Medication vs Psychotherapy in Post-traumatic Stress Disorder - Research Paper Example

Post-traumatic stress disorder (PTSD) mainly occurs after the traumatic events when the individual is no longer in danger and stress is not self-limiting. The multimodal treatment strategies for PTSD management adopted by health care professionals plays an important role in such patients. The different treatment alternatives include psychotherapy and pharmacological intervention. The pharmacological treatment treats physiological symptoms of PTSD victims, which help them to get treated in psychotherapy where the treatments are based on emotional attributes. Also, family education, family therapy, PTSD education groups, stress management, spiritual groups, and recreational therapy are also useful in combating PTSD. The first-line nonpharmacologic therapies for PTSD in the past-focused models are evidence-based psychological treatments include prolonged exposure therapy, cognitive processing therapy and Eye Movement Desensitization and Reprocessing (EMDR). They are based on talk therapy. The present therapies are based on the training the client about the coping strategies to improve functioning (e.g., social skills, relaxation, grounding, and cognitive restructuring). The present-focused models include stress inoculation training and anxiety management. Introduction As the global environment is changing at fast pace offering more challenges, stress and anxiety are the prime factors of many mental and health problems. The individual’s stress response to a traumatic situation is subjective and depends upon the vulnerability and responsivity of a person. Post-traumatic stress disorder (PTSD) is an anxiety disorder which mainly occurs after the traumatic events when the individual is no longer in danger and stress is not self-limiting. The harmful event causing trauma includes the terrifying experience happened to dear ones or strangers or self in which grave physical harm occurred or was threatened. Any perceived unpredictable and uncontrollable, unusual drowning life experience like violent personal assaults, natural or human-caused disasters, accidents, battle-scarred soldiers – and military combat (National Institute of Mental Health (2009) can trigger PTSD. The increasing number of population is getting exposed to unhealthy events like terrorist attacks, school shootings, or assaults, which are leading causes of rise in PTSD cases. The individuals suffering from this debilitating disorder have to fight against mental demons causing them to respond with intense fear, helplessness, or distress. Every individual is unique in his personality, beliefs, personal values, and prior experiences (especially of other traumatic events in their life). Therefore the duration of healing from PTSD differs (Atique, 2005). Ongoing research in PTSD opens up multifaceted approach for the treatment of PTSD. There is a ongoing controversy on the PTSD treatment. Some health care providers feel that if the etiology of PTSD can be well addressed, PTSD can be cured. Others feel that PTSD is a chronic mental health illness with an unremitting course (Monson et al., 2006). The final goal of the treatment strategy offered in PTSD is to improve physical and emotional health of the patient to lead healthy functional life. The possible treatment of PTSD is attributed to several factors like stage and biological characteristics of the PTSD, age & preferences of the patient, advantages and disadvantages of a particular treatment in a specific patient. The person suffering from PTSD might also be suffering from other issues at the same time like , abusive relationship, panic disorder, depression, substance abuse, and feeling suicidal (National Institute of Mental Health (2009). Such multiple problems should be resolved concurrently with the proper treatment approach. Clinicians personal and professional view and competency regarding the diagnosis are also important in deciding a particular strategy for a specific patient (Najavits, 2006). The treatment of the PTSD soldier could be effectively done in Veterans Affairs (VA) hospital. The combat-related PTSD are diagnosed and treated effectively with the capable health care team. VA hospitals are also equipped with knowledgeable and experienced mental health care providers. Also, the veterans are directed to make use of referrals where they could get appropriate intervening and caring (Atique, 2005). The multimodal treatment strategies for PTSD management adopted by health care professionals plays an important role in such patients. The different treatment alternatives include psychotherapy and pharmacological intervention. The pharmacological treatment treats physiological symptoms of PTSD victims, which help them to get treated in psychotherapy where the treatments are based on emotional attributes (Gore & Lucas, 2008). Also, family education, family therapy, PTSD education groups, stress management, spiritual groups, and recreational therapy are also useful in combating PTSD (Atique, 2005). The first-line nonpharmacologic therapies for PTSD in the past-focused models are evidence-based psychological treatments include prolonged exposure therapy, cognitive processing therapy and Eye Movement Desensitization and Reprocessing (EMDR). They are based on