Psychotherapy

in

PostTraumaticStressDisorder

AinShams University Supervised by

Institute of Psychiatry Dr.Mahmood El-Habibi
 Psychotherapy of ASD & PTSD

Introduction

Post-traumatic Stress Disorder (PTSD):

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying

event (war, natural disasters, violent attacks such as a mugging, rape).

The definition of a traumatic stressor is problematic. According to the DSM-IV classification,

for a diagnosis of post traumatic stress disorder, the traumatic event must be one in which
both of the following are present:

1) The person experienced, witnessed or was confronted with an event or events that
involved actual or threatened death or serious injury, or threat to the physical integrity
of self or others.
2) the person’s response involved intense fear, helplessness or horror.

Clinical picture:

 History of stressful event, intrusive symptoms, memories, flashbacks and nightmares.

 Avoidance symptoms: avoidance of thoughts, activities, situations and place of the
trauma.
 Symptoms of autonomic arousal: Insomnia (initial or interval), Irritability Poor
concentration, hyper vigilance, increased startle response.
 Symptoms of anxiety and/or depression.
 Drug abuse commonly associated with this condition. Significant functional
impairment.

Differential diagnosis:
 Depression
 Generalized anxiety disorder
 Unexplained somatic complaints.

N.B: At first the victim may be presented by "Emotional numbness" which is a shock response
which is often misinterpreted as if the victim controlled the effects of the assault. This is only a
temporary defense response.

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 Psychotherapy of ASD & PTSD

Psychotherapy:

 In general:

Psychotherapy or personal counseling with a psychotherapist is an intentional interpersonal

relationship used by trained psychotherapists to aid a client or patient in problems of living.

 Steadman's Medical Dictionary defines psychotherapy as:

Treatment of emotional, behavioral, personality, and psychiatric disorders based primarily

upon verbal or non verbal communication with the patient, in contrast to treatments utilizing
chemical and physical measures.

 And it defines counseling as:

A professional relationship and activity in which one person endeavors to help another to
understand and to solve his or her adjustment problems; the giving of advice, opinion, and
instruction to direct the judgment or conduct of another.

Psychotherapy aims to increase the individual's sense of their own well-being. Psychotherapists
employ a range of techniques based on experiential relationship building, dialogue, communication
and behavior change and that are designed to improve the mental health of a client or patient, or to
improve group relationships (such as in a family).

Psychotherapy may also be performed by practitioners with a number of different qualifications,

including psychiatrists, marriage and family therapists, occupational therapists, licensed clinical
social workers, counselors, psychiatric nurses, psychoanalysts and psychologists. Indeed,
psychotherapy can be a profession in its own right.

 Common Types of Psychotherapy:

 Behavior Therapy
 Cognitive Therapy
 Family Therapy
 Group Therapy
 Interpersonal Therapy
 Psychodynamic Therapy

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Psycho-therapeutic interventions in
post traumatic stress disorder (PTSD)

 Special considerations:

 The nature, duration, intensity and meaning of an individual’s experiences of trauma

vary greatly. There is no simple cause and effect relationship between the event and
subsequent psychological symptoms.
 If a group of people witness any given event, each person’s experience of that event
will be unique and probably very different from that of other members of the group.
 A significant difficulty in accurately assessing trauma responses arises out of the
overlap between symptoms of trauma per se and of those of other disorders. For
example, problems with concentration and sleep need careful, differential diagnosis
to be distinguished from symptoms of anxiety and depression not directly connected
to a traumatic experience. Diagnosis is further compounded when trauma-related
symptoms occur simultaneously with other psychiatric disorders.
 In recent years there has been increasing evidence about the effectiveness of certain
psychological and pharmacological treatments for post traumatic stress disorder.
Irrespective of the treatment chosen, the therapist should first form and maintain a
therapeutic alliance, special attention being given to issues of trust and safety.
 There should be concern for the patient’s physical safety, and education and
reassurance regarding the individual’s psychological symptoms should be provided.
 The patient’s symptoms and general functioning should be monitored over time and
the issue of co-morbidity addressed. It may be important to involve other health
professionals and the patient’s family members and trusted friends. Treatment may
have to continue for a considerable period of time and be flexible in response to the
often fluctuating course of symptoms and the individual’s reaction to other life
stresses that may occur, e.g. inquests, anniversary reactions, bereavements, medical
retirement, unemployment etc.
 A comprehensive management plan may involve a combination of psychological
therapy, pharmacotherapy, and social interventions, particularly in those individuals
whose condition is chronic. When complete recovery may be an unrealistic goal,
rehabilitation can lead to a significant improvement in quality of life. Treatment plans
should be individually tailored as no therapy has a documented successful outcome in
all cases of post traumatic stress disorder.
 Psychological treatment interventions should be grounded in an appropriate
psychological model applied to the individual’s needs. It is important to acknowledge
that some trauma survivors may experience difficulty tolerating the high anxiety and
temporary increase in symptoms; therefore, care should be taken in the use of
exposure based therapies.

