We Treat PTSD?

6:51 AM Posted by Tiffany Taft , ,
A few weeks ago, we had a guest post from Jessica Naftaly on post-traumatic stress disorder (PTSD) in people living with chronic medical illnesses.  If you haven't read it, go check it out.  I wanted to follow up on that post with some information on what we can do to help someone experiencing PTSD.  We've come a long way in the psychology world in this area, thankfully, and there are some really good treatments available.


PTSD isn't a new phenomenon. In fact, I'd venture to guess PTSD has been around as long as people have been around, just called different things and, frankly, poorly understood.  In the U.S. we can go back to World War I for the first real efforts to start to understand and treat PTSD, or "Shell Shock" as it was known then.  The military spearheaded how to identify people who were more susceptible to shell shock with the help of psychologists and psychiatrists, however the treatments remained poor.  Over time, and unfortunately with more wars, our understanding of PTSD evolved as more veterans suffered for years, even decades, with its symptoms.

I did my year-long internship at a large Veteran's Administration (VA) hospital in Chicago so I saw a lot of people with PTSD.  I remember meeting a group of veterans from the Vietnam War for the first time, and all of them had pretty active PTSD symptoms.  At first I thought to myself "well Vietnam wasn't that long ago (this was 2008)."  Then I did the math and realized we were talking about 40 years of PTSD.  Unfortunately, we had failed these men.  And it took these failures to really push PTSD treatments to where they are today.

So, how do we treat PTSD today?  There are 3 main approaches that are supported by research and evidence that I'll talk about.

Thanks to pioneering research by Dr. Edna Foa, we understand that the key to treating PTSD is exposure to the trauma, which allows our brains to reprocess what happened to us.  Dr. Foa worked with rape survivors and developed something called Prolonged Exposure Therapy (more below), and was named by Time Magazine as one of the 100 most influential people in the world in 2010. For someone living with PTSD, they go to great lengths to avoid thinking about what happened because, well it's so friggin' painful and scary.  So, yes, what I'm saying is the treatment for PTSD is to make you think about it.  A lot.

No, I'm not a sadist.  I promise.

The way I explain traumatic memories to clients with PTSD is this:  Your whole life is written in your brain like a storybook.  There's a narrative there that makes sense, full of all sorts of plots and timelines, happy memories, sad memories, boring memories.  It flows and makes sense.  When a major trauma happens, sometimes that event (or, often times in chronic illness, series of events) is so horrible that the pages get removed from the storybook.  Our brain stores it differently so that it doesn't fit neatly in with the rest of the book.  The symptoms of PTSD, like nightmares and flashbacks, are our brain's attempt to put those pages back where they belong but they fail to do so.

This is why we have to retell the story, in a controlled way, so the pages can get put back.  You will learn that you do not have to be afraid of your memories.  The first 2 treatments below do this.
  1. Cognitive Processing Therapy (CPT):  CPT works by giving you a new way to handle the distressing thoughts that come with PTSD, and to gain an understanding of these events. CPT helps you learn how going through a trauma changed the way you look at the world, yourself, and others. The way we think and look at things directly affects how we feel and act.  The goals of CPT are to learn about your specific PTSD symptoms, become aware of your thoughts and feelings related to the trauma and how they affect you today, learn skills to change your thoughts and calm yourself when you're feeling really emotional, and evaluate your beliefs about safety, trust, control, self-esteem, other people, and relationships which often change after trauma.  The treatment involves meeting with a therapist trained in CPT and doing several writing exercises on your own that you'll bring to your sessions.  These writing exercises include writing, in detail, about your trauma.
  2. Prolonged Exposure Therapy (PET): PET works in a very similar way to CPT by helping you approach trauma-related thoughts, feelings, and situations that you have been avoiding due to the distress they cause. Repeated exposure to these thoughts, feelings, and situations helps reduce the power they have to cause distress.  It also has four main parts:  education about PTSD and the treatment, breathing exercises that help you relax, placing yourself in real-world situations that are safe, but which you may have been avoiding because they are related to the trauma, to help your trauma-related distress go down over time, and talking about your trauma memory over and over with your therapist to help you get more control of your thoughts and feelings about the trauma.
  3. Medication: Unfortunately, there aren't many medications that work well for PTSD so, in my opinion, they should be used sparingly and appropriately.  The current evidence base is strongest for the selective serotonin reuptake inhibitors (SSRIs), and currently only sertraline (Zoloft) and paroxetine (Paxil) are approved by the Food and Drug Administration (FDA) for PTSD. All other medication uses are off label, though there are differing levels of evidence supporting their use.  More details can be read here.
These treatments are effective for most people, but they're difficult.  People tend to drop out because they're being asked to face memories that they've done their best to avoid for months or years, and that's just overwhelming.  But if a person can stick with it, the benefits can be incredible and give them their life back.  

It's critical if you're living with PTSD and are considering these treatments that you find a therapist who is trained in them.  You really shouldn't try to do them on your own, either.  There are other treatments out there for PTSD, but their effectiveness remains unclear.  CPT and PET have the most research and data from real-world use as of today.  New treatments that involve virtual reality and neurofeedback are being investigated and may offer a new level of PTSD treatment in the near future.

More great information can be found at the National Center for PTSD.

Best,
Dr. T