talk therapy. The present therapies are based on the training the client about the coping strategies to improve functioning (e.g., social skills, relaxation, grounding, and cognitive restructuring). The present-focused models include stress inoculation training and anxiety management (Najavits, 2006). Pharmacotherapy Pharmacological treatment includes various drugs or their combinations like antidepressants, anxiolytics, antipsychotics, sedative/hypnotics etc. The patients are treated according to the specific symptoms and situation. Antidepressants are often indicated to treat PTSD symptoms including depression and other comorbid symptoms like drug dependency, and insomnia. US Food and Drug Administration (FDA) approved selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, serotonin (sertraline) are indicated treatments for PTSD. SSRIs are emerging a versatile tool, to mitigate all three symptom clusters of PTSD. Also other drugs like SSRI fluoxetine, the alpha 1-adrenergic antagonist prazosin, tricyclic antidepressants, monoamine oxidase inhibitors, and venlafaxine have given positive results to treat PTSD symptoms for randomized clinical trials. Still, more focused approach is required to establish evidence based clinical trials for safety and efficacy of drugs. When the patients are failed to respond to SSRIs, atypical antipsychoytic drugs can be used. Other drugs under investigation antiadrenergic agents, anticonvulsants, and a variety of agents may prove more beneficial with lesser side effects than SSRIs. Benzodiazepines are failed to work to treat PTSD patients. The selection of pharmacotherapy by physician also depends on the presence or absence of comorbid disorders (e.g., depression, panic disorder). Though SSRIs are the first-line treatment used, the selection of other options can be considered like use of antiadrenergic agents for excessively aroused, hyperactive, or dissociating patients; anticonvulsants for labile, impulsive, and/or aggressive patients; and atypical antipsychotics for fearful, hypervigilent, paranoid, and psychotic patients (Friedman, 2006). Psychotherapy Psychological treatments are mainly based on talk therapy. It is necessary to open dialogue with recent PTSD patients about past traumas in detail. The expression about the painful feelings (e.g., sadness, anger) triggers agitation at first in the patient and then these feelings go down slowly (Najavits, 2006). This leads to improvement of problematic signs; thereby assisting in additional therapeutic strategies. Talk therapy is sometime might not be fruitful when the individuals are not able to phrase the horrifying events adequately. This necessitates the use of tangible approach in healing environment to deliver thoughts and emotions. The sand play therapy can be used to treat individually or whole family. In the sand play therapy, the trained therapist predisposes the client to generate a three dimensional picture in a sand tray with toy miniatures. These trays indicate the personal feelings of the client and also measure of client’ s progress. First sessions use dry sand when the client is able to express surface thoughts and durations are silent. This therapeutic tool helps to vocalize the problems in latter sessions. The total duration of a session is 50 to 60 minutes with 35 to 40 minutes are given for creating the picture, which is followed by discussion with the client. Family’s silence and support is necessary during the treatment (Moon, 2006). Cognitive-behavioral therapy (CBT) The cognitive and behavior therapies can be used in the individual, family, or group format. The synergistic approach of cognitive-behavioral therapy is selectively suggested in all PTSD practice guidelines (Friedman, 2006). CBT deals with patient’s cognition to alter emotions, thoughts, and behaviors. This strategy pursues the conditioned fear and cognitive distortions associated with PTSD. The negative cognitions like trauma-related erroneous automatic thoughts causing stress, depression, and anxiety are challenged and treated. The traumatized person starts blaming himself/herself for the negative consequence. The illogical thinking includes catastrophizing (exaggeration of harmful effect), personalizing (holding responsible for negative outcome), all-or-nothing thinking (feeling of losing always), overgeneralizing (fixing oneself to unpleasant endless pattern), and mental filtering (ignoring good part). (Tuller, Jan 22, 2002). Cognitive strategy is basically dealing with alteration of a thought process that made him upset. Basic assumptions about certain event is strategically changed or reframed to reduce negative outcome of the event. This might involve restructuring of words to change their meanings about worrisome event. The bothersome thoughts are displaced by good and pleasing thoughts. This optimistic interpretation would help to sound and feel more pleasant about the same situation, and make the condition more favorable (Pargman, 2006, p. 145). This long term tactic is effective, but requires training, practice and patience to have positive stress reduction. Thus, in the cognitive restructuring technique, well trained therapist challenges such distorted beliefs thereby increasing ability of the patient to overcome intolerable trauma-related emotions such as guilt and