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)

Occupational Therapy

PTSD can be debilitating, with negative impacts in many areas of a person’s life, making it difficult to carry out the normal activities of daily living. Broad areas affected can include health and safety, money management, self-care, transportation, work, relationship duties, and community participation. PTSD also affects a person’s executive planning abilities such as time management and concentration or paying attention.

Occupational therapists work with patients who have PTSD across the lifespan and in all phases of recovery. Following a comprehensive and collaborative evaluation to identify the individual’s strengths and barriers to occupational performance and their causes, OTs provide individual and group therapy sessions that are often done in collaboration with other professionals. Occupational therapy interventions include, but are not limited to:

• Providing individual and/or group sessions that focus on:
  • Trauma triggers and warning signs
  • Developmental issues related to early childhood trauma
  • Symptom stabilization
  • New coping, health, and wellness strategies such as stress management, relaxation techniques, and sensory processing-related techniques
• Training clients, caregivers, and interdisciplinary staff in:
  • Adaptive or modified self- and home care, work, or school-based strategies to avoid inadvertent triggering of hypersensitivity patterns, dissociation, flooding, or flashbacks
• Assisting patients to increase participation in meaningful roles and activities, such as:
  • Creating and using a daily schedule to identify triggers and helpful strategies
  • Identifying and obtaining the type and amount of supports necessary for successful participation
  • Creating and using a sensory diet (a plan of specific activities and experiences used to help balance the nervous system and sensory processing)
  • Implementing exposure techniques
• Assisting patients and caregivers in determining needs and resources for home modification for those with physical barriers to participation
• Promoting veterans’ awareness of the impact of wartime driving experiences on PTSD and assisting them in addressing reactions to civilian driving situations
  (AOTA, 2015)

Physical Therapy

Physical therapists are not involved in the primary treatment of PTSD but may work with those patients who have experienced an injury sustained during a trauma event that requires physical therapy interventions. Additionally, those with PTSD often experience chronic pain as a result of the complexity of the disorder, in which case the role of the physical therapist in PTSD management is one of mitigating chronic pain.

Chronic pain often occurs concurrently with PTSD, and the occurrence of both disorders tends to negatively affect the treatment outcome for each. Because of the high incidence of comorbidity of PTSD and chronic pain, physical therapists should evaluate patients with PTSD for the presence of chronic pain using a pain measure instrument, such as:

• West Haven-Yale Multi-dimensional Pain Inventory (WHYMPI), a self-report questionnaire that may be administered by a qualified therapist or research assistant and takes 20 minutes to complete
• McGill Pain Questionnaire (MPQ), a self-report questionnaire and one of the most widely used pain scales, which allows patients to describe the quality and intensity of their pain and is divided into three categories: sensory, affective and evaluative

Physical therapists are able to help patients build positive self-efficacy. This is accomplished through cognitive restructuring, development of healthy coping skills, and learning to use relaxation responses. Techniques such as situational exposure exercises and interoceptive exposure exercises are used to help decrease catastrophizing and avoidance.

Exposure therapy involves creating a safe environment in which the patient can be exposed to the things feared and avoided. The exposure to these feared objects, activities, or situations helps reduce fear and decrease avoidance.

Interoceptive exposure is a cognitive behavioral technique that can test the expectation that the physical sensations being experienced by a patient with a disorder such as PTSD are intolerable. By triggering feared sensations, patients can gain greater tolerance to distressful feelings and can learn to refute the validity of incorrect beliefs about those sensations, resulting in reduced sensitivity to them.

Physical therapists also provide patient education regarding how PTSD and pain can facilitate each other and result in avoidance. As the individual increases participation in healthy activities, co-occurring disorders such as depression, anxiety, panic, and substance abuse may decrease, resulting in a higher quality of life (O’Sullivan et al., 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?