Dr Robert London

PTSD Patients Deserve First-Line Treatment

PTSD Patients Deserve First-Line Treatment - January 2012

Help me understand something: Why is medication management consistently used first in the treatment of posttraumatic stress disorder in psychiatry today, when solid evidence and the experts report that cognitive-behavioral and exposure therapies are far more effective and should be considered the first line of treatment? Two selective serotonin reuptake inhibitors – paroxetine and sertraline – have been approved to treat PTSD. Could the emphasis on medications over CBT or exposure therapies be tied to those approvals?

Perhaps this disconnect exists because CBT and exposure therapy are more challenging for psychiatrists and other clinicians than we realize. When teaching these strategies to mental health professionals, one of the first remarks I often hear is: “This is not so simple,” or “This is hard work.” In fact, it is hard work to develop CBT or exposure therapy protocols and procedures. Many simply don’t know how to do them and are not encouraged to learn these skills in their training programs. Perhaps it’s easier to prescribe a pill than to put together a treatment plan uniquely designed for each individual patient. In light of the superiority of CBT and prolonged exposure therapy for treating PTSD (Arch. Gen. Psychiatry 2011 Oct. 3 [Epub doi:10.1001/archgenpsychiatry.2011.127]), we’ve got to change course.

Maybe a first step toward shifting gears would be coming to a better understanding of why CBT and exposure/behavioral modification therapies are so effective. CBT is essentially a verbal procedure that teaches patients how to reprocess information. It works because, instead of getting patients to dredge up painful memories like they must do in traditional open-ended psychotherapy, CBT involves changing pathways in the brain by talking to the patient in a way that can have an incredibly healthy role in his or her recovery. Replacing negative schemas of thought with realistic positive thinking therapies is central. Simply put, these therapies recognize the problem, circumscribe it, challenge it, and offer a road to change.

Likewise, exposure therapy is so effective because it encourages patients to reprocess the trauma in a controlled, supportive environment often linking negative traumatic experiences with pleasant thoughts and ideas – especially when using reciprocal inhibition or desensitization techniques. When I learned about Operation Proper Exit, a program that allows wounded American combat veterans a chance to return to Iraq in the hope that their return will help them move forward emotionally, I was reminded that the military understands the power of exposure therapy. My understanding is that Operation Proper Exit is more than that, however. This program encompasses some CBT, too, because it encourages these wounded warriors to think about issues from a different perspective while reprocessing the stressful experiences.

CBT or hypnotic/relaxation/exposure/behavior modifications strategies can be used effectively in 6-, 8-, 12-, or 16-week programs, offering patients a road map at mastery of their disorder. For example, when using a hypnotic behavior modification exposure approach to PTSD, the patient is taught a self-hypnotic technique usually taking only a single visit. Included in this visit are the instructions on how to practice this technique therefore becoming expert in the procedure. Following this, a hierarchy of stressors surrounding the PTSD is developed using the least stressful first. That is, the patient focuses on nontraumatic events before the traumatic event occurred. Then, using the patients’ newly learned ability to enter an alert, focused state, – which we call hypnosis or relaxation – the patients can begin the process of desensitizing the traumatic event.

Dr. Gerard Sunnen, a New York City psychiatrist with more than 30 years’ experience successfully using hypnosis coupled with meditation in the treatment of PTSD, said in an interview that one value of self-hypnosis is that the patients gain a growing sense of control and mastery of their symptoms. This is not the case with medications, he reports.

In addition, Dr. Sunnen says, hypnosis speaks to the cognitive dimensions of the mind. When applied with diligent practice, he says, the technique reinforces more adaptive ways to process PTSD symptoms.

Adding meditation techniques into the hypnotic approach expands a sense of self-awareness and generates calm into the very mechanisms of anxiety production, including PTSD symptoms, according to Dr. Sunnen. PTSD involves limbic system circuitry and its autonomic nervous system outflow. Meditation techniques enable the mind’s executive functions to gradually extend their reach and eventual jurisdiction into the dimensions of calming the mind of the PTSD sufferer – often leading to resolution of the disorder.

A CBT program could be structured in the same manner – as a procedure with a clear endpoint for treatment. Yet, the clinician could give the patient a flexible, open-ended period of time to affect problem resolution in differing circumstances with differing personality types.

Virtual reality or virtual reality exposure therapy, a high-tech method not unlike a video game, uses a head piece and a set of electronically visualized hierarchies to desensitize the traumatic event. The military and some clinicians are using virtual reality. But psychiatry has been slow to embrace it – despite its effectiveness.

So again, why have behavior modification, hypnotic, exposure, CBT, and virtual reality approaches to treating PTSD not become mainstream in mental health care? We need to know the procedures and be able to codify what’s being done, which of course, makes reimbursement straightforward. In some cases, we might need to use exposure therapy and medication concurrently for certain mood-related problems. In cases involving veterans with nightmares, randomized controlled trials suggest that prazosin, a generic antihypertensive, might prove beneficial. My point is that we must be prepared to do what’s best for the individual patient and that medication may be part of the treatment in some cases. But if CBT and exposure behavior modification therapy is considered first line of treatment, we need to start there.

As more and more veterans return from Iraq and Afghanistan, we are bound to see more and more cases of PTSD. We’ve got to make sure that they get the best possible care. Training programs in psychiatry, practicing clinicians, and organized psychiatry need to get serious about addressing this important issue and do more with these well-established non-medicinal therapies.<[QM]>n

Dr. London, a psychiatrist with New York University Langone Medical Center, has no disclosures. He can be reached at cpnews@elsevier.com.