shame (Friedman, 2006). Prolonged exposure is other strategy used in CBT to address trauma treatment. The patients are repetitively exposed to horrifying intolerable traumatic memories in a safe and regulated atmosphere. The client should undergo detailed imaging of the intolerable trauma carefully and cautiously in the presence of well trained therapist. It is necessary to open dialogue with the patients about past traumas in detail through talk therapy approach. They are subjected to construct narratives and reiterate bad memories in guided environment to aid the patient to confront the fear. This helps to regain control of the dread and anguish that was present during the initial trauma leading to positive outcome of clinical remission (Atique, 2005). The perceived threatened thoughts like sensing the world as dangerous, seeing oneself as powerless or inadequate, or feeling guilty for outcomes that could not have been prevented have to be treated. Depending upon the capacity of psychological adjustment to the situation and inner coping capabilities of the patient traumatic memories can be confronted by either a “flooding” mechanism or a “desensitization” process (Atique, 2005). When all distressing traumas and bad memories are worked together, the technique is referred as Flooding. This technique has proven success on veterans (Gore & Lucas, 2008). In the “desensitization’’ method each stressor/trauma is handled independently step by step. The most devastation memories are handled at the later stage (Atique, 2005). The patient’s type of PTSD signs decides the selection of CBT strategy. Whether the client’s traumatized fear-based memories and avoidant behavior should be demolished or whether formulating disrupted core beliefs about the self or others are important, decides the selection of this intervention. Practically, exposure therapy is used to solve erroneous cognitions with favorable outcome. And cognitive therapy has successfully solved the issues related to fear-based avoidant behavior. (Friedman, 2006). It was observed that PTSD cases of the traumatic events of September 11, 2001 or Operation Iraqi Freedom are successfully treated with self-managed, Internet-based cognitive behavior therapy than internet-based supportive counseling. (Gore & Lucas, 2008). Eye Movement Desensitization and Reprocessing (EMDR) In Eye Movement Desensitization and Reprocessing (EMDR), various therapeutic approaches are compounded with rhythmical stimulation methods like hand tapping, eye movement, and sounds to stimulate the brains information-processing mechanisms. (Gore & Lucas, 2008). This method is greatly criticized and not recommended as an evidence-based PTSD treatment. The clients are told to imagine a unpleasant traumatic memory and related negative cognitions (such as guilt or shame) (Friedman, 2006). The client is made to concentrate visually on the rapid movement of the clinician’s finger back and forth across their midline. It has been stated that modification in the attention of the client is beneficial to recruit and sort through their mental vault of trauma (Atique, 2005). Cognitive processing therapy (CPT) Cognitive processing therapy combines the advantages of both cognitive and exposure elements. This therapy was first designed for women suffering sexual assault-related PTSD. Now, this theory has found relevance to treat the veteran population and VA treatment setting. In CPT, both distress emotions and anxiety are tackled successfully. CPT can be individualized or can be given in a group format (Monson et al., 2006). A manualized CPT is divided into12-sessions. In the first psychoeducational session, with the context of cognitive and information processing theory, PTSD symptoms are described. At the end of this session, the patient writes an impact statement about the meaning and beliefs of the terrifying experience. The second session deals with the discussion on the impact statement with special emphasis on stuck points in cognition and beliefs. The clients are trained to connect between events, thoughts, and feelings and practice the exercise. In the session 3, traumatic event is written in detail at home daily and reviewed at the session 4. The patient generally focuses on worst event which can be correlated to intrusive symptoms. During Sessions 4 and 5, the importance is given to natural emotions which are suppressed due to traumatic events. Thus, traumatic memory is exposed CPT includes exposure to the through writing and reading accounts, with a focus on feelings, beliefs, and thoughts those arose from the traumatic incidences. In Session 5, the clients read the second account, and the therapy transitions. The patients are taught to ask questions regarding their assumptions and self statements in order to begin challenging them with Socratic style of questioning. During sessions 5, 6, and 7 patient’s ability to challenge and modify maladaptive thoughts and beliefs related to their traumatic experiences is enhanced. The last five sessions deals with overgeneralized beliefs in five areas (i.e., safety, trust, power/control, esteem, intimacy). Finally all the outcomes are noted. (Monson et al., 2006). It has been reported that intention-to-treat results of randomized controlled trial displayed significant improvements in both clinician- and