Psychological Treatments and Posttraumatic Stress Disorder - Research Paper Example

Psychological Treatments and Posttraumatic Stress Disorder Abstract Posttraumatic stress disorder (PTSD) is an affective disorder that normally develops as an outcome of an intolerably upsetting, life-threatening, or extremely precarious experience. This paper discusses briefly but substantially the description, features, and prevalence of the disorder. The contributing factors are discussed under two categories, namely, (1) psychosocial and (2) neuropsychological. Potential treatments for the disorder are discussed under psychological and medical treatments. The weaknesses and strengths of each form of treatment are taken into account in order to arrive at a compelling conclusion regarding the most effective means to remedy the disorder. There are claims that combination of psychological and medical treatment is the most productive treatment for PTSD. This paper attempts to verify the validity of this assumption. Introduction The concept of posttraumatic stress disorder has existed for several decades, having referred to as war psychosis, shell shock, and rape neurosis disorder. Yet, its official classification in the diagnostic categorization as posttraumatic stress disorder (PTSD) is fairly current (Wilson, Friedman & Lindy, 2001). It was originally established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association, 1980). Due to the current identification of PTSD as a recognized disorder, important concerns such as determinant of failure to recuperate from a neurosis and the advancement and assessment of effective treatments have recently started to be dealt with in research employing thorough methodology (Vasterling & Brewin, 2005). In this literature review, the diagnostic measure for PTSD will be discussed and prevalence of PTSD related with different stressors will be considered. And then, literature on current treatment outcome will be critically reviewed. The DSM-IV analysis of PTSD comprises six measures. The first is the distinguishing trauma (McLean & Woody, 2001). A distressing episode is described as one wherein: (a) the individual witnessed, experienced, or was faced with an incident that involved perceived or real danger to physical reliability or threat to life; and (b) the emotional response of an individual to this incident included severe anxiety, defenselessness, or shock (McLean & Woody, 2001). Psychological indicators of PTSD are grouped into three categories: (1) reexperiencing; (2) avoidance/numbing; and (3) increased arousal (Vasterling & Brewin, 2005). The reexperiencing indications, such as flashbacks or nightmares, have been regarded the trait of PTSD. The second group comprises indicators of severe avoidance, such as intentionally avoiding trauma-associated stimulus, and indicators of emotional anesthetizing; the latter are regarded qualifying attributes of PTSD (Barbanel & Sternberg, 2006). The third indicator group, heightened arousal, involves indications such as bad temper, hyper-alertness, and insomnia (Barbanel & Sternberg, 2006). Based on the epidemiological data detailed by Helzer and associates (1987), more or less 1-2% of the overall population of the United States qualifies for PTSD (p. 1631), though it has been claimed that Helzer and associates miscalculated the frequency of the disorder (Foa & Meadows, 1997). Reflective epidemiological investigations of particular trauma populations determine the occurrence of PTSD at higher rates (Foa & Meadows, 1997). Resnick and colleagues (1993), for instance, discovered that women rape victims, 12.4% qualified for recent PTSD and 32% for lifetime PTSD (p. 986). Given the high rates of distressing incidents and of ensuing PTSD, along with the continuously increasing population of individuals with PTSD due to the persistence of the disorder, it is crucial to be able to diagnose immediately following neurosis individuals who are prone to develop chronic PTSD and to formulate cost-effective and effective treatments for these people. This is particularly justified given that future investigations of trauma victims normally show higher rates of PTSD. Moreover, it may be useful to analyze the responses of victims to other severely traumatic incidents, such as death of a significant other following a chronic disease, as a syndrome that resembles PSTD (Hodgkinson & Stewart, 1998). Researchers have discovered that after death of a spouse, half of the total number of respondents met the symptom criteria for PTSD at some stage throughout the subsequent two years (Hodgkinson & Steward, 1998). Taking this into account, investigations of treatment result for symptoms after such incidents are also discussed. Several methodologies have been employed in PTSD outcome research, in self-report and interview procedures. These methodologies differ broadly in relation to symptoms evaluated, psychometric features, and time to administer, among other measures (Foa & Meadows, 1997). Due to the fact that the choice of methodologies is quite crucial in assessing treatment outcome investigations, this paper review in brief the most generally employed instruments in PTSD studies. The first methodology of trauma-related indications was the Revised Impact of Events Scale (RIES), a self-report instrument that shows two aspects: avoidance and intrusion. Even though the RIES has displayed internal consistency and high test-retest validity, it does not evaluate all PTSD indications