Post-Traumatic Stress Disorder (PTSD), previously known as “hysteria”, “shell shock”, “war neurosis”, and “soldier’s heart” (Crocq & Crocq, 2000), is a severe anxiety disorder (Cahill, 2007) that occurs in those who have experienced or witnessed traumatic events, such as sexual or violent assault (Van der Kolk, 2017), war and/or combat, accidents and natural disasters and terror attacks (Herman, 2015). There are many unpleasant symptoms of PTSD, according to the IDC 10, which generally develop around one to six months after experiencing trauma that can include: reliving the trauma repeatedly through “intrusive flashbacks”, memories and dreams, being unable to recall parts of the trauma they experienced, as well as avoiding situations which they did not avoid before experiencing the trauma, increased anger, difficulty sleeping and concentrating, and an increased startle response (WHO, 1993). As there are multiple symptoms, many which are very different from each other, there are multiple therapies which are aimed at lessening the symptoms.
The first therapy to be discusses is Cognitive Behavioural Therapy (CBT). This is a very common evidence based talking therapy that is recommended by the NHS for multiple mental health issues and disorders. It aims to change thoughts and behaviours of people who experience mental distress by identifying thoughts or behaviours which may be causing problems or even be keeping the person from changing bad habits that stop a person carrying out normal daily tasks. CBT is widely used to treat anxiety disorders, such as PTSD and coinciding disorders such as depression, suicidal thoughts, obsessive and compulsive behaviours, anger management and other anxiety symptoms. (Kar, 2011). As the earliest forms of CBT have been around since the 1950s, there is plenty research on its effectiveness, extensively on multiple areas of trauma. As mentioned previously, one way trauma forms is from experiencing terrorist attacks. One study administered CBT to survivors of the 9/11 terrorist attack on the World Trade Center (Levitt, Malta, Martin, Davis & Cloitre, 2007). The therapists administering the CBT had varying levels of training prior and the therapy was delivered from 12 to 25 sessions. The results from this showed positive effects for the sample as it was able to reduce several symptoms of PTSD that the participants were experiencing. It also reduced symptoms of emotional and social disturbances as well as symptoms of depression. CBT has also been shown to improve symptoms of PTSD in other areas of trauma, such as war trauma. Beidel, Frueh, Uhde, Wong and Mentrikoski, (2011) found that CBT was successful in reducing the core symptoms of PTSD in 35 male Vietnam veterans, especially increasing interpersonal functioning and social engagements, but was less successful at reducing anger outbursts compared to Trauma Management Therapy. Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin (2005) administered CBT to 171 rape survivors who all had chronic PTSD. This study gained similar results and it was observed that participants had reduced depression and PTSD symptoms. It was also found that in all of the studies that the level of CBT training the counsellors had prior to the experiments had no significant difference. CBT has also been the basis for the development of other therapies, one therapy in particular which is a mutation of CBT is Compassion Focused Therapy (CFT).
CFT was created for people who experience high levels of shame and self-criticism in complex mental health issues. Compassion is an important component for any client-therapist relationship, and the aim of CFT is to reinforce the feelings of relief, safety and reassurance to counteract the shame, guilt and any other unpleasant emotions or feelings. CFT is especially for people who have a more dominant sense of impending threats (Gilbert, 2009). This therapy is appropriate for PTSD as those who have the disorder have experienced extremely unpleasant events, such as war or sexual assault, and therefor are more alert and may interpret and anticipate the previous events to happen in their daily life. They may also criticize themselves for not acting differently before the traumatic event which can lead to unpleasant thoughts, shame and self-criticism (Lee, Scragg & Turner, 2001). It is not as widely used as CBT and because of this, there is much less research on CFT and PTSD, however the research available is positive. Au, Sauer-Zavala, King, Petrocchi, Barlow and Litz (2017) explored how CFT contributed to the reduction of elevated trauma-related shame in PTSD. Their results were positive and showed a large number of participants having a reduction in shame and also in symptom severity.
Exposure Therapy (ET) targets learned avoidant behaviours in response to situations that someone with PTSD might associate with the reason for their trauma. The aim of the therapy is to “expose” a client to what they fear or avoid in a safe way in order to decrease the fear and reduce avoidance by desensitization (Craske, Treanor, Conway, Zbozinek & Vervliet, 2014). Due to ET targeting learned behaviours, it is used regularly in conjunction with CBT (Foa, Rothbaum & Furr, 2003). A more modern take on ET is using Virtual Reality, and it is mainly used with veterans of war, as the scenes they were exposed to are easier to recreate than other forms of trauma, such as sexual assault, and is an alternative to imagination exposure (Rothbaum et al., 1999). Miyahira, Folen, Hoffman, Garcia-Palacios and Schaper (2010) conducted a case study of a Vietnam veteran that had completed 18 months in Iraq over two deployments. In this study, the soldier was treated with Virtual Reality Exposure (VRE) over 6 sessions. The participant reported that the VR headset made him feel as though he were back in Iraq and helped him to remember events of what happened more clearly. This is encouraging as the point of ET is to enable participants to re-live their trauma to be able to process it properly and therefor begin the healing process and to prevent sufferers of PTSD from developing long-term psychological damage (CITE). Difede and Hoffman (2002) also found promising results. Their case study consisted of administering VRE to survivors of the 9/11 terrorist attacks. The participant’s symptoms were measured using the Beck Depression Inventory and the Clinically Administered PTSD Scale. It was seen that there was a 90% reduction of symptoms of PTSD and an 83% reduction in symptoms of depression after completion of the therapy. Another treatment that works in similar ways is Eye Movement Desensitization and Reprocessing (EMDR).