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 Early Intervention
 Initial anxiety and distress is very common after a traumatic incident and should not
be viewed as pathological. The majority of those exposed to traumatic stressors copes
with the support of family and friends and do not develop a clinically significant illness.
Therefore, in the first instance, support for those involved in traumatic incidents and
their friends or relatives should be along practical lines. Crisis Support Teams are
available and each Board has set up a Trauma Advisory Panel to develop a support
network.
 At present there is no good evidence to support the use of routine medications in the
early aftermath of trauma but clinical expediency may mean that targeting specific
symptoms if they are very disturbing or troublesome, such as agitation, marked
arousal or severe sleep disturbance may be necessary.

 Management & Treatment of an established Case

In this search we will focus only in the psychotherapy part of the management.

Psychotherapeutic interventions:

 Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing
(EMDR) have been clearly shown to be effective in treating post traumatic stress disorder,
the exposure and cognitive restructuring elements of treatment probably being the most
important.
 Supportive group therapy, psychodynamic group therapy and cognitive behavioral group
therapy have all proved promising in research.
 The specific indications and contraindications for group therapy are similar to those with
regard to group therapy for other anxiety based conditions. Of particular importance is that
individuals have shared similar traumatic experiences and that due consideration is given to
gender, sexual orientation, ethnicity, culture and religion.

Treatment duration:
 Within the overall course of treatment, 8–12 sessions of trauma-focused treatment are
generally needed but more may be required for more severe or complex cases.
 Ninety minutes should be allowed for sessions that involve imaginal exposure.
 Further sessions may be required where PTSD is chronic and associated with
significant disability and co morbidity.

Refined cognitive-behavioral model

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I- Cognitive and behavioral therapies (the most effective treatment in PTSD):

 Cognitive behavior therapy in ASD or PTSD targets the distorted threat appraisal
process (in some instances through repeated exposure and in others through
techniques focusing on information processing without repeated exposure) in an
effort to desensitize the patient to trauma related triggers by Identifying, challenging
and modifying biased or distorted thoughts and interpretations about the event and
its meaning.
 A course of cognitive behavior therapy generally begins with education about the
symptoms of the disorder, as well as a rationale for asking the patient to recall painful
experiences and relaxation training. After the therapist assesses the patient’s ability
to tolerate within-session anxiety and temporary exacerbations of symptoms, the
patient is led through a series of sessions in which the traumatic event and its
aftermath are imagined and described, and the patient is asked to focus on the
negative affect and arousal until they subside. Reassurance and relaxation exercises
aid the patient
 A limited number of well-designed studies demonstrate some success not only in
speeding recovery but also in preventing PTSD when cognitive behavior therapy is
given over a few sessions beginning 2–3 weeks after trauma exposure. Both stress
inoculation and prolonged exposure techniques have demonstrated efficacy in
women with PTSD resulting from assault or rape.
 However, several studies have noted that exposure may increase rather than decrease
symptoms in some individuals.