and hence cannot specify diagnostic condition (Williams & Sommer, 1994). Two levels that have first-rate psychometric features, but that do not match up wholly with the symptoms of DSM, are the Penn Inventory and the Mississippi Scale. The latter was initially created for combat-associated PTSD, though a civilian equivalent exists (Barbanel & Sternberg, 2006). Since both Mississippi Scale and Penn Inventory were authenticated with veteran populations, their soundness in other trauma populations remains unknown. The PTSD Symptom Scale-Self Report (PSS-SR) and its offspring, the PTSD Diagnostic Scale (PDS), were created as instruments of self-report that would present data about each of the 17 DSM-IV indicators (Barbanel & Sternberg, 2006). Hence, they present severity and indicative data. The PSS-SR displayed excellent validity and reliability in a sample of female victims of harassment. The PDS seeks to evaluate all the criteria of DSM-IV, and hence it contains information about the characteristic of the traumatic incident and the extent of functional intervention (Foa & Meadows, 1997). On the other hand, the Structured Clinical Interview for DSM (SCID) is perhaps the most commonly applied diagnostic interview instrument, and it is commonly regarded the alleged gold criterion against which other instruments are evaluated (Foa & Meadows, 1997). Even though helpful as a marker of diagnostic condition prior to and following treatment, it is not possible to use SCID to measure the severity of symptom. Having briefly discussed the components of treatment outcome research, the discussion will now turn to literature on treatment outcome with an aim toward assessments with the ideal. Literature Review In an effort to explain post-trauma responses, psychosocial theorists put emphasis on notions such as catharsis, denial, abreaction, and phases of recuperation from trauma in formulating treatment for post-trauma problems (Wilson et al., 2001). Even though drawing from an alternative theoretical perspective, such treatments involve elements resembling those observed in the cognitive-behavioral treatments (Hodgkinson & Stewart, 1998). For instance, Horowitz’s (1976, 13) notion of ‘encouraging expression’ and of ‘dosing’ of the distressing incident somehow resembles exposure strategies. Other psychosocial scholars concentrate mainly on group process. Even though the psychosocial treatments were drawn from controversial assumptions of trauma and its resulting illness, they have not been extensively verified in controlled outcome investigations, and those existing investigations have endured from several methodological problems (Foa & Meadows, 1997). However, numerous studies have proposed that psychosocial therapies may be effective in PTSD treatment. Lindy and colleagues (1983), in an investigation of survivors of the fire in Beverly Hills Supper Club, studied the application of short-term psychosocial treatment. Survivor, identified as those who were actually present at the scene, relatives of the casualties, rescue people, and those who identified the victims, were evaluated for trauma-related analyses applying DSM-III measures, even though the technique of evaluation was not explained (Lindy et al., 1983). Only 9, among the 30 participants in this research, qualified for PTSD (p. 598). The others were subjected to different trauma-related diagnoses, and two participants did not receive these same diagnoses. Since this investigation barely meets any of formal standard measures, the findings are difficult to interpret. At most they may indicate the effectiveness of the psychosocial therapy used with victims of trauma who do not show considerable trauma-related disorder. Roth and colleagues (1988) subjected 13 female victims of sexual harassment in group therapy in accordance to Horowitz’s paradigm of reactions to trauma. The single inclusion measure was having been sexually harassed. There was a control case, but respondents were not arbitrarily placed to these two clusters. Due to significant attrition, just 7 females were taken in the final investigation (Roth et al, 1988, 82-93). Most female participants in the therapy group were also in regular therapy prior to joining the group, and others started such therapy at some stage in the group therapy, which contributed further discrepancy in the experimental case. Among other setbacks in methodology, blind assessments were not employed, and the Impact of Events Scale (IES) was not employed as initially confirmed (Roth et al., 1988, 87). Because of the control respondents’ attrition, aforementioned, only a subdivision of evaluations integrated comparison with the control cluster. Among these, most did not exhibit variations between the two clusters, and one exhibited a higher decrease in indications in the control cluster in relation of the therapy group (p. 89). This lack of group variations could have been caused by the small sample and hence absence of adequate strength to distinguish variations. Findings over a longer period commonly demonstrated more significant progress in the therapy respondents. Even though these findings seem encouraging, they cannot be ascribed to therapy alone, owing to the methodological setbacks aforementioned and because, owing to attrition in the control cluster, sets of information for this cluster were presented for only the initial several months. To sum up, previous studies of psychosocial treatment were burdened with methodological defects, such