This therapy is designed to target and treat the symptoms of trauma and is especially used to treat symptoms of PTSD and is recommended by NICE as a primary treatment (NICE, 2018). It is seen as a cognitive-behavioural treatment combined with aspects of exposure therapy (Boudewyns & Hyer, 1996) and it works by the participant recalling the traumatic events that they experienced whilst simultaneously having their attention directed to a physical bilateral stimulation they are receiving, such as hearing tones in alternating ears, moving eyes rapidly from side to side, or tapping sensations of either side of the body. Similarly to ET, this therapy works by allowing the mind to safely experience traumatic events, letting the mind process them fully in order to heal appropriately (Shapiro, 1996). A systematic narrative review was carried out on the effectiveness of EMDR for PTSD from four randomized control trials and two meta-analyses. It was found that the therapy was able to reduce the symptoms as well as symptoms that were trauma related, and also appeared more effective than other treatments for trauma as well as effective across different cultures. However, there was a consistent limitation which was the small sample sizes. It also did not take into account the amount of people who were withdrawn from the trials. Despite this, EMDR is shown to be able to reduce the symptoms of PTSD by treating the cause of the problem (Wilson, Farrell, Barron, Hutchins, Whybrow & Kiernan, 2018). This, in turn, leads to a lessening of symptoms.
Although the above mentioned therapies may be effective at treating the psychological damages, there is evidence to show that people who suffer with PTSD have physiological changes too. A meta-analysis studied brain regions of PTSD participants compared to controls and found that the hippocampus and left amygdala volumes as well as the anterior cingulate cortex were all significantly smaller compared to controls and trauma-exposed participants (Karl, Schaefer, Malta, Dorfel, Rohleder & Werner, 2006). Other studies have made observations that there are differences in grey matter volumes, hypothalamus, and even the prefrontal cortex between PTSD participants and controls (Flemingham et al, 2009). Multiple types of medication can be prescribed to alleviate the symptoms of PTSD, and these can include anti-depressants, anti-anxiety medication and anti-psychotics (Ipser & Stein, 2012), however the most commonly used in the U.K. as a treatment for PTSD are antidepressants (De Vries, De Jonge, van den Heuvel, Turner & Roest, 2016). In one RCT, it was observed that Sertraline (antidepressant reserved for treatment of PTSD) showed a significant improvement in reducing the symptoms of PTSD compared to the placebo group (Brady et al, 2000). Similar results were found in another study which showed that the participants that remained on the antidepressant treatment (Sertraline or Fluoxetine) had a reduction in symptoms but also improved quality of life (Dow & Klein, 1997).
In conclusion, CBT is used to treat anxiety disorders and there is evidence to show that it can affectively lessen the symptoms of PTSD when used appropriately, even if the counsellors providing the service have not long been qualified. This is a strength of the therapy as it means it is cost effective and easier to gain access to as a service user. CBT is the most recommended therapy according to the NHS but it is not without its limitations. CBT may not be appropriate for some as it requires a lot of work from the participant. Some participants may not want to put so much effort into helping themselves and may not complete the allotted number of sessions.
CFT was adapted from CBT and addresses a specific symptom of PTSD. Although the evidence presents results, the literature is very limited in regards to treating PTSD, and it is only able to treat one symptom, not any others or even the root cause which does not suggest much for long term psychological effects.
ET is a way to safely expose the participant to the traumas that they experience and that has caused them to develop PTSD to begin with. This therapy has been shown to be effective as it allows the participant to begin processing the trauma properly instead of repressing it. Although this therapy has been shown to be effective, the studies conducted have mostly been individual case studies. Also, it is not appropriate for everyone, but mainly for those who experience replicable trauma.
EMDR also stems from CBT but in conjunction with ET in that it aims to aid participants by getting them to recall trauma whilst subjecting them to physical, bilateral stimulation. Although this therapy shows promising results, it is still a relatively new therapy and it will be harder to gain access to as a service user.
Medication is predominantly associated with treating physiological disorders but as the research suggests, PTSD can be treated as such. The evidence shows that it can be effective at treating PTSD. Although the trials were successful, they only treated the symptoms and not the cause. Again, this could potentially be a problem for long term-psychological effects.
