INTERVENTIONS

Caring for the patient diagnosed with PTSD involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment.

Interventions for PTSD are generally divided into psychotherapy and pharmacology, with psychotherapy being the primary choice. There are a number of treatment modalities. Some patients respond well to one treatment modality, while others may require a combination of modalities.

Goals and Outcomes

The overall goal for patients with PTSD is to regain a sense of control over life. Following are examples of specific goals and outcomes for a patient diagnosed with PTSD:

• Maintain safety of self and others
• Demonstrate control
• Distinguish between the present and memories
• Recognize triggers
• Receive treatment for comorbid conditions, such as alcohol/drug misuse, depression, anxiety disorders, and panic attacks
• Recognize ineffective coping strategies that correlate to negative outcomes
• Attend support group meetings
• Expand social support network
• Have increased restful sleep periods
• Have fewer nightmares and flashbacks
• Express decreased irritability
• Report feeling control over factors likely contributing to fear
• Demonstrate effective anxiety-reducing techniques, either cognitive or behavioral
  (Varcarolis, 2018)

Psychotherapy

Psychotherapy is clearly more effective than medication, and the most effective types of psychotherapy for treatment of PTSD are various forms of trauma-focused cognitive behavioral therapy (TF-CBT), with the strongest evidence for prolonged exposure (PE) and eye movement desensitization and reprocessing (EMDR).

Cognitive approaches assist patients to correct false perceptions. They are based on the theory that the meanings we impose on events contribute to our emotional states. Therefore, changing how we think about them can reduce PTSD symptoms and promote a sense of well-being.

Trauma-focused psychotherapies use cognitive, emotional, or behavior techniques to assist in processing the traumatic event, with the trauma focus being the central component of the therapeutic process and including both image exposure and live exposure to safe situations that have been avoided because they elicit reminders of the trauma (Hamblen et al., 2020).

Cognitive Processing Therapy

Cognitive processing therapy (CPT) is one of the most widely researched cognitive approaches, with a primary focus on challenging and modifying maladaptive beliefs related to a trauma. CPT has four main elements and includes a written exposure component:

• Education about PTSD symptoms and how treatment can help
• Developing awareness of thoughts and feelings
• Learning new skills for challenging thoughts and feelings (cognitive restructuring)
• Learning and developing an understanding about the common changes in beliefs that occur after going through trauma

This form of therapy requires 12 regular sessions of 60 to 90 minutes each with a therapist as well as completing practice assignments at home outside of therapy to help improve skills. CPT can be done individually or in a group. Assignments often include hand writing impact statements that address topics such as why the traumatic event occurred and what it means to the patient (NCPTSD, 2020).

PROLONGED EXPOSURE

Exposure-based treatments involve having patients repeatedly re-experience the traumatic event. They are intended to help patients face and gain control of overwhelming fear and distress following the traumatic experience.

Prolonged exposure (PE) is delivered in 8 to 15, 90-minute sessions, usually on a weekly basis. The key components of PE are:

• Psychoeducation about treatment, common reactions to trauma, and breathing retraining
• Imaginal exposure, requiring using the imagination to repeatedly retell the trauma memory out loud in present tense with eyes closed, and having the patient listen to an audio recording of the narrative between treatment sessions
• Live exposure to places, things, and situations that are being avoided because they cause distress and anxiety, in some cases using virtual reality technology when live exposure is not practical
• Emotional processing, focusing on reviewing the experience of exposure and the impact on thoughts related to the self, the world, and the trauma
  (Sweeney et al., 2019)

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

EMDR is another form of cognitive-behavioral therapy that can help change how a person reacts to memories of a traumatic event. It is fairly new, and guidelines have been issued by more than one professional organization, boosting its credibility. No one yet knows how this process works, but the mechanisms of EMDR are likely similar to that of other trauma-focused exposure and cognitive therapies, allowing the patient to better control upsetting thoughts.

EMDR does not rely on talk therapy or medications. Instead, it uses a patient’s own rapid, rhythmic eye movements. These eye movements dampen the power of emotionally charged memories of past traumatic events. A session can last up to 90 minutes and involves the therapist moving his/her fingers back and forth in front of the patient’s face and asking the patient to follow the movement with the eyes. At the same time, the patient is asked to recall the disturbing events, which will include emotions and body sensations that accompany it. Gradually, the therapist guides the patient to shift thoughts to more pleasant ones (Bhandara, 2019).