as lack of satisfactory evaluation of outcome, absence of controls, and imprecisely defined treatments. Nevertheless, more recent investigations have applied more accurate measures. With more investigations employing such measures, future researchers will be able to assess the usefulness of these therapies for the treatment of PTSD. The highly researched psychosocial therapies for PTSD are the cognitive-behavioral treatments. These involve various treatment courses, including anxiety management courses, cognitive restructuring techniques, exposure methods, and their combinations (Vasterling & Brewin, 2005). Exposure therapies, all comprising the general attribute of having patients face their anxieties, differ on the features of exposure instrument, length of exposure, and level of arousal during exposure. A number of controlled studies assessed the effectiveness of exposure treatment in relation to other therapies or to a wait-list status (Vasterling & Brewin, 2005). Other investigations have studied either the effectiveness of a particular exposure course itself or contrasted the effectiveness of particular exposure techniques (Barbanel & Sternbeg, 2006). In a study of exposure therapy in PTSD-afflicted veterans, Boudewyns and associates (1990) published two papers on investigation carried out with Vietnam veterans in a designated inpatient division of a VA infirmary. Exclusion and inclusion were evidently differentiated in this issue, as were the target indicators, or physiological stimulation in reaction to trauma-related stimuli and overall severity of PTSD, and analysis was measured by structured interviews carried out by expert analysts. Even though no lowest symptom severity threshold was needed, all patients in the research were also taking part in an inpatient course at the moment and hence were prone to have had serious psychopathology. Neuropsychological Factors Studies have proved that PTSD is related with permanent alterations in brain areas and neurobiological systems that intermediate both cognition and stress response. Severe psychological trauma has been linked to changes in neurons of the hippocampus, an area of the brain responsible for memory and learning (Vasterling & Brewin, 2005). Several neuroimaging studies have discovered smaller volume of hippocampus in neurotic people with PTSD. Moreover, functional imaging research has revealed changes in brain activity in other areas connected to memory, including medial prefrontal cortex and amygdala, in individuals with PTSD (Vasterling & Brewin, 2005). It has been assumed that these alterations may, partly, be connected to stress-stimulated changes in serotonergic performance (Stein, Kennedy & Twamley, 2002). Concerns about neuropsychological factors in posttraumatic stress disorder (PTSD) surfaces in response to the complaints of patients about difficulties with concentration, attention, and memory (Wilson, Friedman & Lindy, 2001); several studies have diagnosed weakened performance in learning and verbal memory in individuals with PTSD compared with control groups (Golier & Yehuda, 2002). Other investigations have reported variations between groups without and with PTSD in the domains of attention and working memory (Gilbertson, Gurvits, Lasko, Orr, & Pitman, 2001) and of speed in processing (Brandes, Ben-Schachar, Gilboa, Bonne, Freedman & Shalev, 2002). Even though Uddo and colleagues (1993) and Brandes and associates (2002) discovered impaired visual memory functioning in people with PTSD, most investigations have failed to identify PTSD-linked impairments in visual memory (Stein, Kennedy & Twamley, 2002). Findings of neuropsychological impairments in PTSD are inconsistent, though, and a number of investigations have not reported variations between groups without and with PTSD in memory functioning (Crowell, Kieffer, Siders & Vanderploeg, 2002). Such discrepancies in findings may be partly due to sample limitations intrinsic in groups with PTSD. Majority of neuropsychological studies of PTSD include veterans with PTSD who commonly show signs of comorbid psychiatric diagnoses (Crowell et al., 2002). Vasterling and associates (2002) discovered that veterans with PTSD displayed more disturbing reactions and had inadequacies in primary and delayed memory as well as recollection of a verbal learning activity, and learning on a visual memory activity. Combination of Medication and Psychotherapy in the Treatment of PTSD There are no available methodical data on combining psychotherapy and medication in the treatment of people with posttraumatic stress disorder, in spite of its well-known administration. Systematic review of literature on acute trials shows that pharmacologic and psychosocial therapies each leave a considerable percentage of patients with residual symptoms (Barbanel & Sternberg, 2006). In a current professional consensus paper on the treatment of PTSD, the major proposals for treatment of adults with PTSD was either an independent trauma-oriented psychotherapy or the combination of supportive psychotherapy with medication (McLean & Woody, 2001). Specialists keenly advised integrated therapy if psychiatric comorbidity exists, comprising anxiety disorders such as acute depressive disorder (Mcnally, 2003). Medications generally advised were venlafaxine, nefazodone, and SSRIs. Notably, medication alone was not a highly preferred recommendation (Vasterling & Brewin, 2005). Existing empirical findings to date on a number of trauma-oriented