Throughout the research, it can be seen that the therapies available to PTSD suffers is generally split between treating the cause or treating the symptoms. For example, medication is effective at treating the symptoms quickly, enabling people to behave normally and go about their lives as before, however it only masks the main problem. ET on the other hand, gets to the root cause and begins to fix the problem gradually. However there are issues with this too. Many people with PTSD may have trouble attending the therapy sessions due to their symptoms which may be paradoxical. An appropriate treatment would be a combination of medication and a behavioural therapy appropriate to the trauma the client was exposed to. Future research that could be conducted could be on exploring newer therapies, like CFT, and evaluating their efficacy for PTSD, and also exploring the types of trauma and how they each individually respond to different types of trauma.
What is Post-Traumatic Stress Disorder?
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that can develop when someone is exposed to, involved in, or witnesses a traumatic event. PTSD has been around for a long time but has had different names in the past, such as “shell shock”, which was used for veterans of war, or “hysteria”, used to define women who had experienced sexual assault in the late 19th century. PTSD can also have other disorders develop alongside it such as depression, general anxiety or suicidal thoughts. (WHO, 1993)
How is PTSD diagnosed?
In order to be diagnosed with PTSD, you will have been exposed to an extreme stressful traumatic event/s that would cause catastrophic distress in any normal person. These events can include accidents or natural disasters, terror attacks, sexual or psychical violent assault and war and/or combat. Witnessing these events or being told that these events happened to a friend or family member can lead to a number of unpleasant experiences, such as:
- Having nightmares
- Intrusive flashbacks or reliving the experience
- Extremely vivid memories
- Avoiding situations that are associated with the trauma
- Becoming distressed in situation that are associated with the trauma
- Having trouble remembering parts of the trauma
- Inability to fall or stay asleep
- Increased anger or angry outbursts
- Inability to concentrate
- Being easily startled
When trauma is experienced, these symptoms can occur in anyone, however, they need to be present for at least one month following the trauma and they must be causing significant stress and be inhibiting daily life. The symptoms must also not be due to any substance use or medication (WHO, 1993)
If these symptoms are being experiences and the criteria fits, there are available treatments that can help.
TREATMENTS
Cognitive-Behavioural Therapy
Cognitive Behavioural Therapy (CBT) is a talking therapy that works by focusing on negative thoughts and behaviours that are affecting daily life. By talking through these problems with a therapist, they can help identify the thought patterns and negative challenges (Kar, 2011). This therapy has been researched thoroughly and the evidence that is available is extremely positive. It is easily available and the sessions can be very straightforward. However, there is a down side. The therapy doesn’t stop after the sessions end. Clients are given homework to complete and a lot of people feel this is too much.
Compassion Focused Therapy
Compassion Focused Therapy (CFT) focuses specifically on people who experience high levels of shame, guilt and self-criticism. This therapy also has a very strong client therapist relationship. This therapy reinforces compassion, reassurance and feelings of safety within the sessions (Lee, Scragg & Turner, 2001). This therapy has been proved effective, but there are also limitations. It is not very researched and also not easy to gain access to. Also, it does not treat the root cause of the problem, but only one specific symptom.
Virtual Reality Exposure Therapy
Exposure Therapy (ET) aims to help people confront the trauma they were exposed to. It works by recalling traumatic scenes or imagining the trauma repeatedly to create desensitisation toward the situation. When used with Virtual Reality (VR) it takes away the responsibility of the client as they may not remember in great detail the trauma they were exposed to (Craske, Treanor, Conway, Zbozinek & Vervliet, 2014). This therapy again has had lots of research done and it has yielded great results, but again, there are limitations. Not all types of trauma can be replicated. Also, some may feel the therapy is too intense and might not want to complete the treatment.
Eye Movement Desensitisation and Reprocessing
Eye Movement Desensitisation and Reprocessing is similar to ET in that it works by reliving through the experienced trauma whilst simultaneously having a secondary stimulation on either side of the body (such as tapping on their side, watching something go left to right, hearing tones in left then right ear) (Shapiro, 1996). This treatment has aspects of CBT and ET combined with a physical sensation and this therapy is great for those who feel they have trouble talking about the trauma they experienced. Although this therapy is effective, there are some side effects. In some cases is can cause vivid dreams (if they aren’t already being experiences), light-headedness, and heightened awareness.
Medication
The medication used to treat PTSD is primarily antidepressants, and they work by increasing the neurotransmitter that is associated with happiness and pleasure called serotonin. Medication can work well if used properly and has been shown to be effective at alleviating the some symptoms of PTSD (Ipser & Stein, 2012). There are different medications out there which may be more appropriate for each individual but your doctor will decide which is best. Although medication is great for symptom management and can help give people the ability to go about their daily lives as they did before experiencing trauma, it is not suitable as a long term treatment. Medication only treats the symptoms, not the root cause which means the symptoms will never go away. Also, over time it is possible that a tolerance will be built up which may render the medication ineffective.
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