Once a diagnosis of PTSD has been made, treatment should be vigorous because chronic PTSD is hard to treat. Even if the traumatic events took place some time before (>1 year) it might still be worth trying exposure therapy, if the patient can tolerate it. Antidepressant treatment should also be instituted. However, the prognosis after 1–2 years is not good.
Although the natural history of the disorder is for very gradual improvement over time, the concurrent effects on family and work life continually retard this process. Once chronic PTSD is established, the therapeutic focus may need to be these concurrent problems.
The principal treatment modalities are:
* behavioural and cognitive strategies
* short- and long-term psychological therapies
* medication.
All three may form part of different therapeutic strategies for the same patient over time, depending on the patient’s needs. Box 6Go shows the range of treatments available, the optimal types of therapy for different disorders and their timing. There is no evidence that single one-off debriefing sessions are helpful for treatment or that they reduce the incidence of PTSD after trauma (National Institute for Clinical Excellence, 2005).
Behavioural and cognitive strategies
The rationale for behavioural and cognitive treatments is breaking the cycle of intrusion and avoidance described in Horowitz’s model of PTSD (Horowitz, 1973). By exposing the patient to their feared memories or their thoughts about the trauma, avoidance is reduced and control over intrusion is introduced. It is likely that exposure to feared memories is an important part of most post-traumatic therapies. Addressing failures in cognitive processing of fear responses has also been shown to be effective in PTSD (Resick & Schnike, 1992). Behavioural and cognitive strategies are probably indicated as first-line treatments where there is good psychological health before the traumatic event and when the event itself is discrete.
Psychological therapies
Shame-based PTSD reactions are likely to be more common after prolonged childhood trauma, and overlap with the concept of complex PTSD (Herman, 1992) and borderline personality pathology. This type of reaction may be better addressed with shame-based therapies that aim to address the traumatised sense of self through the developing narrative and help restore a sense of meaning (Lindy, 1996). Unlike fear-based therapies, in shame-based therapy the relationship between the patient and the therapist is likely to be itself a major part of the therapeutic process. Previous experiences of fear and safety will be relevant to both types of reaction, especially in relation to forming a therapeutic alliance. Therapeutic approaches such as interpersonal and psychodynamic therapy may be helpful here. There is little evidence that exposure-based approaches are helpful, and they may even exacerbate the problem.
Group psychotherapy may be of particular use when the trauma occurs in a group context, such as occupational settings or transport disasters. Therapeutic communities have been used principally with combat veterans (Silver, 1986). Brief group work is possible when the group focuses on a particular task, such as in the critical incident stress debriefing model described by Mitchell (1983). Group work may be of particular use after sexual assaults, when shame and guilt may be reduced by making the experience less individual (Roth et al, 1988).
Box 6 Indicated treatments for post-traumatic disorders
Acute stress responses
* Debriefing
* Social supports
* Pharmacological supports, e.g. hypnotics
* Information and advice to families
Acute PTSD
* Exposure therapy may be first-line treatment if intrusive phenomena prominent
* Cognitive therapy
* Brief psychodynamic psychotherapy
* Antidepressants (especially where avoidance prominent)
Chronic PTSD
* Exposure therapy if trauma never discussed
* Cognitive–behavioural approaches may still be effective (group or individual)
* Long-term psychotherapy (group or individual)
* Antidepressants, lithium, carbamazepine
Medication
Medication has an important role in the treatment of post-traumatic disorders, both as symptomatic relief and directly addressing pathology. Detailed accounts of the use of various types of medication are given by Davidson (1992) and Stein et al(2000). Antidepressants, especially the serotonergic agents, may be helpful, as may tricyclics because of their hypnotic effects. Medication alone is unlikely to be helpful but may be necessary to enable patients to undertake other types of therapy later, and may enhance the efficacy of psychotherapy.
Choosing a treatment
There are particular questions relevant to the selection of treatment.
What is the worst problem at the moment?
If intrusive phenomena are prominent, this may suggest exposure therapy as part of a cognitive–behavioural package. If depression and distress are worst, then regular supportive therapy sessions plus antidepressants may be most effective.
What supports does this person have?
Many forms of treatment for PTSD are quite stressful. It is therefore important to ensure that the patient will be well supported, and that the family are informed about the nature and process of therapy.
What solutions to stress is the patient adopting now?
If a patient is misusing alcohol or drugs as a means of managing their PTSD symptoms this needs to be addressed before any specific PTSD treatment can be implemented. Rarely, patients present with acts of self-harm such as overdoses, and these should not be dismissed as ‘attention-seeking’.
References
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Gwen Adshead and Scott Ferris
Gwen Adshead is Consultant Forensic Psychotherapist at Broadmoor Hospital (Dadd Centre, Crowthorne, Berkshire RG45 7EG, UK. Email: gwen.adshead@wlmht.nhs.uk). Her research interests include psychiatric ethics, moral reasoning in psychiatry and attachment histories in abusive parents. Scott Ferris is Specialist Registrar in Psychotherapy at Forest House, Walthamstow, London and was previously Specialist Registrar in Forensic Psychiatry working in the trauma service at St George’s Hospital, London. His other research interests include attachment and offence representations.