II- Eye movement desensitization and reprocessing (EMDR)

 EMDR is a form of psychotherapy that includes an exposure-based therapy (with

multiple brief, interrupted exposures to traumatic material), eye movement, and recall
and verbalization of traumatic memories of an event or events. It therefore combines
multiple theoretical perspectives and techniques, including cognitive behavior
therapy.
 Some point to the use of directed eye movements as a feature markedly
distinguishing this form of therapy from other cognitive behavior approaches. Others
point to the fact that traumatic material need not be verbalized; instead, patients are
directed to think about their traumatic experiences without having to discuss them.
 Like many of the studies of other cognitive behavior and exposure therapies, most of
the well-designed EMDR studies have been small, but several meta-analyses have
demonstrated efficacy similar to that of other forms of cognitive and behavior
therapy.

III- Psychological debriefing

 Psychological debriefing was developed as an intervention aimed at preventing the

development of the negative emotional sequelae of traumatic events, including ASD
and PTSD. This staged, semistructured group (or, as often administered, individual)
interview and educational process includes education about trauma experiences in

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general and about the chronological facts of the recently experienced traumatic event
and exploration of the emotions associated with the event.
 Since debriefing has received considerable publicity, it may be expected (or
specifically requested) by leaders or managers when a group confronts disaster. In the
military, for example, group debriefings have been used as a means for describing
normative responses to trauma exposures and educating individuals about pursuing
further assistance if symptoms persist or cause significant dysfunction or distress.
 Although some trauma survivors have reported that they experienced such
debriefings as helpful, there is no evidence at present that establishes psychological
debriefing as effective in preventing PTSD or improving social and occupational
functioning. In some settings, it has been shown to increase symptoms.

IV- Group therapy: they provide an efficient means of delivering treatment, normalize individuals’
experiences, and create a supportive environment. But not enough evidence.

V- Psychotherapy and support

 Clinical experience indicates that both support and psycho-education appear to be

helpful as early interventions to reduce the psychological sequelae of exposure to
mass violence or disaster. When access to expert care is limited by environmental
conditions or reduced availability of medical resources, rapid dissemination of
educational materials may help many persons to deal effectively with sub-syndromal
manifestations of trauma exposure.
 Such educational materials often focus on :
1. The expected physiological and emotional response to traumatic events.
2. Strategies for decreasing secondary or continuous exposure to the traumatic
event.
3. Stress-reduction techniques such as breathing exercises and physical exercise.
4. The importance of remaining mentally active.
5. The need to concentrate on self-care tasks in the aftermath of trauma.
6. Recommendations for early referral if symptoms persist.
 Encouraging persons who are acutely traumatized to first rely on their inherent
strengths, their existing support networks, and their own judgment may reduce the
need for further intervention.

The Treatment of Chronic PTSD

 Some patients with chronic PTSD develop a severe disabling mental disorder which becomes
entrenched and damages personal, recreational and occupational relationships.
 Chronic PTSD is associated with a higher incidence of co-morbidity, The commencement of
psychotherapy and medication from the start is recommended, when a co-morbid psychiatric
disorder is present. For example, when PTSD presents co-morbidly with depression, an SSRI
should be considered with CBT. At present, CBT has the strongest evidence base of the
psychological therapies for efficacy in treating chronic
 One important limitation of exposure therapy is the capacity of patients to tolerate large
amounts of high affect associated with exposure treatment.

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SPECIFIC POPULATION S AND TRAUMA TYPES

Refugees and Asylum seekers

 Nature of the psychological trauma:

Refugees and asylum seekers are usually exposed to Extreme forms of violence that is repeated
or prolonged. They witness atrocities such as mass killings, children targeted violence, the violation
of sacred values, betrayal, and the weakness of restorative justice. They are confronted with
impossible choices, such as choosing who should die or who should be left behind and even basic
functions of eating, sleeping are closely controlled. This results in breakdown of families and
communities with erosion of personal integrity and severe psychological traumas.