Psychopharmacology

Studies indicate that cognitive-behavioral therapies have greater effects in improving PTSD symptoms than medications, and while a number of medications have been tried, few have been shown to have any efficacy.

The therapeutic goals of pharmacologic therapy are to decrease intrusive thoughts and images, phobic avoidance, pathological hyperarousal, hypervigilance, irritability and anger, and depression. Drug therapies have been most beneficial in decreasing hyperarousal and mood symptoms (e.g., irritability, anger, depression), but are somewhat less effective for symptoms of re-experiencing, emotional numbing, and behavior avoidance (Stein, 2019).

ANTIDEPRESSANTS

These medications can help reduce symptoms of depression and anxiety. They can also help improve sleep problems and concentration. There are only two FDA-approved medications for treatment of PTSD, sertraline (Zoloft) and paroxetine (Paxil). Sertraline may be particularly useful in women who have experienced sexual or physical assaults.

These medications belong to the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). (Serotonin is important in regulating mood, anxiety, appetite, sleep, as well as other bodily functions.) SSRIs are the first-line medications for treatment of PTSD. They do, however, have significant side effects and carry a “black box” warning for suicidal ideation (Gore, 2018).

ANTI-ANXIETY MEDICATIONS

These drugs can relieve severe anxiety and related problems; however, they are not recommended for use in PTSD, as they can worsen symptom outcome. They also have potential for abuse. If benzodiazepines are used, it should be short term (e.g., no more than five days), with frequent re-evaluation for side effects. These medications include:

• Lorazepam (Ativan)
• Clonazepam (Klonopin)
• Alprazolam (Xanax)
• Diazepam (Valium)
  (Jeffreys, 2019)

Complementary and Integrative Approaches

There is a growing body of research supporting the use of complementary and integrative treatment modalities for PTSD. Clinicians can use modalities such as mindfulness-based interventions and yoga when treating patients with PTSD.

MINDFULNESS-BASED INTERVENTIONS

Mindfulness-based interventions (MBIs) involve paying attention in a particular manner, on purpose, in the present without making any judgments. Present-centered awareness and nonjudgmental acceptance may function as indirect exposure to trauma-related stimuli, both internal and external, resulting in a reduction of behavioral avoidance and physiological arousal.

Present-centered awareness diminishes worry and catastrophic thinking, and through this training, the patient is able to gain an understanding that cognitions and beliefs are mental phenomena rather than facts. Hyperarousal and the behavioral elements of PTSD are also affected positively or lessened by MBIs.

Several benefits may result from using MBIs to strengthen evidence-based, trauma-focused psychotherapies that do not already emphasize mindfulness. These interventions can assist with engagement, facilitate preparation for involvement in trauma-focused psychotherapies, and foster adherence to treatment. MBIs can also help maintain the patient’s commitment to the further development of the skills learned in treatment (Sornborger et al., 2017).

YOGA

Yoga involves a combination of physical postures, controlled breathing, meditation, and yogic ethics and philosophy. Yoga has been associated with improvement in depression, anxiety, and stress, with few to no side effects.

Yoga is believed to restore balance in the autonomic nervous system and enhance interoceptive awareness. Its effects may also be mediated by increased mindfulness and self-compassion. This can assist trauma survivors to approach symptoms with acceptance and potentially decrease reactivity and avoidance behaviors.

Clinicians should be aware that it is important that yoga be considered a possible adjunctive intervention for PTSD and not a foundational or stand-alone treatment (Gallegos et al., 2017; Sornborger et al., 2017).

Evaluation of Interventions

Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. The primary outcome is symptom reduction. This is evaluated using clinician-rated and self-reported measures that address the symptoms the patient presented with, and asks if they have lessened, remained the same, or increased. Other goals to be evaluated include:

• Have comorbid medical or psychiatric conditions been prevented or reduced?
• Has there been a remission of all symptoms?
• Has the patient’s quality of life improved?
• Has the patient effectively dealt with disability/functional impairment?
• Has the patient returned to work or to active duty?