5.6: Trauma- and Stressor-Related Disorders - Treatment

Learning Objectives

• Describe the treatment approach of the psychological debriefing.
• Describe the treatment approach of exposure therapy.
• Describe the treatment approach of CBT.
• Describe the treatment approach of Eye Movement Desensitization and Reprocessing (EMDR).
• Describe the use of psychopharmacological treatment.

Psychological Debriefing

One way to negate the potential development of PTSD symptoms is thorough psychological debriefing. Psychological debriefing is considered a type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event (Kinchin, 2007). While there are a few different methods to a psychological debriefing, they all follow the same general format:

1. Identifying the facts (what happened?)
2. Evaluating the individual’s thoughts and emotional reaction to the events leading up to the event, during the event, and then immediately following
3. Normalizing the individual’s reaction to the event
4. Discussing how to cope with these thoughts and feelings, as well as creating a designated social support system (Kinchin, 2007).

Throughout the last few decades, there has been a debate on the effectiveness of psychological debriefing. Those within the field argue that psychological debriefing is not a means to cure or prevent PTSD, but rather, psychological debriefing is a means to assist individuals with a faster recovery time posttraumatic event (Kinchin, 2007). Research across a variety of traumatic events (i.e., natural disasters, burns, war) routinely suggests that psychological debriefing is not helpful in either the reduction of posttraumatic symptoms nor the recovery time of those with PTSD (Tuckey & Scott, 2014). One theory is these early interventions may encourage patients to ruminate on their symptoms or the event itself, thus maintaining PTSD symptoms (McNally, 2004). In efforts to combat these negative findings of psychological debriefing, there has been a large movement to provide more structure and training for professionals employing psychological debriefing, thus ensuring that those who are providing treatment are properly trained to do so.

Exposure Therapy

While exposure therapy is predominately used in anxiety disorders, it has also shown great success in treating PTSD-related symptoms as it helps individuals extinguish fears associated with the traumatic event. There are several different types of exposure techniques—imaginal, in vivo, and flooding are among the most common types (Cahill, Rothbaum, Resick, & Follette, 2009).

In imaginal exposure, the individual mentally re-creates specific details of the traumatic event. The patient is then asked to repeatedly discuss the event in increasing detail, providing more information regarding their thoughts and feelings at each step of the event. During in vivo exposure, the individual is reminded of the traumatic event through the use of videos, images, or other tangible objects related to the traumatic event that induces a heightened arousal response. While the patient is re-experiencing cognitions, emotions, and physiological symptoms related to the traumatic experience, they are encouraged to utilize positive coping strategies, such as relaxation techniques, to reduce their overall level of anxiety.

Imaginal exposure and in vivo exposure are generally done in a gradual process, with imaginal exposure beginning with fewer details of the event, and slowly gaining information over time. In vivo starts with images or videos that elicit lower levels of anxiety, and then the patient slowly works their way up a fear hierarchy, until they are able to be exposed to the most distressing images. Another type of exposure therapy, flooding, involves disregard for the fear hierarchy, presenting the most distressing memories or images at the beginning of treatment. While some argue that this is a more effective method, it is also the most distressing and places patients at risk for dropping out of treatment (Resick, Monson, & Rizvi, 2008).

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy, as discussed in the mood disorders chapter, has been proven to be an effective form of treatment for trauma/stress-related disorders. It is believed that this type of treatment is effective in reducing trauma-related symptoms due to its ability to identify and challenge the negative cognitions surrounding the traumatic event, and replace them with positive, more adaptive cognitions (Foa et al., 2005).

Trauma-focused cognitive-behavioral therapy (TF-CBT) is an adaptation of CBT that utilizes both CBT techniques and trauma-sensitive principles to address the trauma-related symptoms. According to the Child Welfare Information Gateway (CWIG; 2012), TF-CBT can be summarized via the acronym PRACTICE:

• P: Psycho-education about the traumatic event. This includes discussion about the event itself, as well as typical emotional and/or behavioral responses to the event.
• R: Relaxation Training. Teaching the patient how to engage in various types of relaxation techniques such as deep breathing and progressive muscle relaxation.
• A: Affect. Discussing ways for the patient to effectively express their emotions/fearsrelated to the traumatic event.
• C: Correcting negative or maladaptive thoughts.
• T: Trauma Narrative. This involves having the patient relive the traumatic event (verbally or written), including as many specific details as possible.
• I: In vivo exposure (see above).
• C: Co-joint family session. This provides the patient with strong social support and a sense of security. It also allows family members to learn about the treatment so that they are able to assist the patient if necessary.
• E: Enhancing Security. Patients are encouraged to practice the coping strategies they learn in TF-CBT to prepare for when they experience these triggers out in the real world, as well as any future challenges that may come their way.

Eye Movement Desensitization and Reprocessing (EMDR)

In the late 1980s, psychologist Francine Shapiro found that by focusing her eyes on the waving leaves during her daily walk, her troubling thoughts resolved on their own. From this observation, she concluded that lateral eye movements facilitate the cognitive processing of traumatic thoughts (Shapiro, 1989).