selfreported PTSD manifestations in veterans with military-related PTSD. In addition to this positive results were observed in frequently co-occurring symptoms of depression and general anxiety, affect functioning, guilt distress, and social adjustment. The reexperiencing and emotional numbing syndromes are also positively treated than wait-list condition. VA-rated disability for PTSD was not detected post treatment and follow ups. Therefore the clinicians and patients both feel motivated for CPT approach. (Monson et al., 2006). However, ethical issues prevent the patients to remain in long waiting period for follow up studies. The individual’s therapist effects are not evaluated due to small number of population undergoing CPT. However, positive feature about the treatment is that the veterans are not required to discontinue their psychopharmacological therapies. Dual Diagnosis Population/ Dual Representation theory The clinician’s preferences for the choice of present and past focused therapy for PTSD/substance abuse were studied (Najavits, 2006). The factors like parameters for administering them (e.g., group vs. individual therapy), and clients abstinence from substances were also studied. The clinicians gave lower ranking to past-focused approach consisted of length of clinical experience, higher degree of burnout, and mental health as a primary work setting; while higher rating were given might be due to personal history of trauma associated with substance abuse disorder as a primary work setting (Najavits, 2006). PTSD treatment also stresses on the factors associated with clinician’s training and interest in the model, the type of client and appropriate settings (Najavits, 2006). In the last decades, the clients with co-occurring PTSD and substance-use disorder were considered most vulnerable and not considered suited for past-focused PTSD treatments until they refrain substance abuse (Najavits, 2006). This dual diagnosis population is important since it is most prevalent (52% of long term condition PTSD patients develop alcohol abuse) and have greater severity and serious outcomes than those with either disorder alone. Therefore to treat dual diagnosis population becomes a challenging task for the clinician (Najavits, 2006). Inspite of the developments in drug treatment and strategies PTSD is still considered to offer unmet challenges in the individuals. The recent research on PTSD, memory, and neuroscience has given rise to new approaches to treat PTSD patients. It has been studied in pilot studies that the treatment with a beta-adrenergic blocker e.g. propranolol following an acute psychologically traumatic event might alleviate the chances of developing PTSD manifestations (Pitman et al., 2002). Conclusion Every individual is unique in his personality, beliefs, personal values, and prior experiences (especially of other traumatic events in their life). Therefore the duration of healing from PTSD differs. The final goal of the treatment strategy offered in PTSD is to improve physical and emotional health of the patient to lead healthy functional life. Ongoing research in PTSD opens up multifaceted approach for the treatment of PTSD. Early symptomatic treatment in the individuals can help the PTSD individuals from becoming a long-term condition and also to forestall the later progression of comorbid psychiatric and/or medical disorders. The focus of prevention program should be on vulnerable population for early intervention after exposure to stress, or even protection from stressful exposures, when possible. References Atique, Ayesha. (2005). An In-Depth Dual Perspective On PTSD in War Veterans Pacific College of Oriental Medicine. Frank Scott-Fall 2005 OM 6 Research Paper. Friedman, M. J. (2006). Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq. Am J Psychiatr, 163, 586-593. Gore, T. A. & Lucas J. Z. (2008). Posttraumatic Stress Disorder. http://emedicine.medscape.com/article/288154 Moon, P. K. (2006). Sand Play Therapy With U.S. Soldiers Diagnosed With PTSD and Their Families. In G. Walz, J. Bleuer & R. Yeo, (Eds.), VISTAS: Compelling Perspectives on Counseling 2006 (pp 63-66). Alexandria, VA: American Counseling Association. From: counselingoutfitters.com/vistas/vistas06/vistas06.13.pdf Monson, C. M., Schnurr, P. P. , Resick, P. A. , Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive Processing Therapy for Veterans With Military-Related Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology, 74 (5), 898–907. Najavits, L. M. (2006). Present- Versus Past-Focused Therapy for Posttraumatic Stress Disorder/Substance Abuse: A Study of Clinician Preferences. Brief Treatment and Crisis Interventio, 6(3),248-254. National Institute Of Mental Health (2009). Post Traumatic Stress Disorder from http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/what-efforts-are-under-way-to-improve-the-detection-and-treatment-of-ptsd.shtml Pargman, D. (2006). Managing Performance Stress: Models and Methods. Illustrated CRC Press. Pitman, R.K., Sanders, K.M., Zusma, R. M., Healy, A. R., Cheema, F., et al. (2002) Pilot Study of Secondary Prevention of Posttraumatic Stress Disorder with Propranolol. Biological Psychiatry, 51, 189–192. Tuller, D. (2002). Calculating the Benefits of Managing Stress.New York Times, New York, N.Y.; Jan 22, 2002. Read More