 Special considerations:

a) The violence and traumatic events are repeated or prolonged.

b) They live under conditions of inescapability and unpredictability that maximize the
experience of helplessness.
c) Refugees need to be seen in a safe place which does not trigger traumatic memories
of overly-officious, authoritarian behavior.
d) Trust and rapport are very important several appointments may be needed for a
comprehensive assessment.
e) Practitioner is faced with a number of complex factors including language, ethno
cultural, socio-political and community issues. They need to aware of biases, values,
potential conflicts between traditional values and values of the dominant culture and
should be able to choose the appropriate approach.
f) Medical settings may act as reminders of torture.
g) Information should be provided and the person encouraged asking questions to
promote a sense of control.
h) Explanations of the meaning of confidentiality are helpful.
i) Intrusive investigative procedures may be frightening.
j) There are multiple Losses under violent circumstances with consequences such as
prolonged grief.

Terrorism

 Special considerations:
a) The first tasks in disaster management are to secure the scene, to triage, and to
evacuate victims to definitive care
b) Treating established PTSD has only a marginal effect and so practitioners should
intervene early so as to prevent, or at least minimize, psychological morbidity
following traumatic events (by limiting the establishment of maladaptive and
disruptive cognitive or behavioral patterns).

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Military and Emergency Service Personnel

 Nature of the trauma:

These victims are exposed to situations of considerable human suffering including witnessing
of death of a close friend during military operations or training accidents, separation from the
family or orders to kill other human beings in the course of their duties.
 Special considerations:
1. Individuals with a work-related disability are often placed in a difficult conflict about
seeking assistance because this can lead to significant discrimination and
disadvantage in the workplace
2. Treatment planning needs to take into consideration the multiplicity of traumatic
exposures that military and emergency service personnel have had to deal with and
the consequent multiple triggers or trauma reminders.( past exposures to traumatic
events or past PTSD may increase the likelihood of current PTSD from a new
exposure)
3. It was initially thought that peace keepers suffered low rates of exposure to traumatic
stressors, however a number of studies have indicated that peace keeping missions
may present a range of unique stressors than can have a significant psychological
impact on deployed persons.

Motor Vehicle Accident and other injury survivors

 Special considerations:
1. Development of PTSD doesn't depend on the severity of the physical injury.
2. Depression is very commonly co morbid with PTSD in injury survivors due to loss of
important roles, financial difficulties and uncertainty about the future.
3. Victims with traumatic brain injury (TBI) are less likely to develop PTSD (due to the
associated amnesia).

Sexual assaults

 Definition: Sexual assault is a criminal offense for a person to engage in sexual contact or
sexual intercourse with any other person without his/her consent.

 Nature or the trauma: The assault is an invasion of the victim's physical, intellectual, social
and emotional self. The experience of assault exposes the victim to the stark reality that they
cannot always protect themselves no matter how hard they try. Victims' previous
assumptions about themselves, their rights and the world lose their meaning

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 Special considerations:

1. Sexual assault is a unique crime in that it is most often carried out in private and
involves a victim who often has strong guilt sensations either due to feeling that they
reacted in a manner that caused the assault. Or that they brought shame to their
families by reporting the assault. (Caregivers must be careful that they do not
participate in increasing these feelings.)
2. Due to many cultural background factors, most victims are embarrassed and fearful of
reporting the assault (fear of the stigma). This silence increases the severity of
psychological injury.
3. The gender of the therapist can be especially important for survivors of sexual assault.
4. Sexual harassment: is a type of sexual assault and victims of severe or chronic sexual
harassment can suffer the same psychological effects as rape victims.
5. In children the majority of sexual abuse is perpetrated by a family member or person
known to the child. Usually children do not make a direct and detailed verbal report of
the abuse when they are admitted to the hospital. So the physician should be aware
and should have a great level of suspicion.
6. Each individual victim of sexual assault has his/her own perception and response to
the assault. e.g.: some patients despite having offenses that could be considered not
severe, they perceive it as very severe and so have a greater psychological arm and
vice versa.

Victims of Crimes
 Nature of the psychological trauma:
These victims have individually or collectively suffered from physical or mental or emotional
injury, economic loss or substantial impairment of their fundamental rights, through acts or
omissions that are in violation of criminal laws.