While EMDR has evolved somewhat since Shapiro’s first claims, the basic components of EMDR consist of lateral eye movement induced by the therapist moving their index finger back and forth, approximately 35 cm from the client’s face, as well as components of cognitive-behavioral therapy and exposure therapy. The following 8-step approach is the standard treatment approach of EMDR (Shapiro & Maxfield, 2002):

1. Patient History and Treatment Planning – Identify trauma symptoms and potential barriers to treatment.
2. Preparation – Psychoeducation of trauma and treatment.
3. Assessment – Careful and detailed evaluation of the traumatic event. Patient identifies images, cognitions, and emotions related to the traumatic event, as well as trauma-related physiological symptoms.
4. Desensitization and Reprocessing – Holding the trauma image, cognition, and emotion in mind, while simultaneously assessing their physiological symptoms, the patient must track the clinician’s finger movement for approximately 20 seconds. At this time, the patient must “blank it out” and let go of the memory.
5. Installation of Positive Cognitions – Once the negative image, cognition, and emotions are reduced, the patient must hold onto a positive image or thought while again tracking the clinician’s finger movement for approximately 20 seconds.
6. Body Scan – Patient must identify any lingering bodily sensations while again tracking the clinician’s fingers for a third time to discard any remaining trauma symptoms.
7. Closure – Patient is provided with positive coping strategies and relaxation techniques to assist with any recurrent cognitions or emotions related to the traumatic experience.
8. Reevaluation – Clinician assesses if treatment goals were met. If not, schedules another treatment session and identifies remaining symptoms.

As you can see from above, only steps 4-6 are specific to EMDR; the remaining treatment is essentially a combination of exposure therapy and cognitive-behavioral techniques. Because of the high overlap between treatment techniques, there have been quite a few studies comparing the treatment efficacy of EMDR to TF-CBT and exposure therapy. While research initially failed to identify a superior treatment, often citing EMDR and TF-CBT as equally efficacious in treating PTSD symptoms (Seidler & Wagner, 2006), more recent studies have found that EMDR may be superior to that of TF-CBT, particularly in psycho-oncology patients (Capezzani et al., 2013; Chen, Zang, Hu & Liang, 2015). While meta-analytic studies continue to debate which treatment is the most effective in treating PTSD symptoms, the World Health Organization’s (2013) publication on the Guidelines for the Management of Conditions Specifically Related to Stress, identified TF-CBT and EMDR as the only recommended treatment for individuals with PTSD.

The National Institute for Health and Care Excellence (NICE) says to consider EMDR for adults with a diagnosis of PTSD and who presented between 1 and 3 months after a non-combat related trauma if the person shows a preference for EMDR and to offer it to adults with a diagnosis of PTSD who have presented more than three months after a non-combat related trauma. They state that EMDR for adults should (cited directly from their website):

• be based on a validated manual
• typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas
• be delivered by trained practitioners with ongoing supervision
• be delivered in a phased manner and include psychoeducation about reactions to trauma; managing distressing memories and situations; identifying and treating target memories (often visual images); and promoting alternative positive beliefs about the self
• use repeated in-session bilateral stimulation (normally with eye movements but use other methods, including taps and tones, if preferred or more appropriate, such as for people who are visually impaired) for specific target memories until the memories are no longer distressing
• include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions.

For more on NICE’s PTSD guidance (2018) as it relates to EMDR, please see Sections 1.6.18 to 1.6.20: https://www.nice.org.uk/guidance/ng116/chapter/Recommendations

Psychopharmacological Treatment

While psychopharmacological interventions have been shown to provide some relief, particularly to veterans with PTSD, most clinicians agree that resolution of symptoms cannot be accomplished without implementing exposure and/or cognitive techniques that target the physiological and maladjusted thoughts maintaining the trauma symptoms. With that said, clinicians agree that psychopharmacology interventions are an effective second line of treatment, particularly when psychotherapy alone does not produce relief from symptoms.

Among the most common types of medications used to treat PTSD symptoms are selective serotonin reuptake inhibitors (SSRIs; Bernardy & Friedman, 2015). As previously discussed in the depression chapter, SSRIs work by increasing the amount of serotonin available to neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are also recommended as second-line treatments. Their effectiveness is most often observed in individuals who report co-occurring major depressive disorder symptoms, as well as those who do not respond to SSRIs (Forbes et al., 2010). Unfortunately, due to the effective CBT and EMDR treatment options, research on psychopharmacological interventions has been limited. Future studies exploring other medication options are needed to determine if there are alternative medication options for stress/trauma disorder patients.

Key Takeaways

You should have learned the following in this section:

• Several treatment approaches are available to clinicians to alleviate the symptoms of trauma- and stressor-related disorders.
• The first approach, psychological debriefing, has individuals who have recently experienced a traumatic event discuss or process their thoughts related to the event and within 72 hours.
• Another approach is to expose the individual to a fear hierarchy and then have them use positive coping strategies such as relaxation techniques to reduce their anxiety or to toss the fear hierarchy out and have the person experience the most distressing memories or images at the beginning of treatment.
• The third approach is Cognitive Behavioral Therapy (CBT) and attempts to identify and challenge the negative cognitions surrounding the traumatic event and replace them with positive, more adaptive cognitions.
• The fourth approach, called EMDR, involves an 8-step approach and the tracking of a clinician’s fingers which induces lateral eye movements and aids with the cognitive processing of traumatic thoughts.
• Finally, when psychotherapy does not produce relief from symptoms, psychopharmacology interventions are an effective second line of treatment and may include SSRIs, TCAs, and MAOIs.

Review Questions

1. Identify the different treatment options for trauma and stress-related disorders. Which treatment options are most effective? Which are least effective?

Module Recap

In Module 5, we discussed trauma- and stressor-related disorders to include PTSD, acute stress disorder, adjustment disorder, and prolonged stress disorder. We defined what stressors were and then explained how these disorders present. In addition, we clarified the epidemiology, comorbidity, and etiology of each disorder. Finally, we discussed potential treatment options for trauma- and stressor-related disorders. Our discussion in Module 6 moves to dissociative disorders.