psychotherapies have reported that these time-constricted psychosocial therapies can be highly successful in a fairly short period of time (Foa & Meadows, 1997). General attributes across these treatments comprise (1) applying a psycho-educational approach that explains PTSD making use of experience-direct examples and language; (2) vigorously intervening to assist in normalizing the reaction to trauma and in so doing thwart perceptions of the self as impaired or weak; (3) teaching of strategies for independent coping with anxiety symptoms; (4) promoting counteraction of avoidance difficulties, especially when the behavior signifies avoidance of prompts that are neutrally undisruptive; and (5) encouraging further cognitive and emotional processing of the neurosis through narrative or imagistic evaluation of the distressing experiences (Wilson et al., 2001). There are fewer interesting and reliable controlled pharmacotherapy investigations in the literature and thus far no medication classification could have been regarded a verified treatment. Nonetheless, it is possible that the selective serotonin reuptake inhibitors (SSRIs) will attain identification as an effective treatment of PTSD on the basis of current controlled studies (Vasterling & Brewin, 2005). Moreover, the Food and Drug Administration currently granted the first pharmacologic signal for the administration of the SSRI sertraline for PTSD according to the outcomes of multicenter experiments (Barbanel & Sternberg, 2006). Medication vs. Psychotherapy Treatments Medication can be very effective when prescribed appropriately particularly for psychosis, bi-polar disorders and acute depression. Obviously each patient requires to be cautiously assessed but medication can assist in alleviating several of the serious symptoms that can be quite harmful and disruptive (Wilson et al., 2001). Generally medication can lessen suicidal tendencies; hinder impulsive and unstable behaviors, calm fear or panic, and control extreme mood changes. Often acute problems require the administration of medication to help in the productive administration of psychotherapy (McLean & Woody, 2001). For instance, because self-exploration can and usually does produce anxiety several temporary medication may help an individual stay with the psychotherapy procedure long enough to obtain positive and helpful outcomes (Stein et al., 2002). However, medications are not magic potions and can bring about considerable setbacks in therapy. For some individuals an advice to take account of medication can leave them mentally unstable and miserable. This response necessitates skill and patience to discover the personal essence of taking medication for emotional problems (McLean & Woody, 2001). Concerns about family history, genetics, side effects, and hopelessness or, on the other side, a certainty that difficulties are outside their control and medication will make all everything go back to normal, are some of the issues that merit attention (Foa & Meadows, 1997). Individuals can occasionally feel they should choose between medication and psychotherapy. It is ill advised and adverse for an individual in the medical profession to proclaim that all emotional difficulties are the consequence of biochemical imbalance or genes and that medication is the only way to recover from them (Wilson et al., 2001). Some can be influenced by this viewpoint that diverse ‘high dose medications’ are recommended making patients confused, anxious, and desensitized (Williams & Sommer, 1994). On the other side, several therapists proclaim that all difficulties are wholly emotional or psychological and fail to make a well-timed recommendation, which may lessen needless misery or suffering (Hodgkinson & Stewart, 1998). An individual amid a manic experience or immobilized by serious anxiety can gain from all the assistance they can obtain, involving medication in several instances (Foa & Meadows, 1997). Conclusion This review has presented a critical evaluation of the literature regarding treatment outcome for posttraumatic stress disorder. Sufficient research has amassed to enable at least some initial assumptions about effectiveness of treatment for PTSD. In general, cognitive-behavioral therapies enjoy the highest volume of controlled outcome research, and have been the most systematically verified. These studies come together to show that both stress inoculation training and prolonged exposure processes are efficacious in alleviating PTSD symptoms. In contrast to medical perception, there is no substantiation suggesting the dominance of programs that merge various treatments for PTSD. Possibly the combination courses that have been studied have not been the most appropriate and misled the individual elements by restricted time given for each. Therapies that are non-behavioral have not been the topic of well-controlled investigations to the point that cognitive-behavioral therapies have. Nevertheless, this is not to conclude that they are not effective. Confidently, the currently growing literature on these therapies may explain their effectiveness for alleviating PTSD. References American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: American Psychiatric Association. Barbanel, L. & Sternberg, R.J. (eds). (2006). Psychological Interventions in Times of Crisis. New York: Springer. Brandes, D., Ben-Schachar, G., Gilboa, A., Bonne, O., Freedman, S. & Shalev, A. 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