 Special considerations:
a) The practitioner should clarify with the person whether the interview is completely of
a therapeutic nature and not a part of forensic investigations.

b) Due to the nature of criminal compensation some people may perceive a vested
interest in maintaining symptomatology until all proceedings have completed. It is
advised that the therapist address this issue with the person before initiating
treatment.

c) Prolonged imaginal exposure to the event, when managed by a well trained therapist,
has demonstrated efficacy with victims of crime and should be administered,
sensitively, as a matter of course.

d) Treatment sessions should be recorded, where possible, so that any accusations of

tainted evidence arising during later litigation can be evaluated. Of course the
rationale for recording sessions should be carefully explained to the person and their
consent obtained before recording begins.

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Victims of Disasters

 Nature of the psychological trauma:

Disasters are very costly to victims—in terms of money, life disruption, loss of resources, loss of a
sense of community, and becoming homeless for a protracted period of time.

 Special considerations:
a) Large numbers of people will potentially require access to treatment over a
prolonged period of time. It is important that Treatment facilities are available to
these affected communities. This is a particular challenge in rural and remote
communities where there is often a paucity of appropriately trained practitioners.

b) Multiple members of the same family may be suffering simultaneously, possibly

impacting upon the pattern of symptomatic distress; for example, if both a husband
and wife are suffering. Treatment may need to address these relationship dimensions
because they can serve to influence the patterns of withdrawal and avoidance.

c) In cases where the individual with PTSD has suffered economic and social
disadvantage as a result of the disaster, the circumstances in which they find
themselves can serve as a constant reminder of their traumatic experience and thus
complicate the treatment.

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References:
(1) Stedman's Electronic Medical Dictionary,
New York:Williams and Wilkins Co, 1994.
(based on Stedman's Medical Dictionary,
1990.
(2) Wolberg, Lewis R. (1977) The Technique
of Psychotherapy. New York: Grune &
Stratton, 1977, p3
(3) http://mentalhealth.about.com/cs/psycho
therapy/a/psychotherapy.htm
(4) Professor Robin Davidson Consultant
Clinical Psychologist, Belvoir Park Hospital
& Dr Anne Montgomery Consultant
Psychiatrist, Mater Infirmorum Hospital;
The Management of Post Traumatic
Stress Disorder In Adults, June 2003.
(5) Robert J. Ursano, M.D., Chair; Practice
Guideline For The Treatment of Patients
With ASD and PTSD
(6) Acute Stress Disorder and Posttraumatic
Stress Disorder by the Australian center
of post traumatic mental health
(7) Forbes D, Creamer M, Phelps A, Bryant R,
McFarlane A, Devilly GJ, Matthews L,
Raphael B, Doran C, Merlin T, Newton
S.Australian Centre for Posttraumatic
Mental Health, West Heidelberg, Vic,
Australia. Australian guidelines for the
treatment of adults with acute stress
disorder and post-traumatic stress
disorder. Aust N Z J Psychiatry. 2007
Aug;41(8):637-48.
Psychotherapy of ASD & PTSD
(8) The Clinical Resource Efficiency Support
Team (CREST), The Management of Post
Traumatic Stress Disorder In Adults, June
2003
(9) Hammond J, Brooks J. The World Trade
Center attack. Helping the helpers: the
role of critical incident stress
management. Crit Care. 2001
Dec;5(6):315-7. Epub 2001 Nov 6.
(10) Jessica L. Hamblen, Paula P. Schnurr,
Anna Rosenberg, and Afsoon Eftekhari, A
Guide to the Literature on Psychotherapy
for PTSD, Psychiatric Annals, Volume 39,
Issue 6, June 2009
(11) Leonard Berlin, Sexual Harassment,
AJR:187, August 2006
(12) JANE LESERMAN, Sexual Abuse History:
Prevalence, Health Effects, Mediators,
and Psychological Treatment,
Psychosomatic Medicine 67:906–915
(2005)
(13) Professor Robin Davidson Consultant
Clinical Psychologist, Belvoir Park Hospital
& Dr Anne Montgomery Consultant
Psychiatrist, Mater Infirmorum Hospital;
The Management of Post Traumatic
Stress Disorder In Adults, June 2003.
(14) Robert J. Ursano, M.D., Chair; Practice
Guideline For The Treatment of Patients
With ASD and PTSD
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