Strategies for Treating PTSD

Clinical Psychiatry News - Volume 32, Issue 12, Page 20 (December 2004)

In the course of our careers, many of us have run across terms like shell shock, soldier's heart, combat neurosis, combat fatigue, or—get this—Da Costa syndrome, known for more than a century as neurocirculatory asthenia, and a favorite term that my father, an ophthalmic surgeon, used for patients he thought had visual difficulties that were secondary to severe emotional stress.

Historically, these syndromes appear to be labels for severe emotional responses to life.

As you know, such psychological stress leads to recurrent thoughts, nightmares, and flashbacks to the dreaded event. The patient may avoid people and places, and interpersonal relationships may deteriorate. Insomnia, irritability, emotional detachment, anger, and concentration difficulties may occur.

That collection of stress reactions—named posttraumatic stress disorder (PTSD) in 1980 by the American Psychiatric Association—also leads to increased heart rates and hyperactivity of the sympathetic nervous system (Biol. Psychiatry 1997;41:319-26). Furthermore, models of neuroimaging techniques have shown smaller hippocampal volume in patients who have chronic, severe PTSD (Psychiatric Annals 2004;34:845-56).

With the recognition of PTSD as a disorder in the DSM-III, the many symptoms of acute stress reactions secondary to life-threatening situations began to be codified, organized, and better understood.

Such recognition is often an important first step to better treatment. Not only is the clearly evident PTSD seen, but the subtle, less intense variations become obvious and, indeed, treatable.

The results of PTSD can be devastating. In the United States, 1%-3% of the population is affected by PTSD; at the subclinical level, 5%-15% of the population is affected. Among Vietnam veterans, 30% of the soldiers were affected, and an additional 25% were affected at the subclinical level (“Concise Textbook of Clinical Psychiatry” [Baltimore: Williams and Wilkins, 1996, p. 211]). Clearly, PTSD is one of the most commonly seen psychiatric disorders.

Treatments for the disorder abound, although their rates of success appear to vary. Medications, cognitive-behavioral therapy (CBT), group therapy, traditional behavioral therapy, and hypnosis are used. In my experience with PTSD, I have found that a place exists for most of these treatments.

The medications, of course, are critical—not so much for the PTSD itself as for the severe, life-threatening depressions that can coexist with this disorder.

I've treated several PTSD patients using CBT as well as behavior modification and hypnosis. My approach is to evaluate for depression and, if it is present, to treat it as soon as possible. Relief of the symptoms and thoughts of depression sometimes leads to control of the PTSD and to its subsequent remission. In other cases, my preferred treatment has been a combination of hypnosis and behavior modification.

I was able to get the best results combining the two approaches. For other clinicians, CBT alone or in groups may work better. In vivo treatments have been effective but are time-consuming. Newer techniques—such as eye movement desensitization reprocessing (EMDR) or virtual reality techniques—are now being used. The data on those approaches are not yet in, but they hold great promise.

I have successfully treated PTSD many times over the years, but two cases stand out. One involved a woman who was attacked by a dog while walking home from work one winter day. She was bitten on both arms and, in her effort to escape, she slipped on ice and shattered her left patella. The patient was hospitalized; she had to undergo a partial knee replacement and a subsequent referral to rehabilitation medicine. The referral came to me through her orthopedic surgeon.

The second case involved a father whose 8-year-old son had been playing at a friend's house and was being dropped off in a school parking lot where the father waited to pick him up. As the father watched, the boy began to exit the back door of the friend's car, catching his coat in the door. The oblivious driver took off, dragging the boy about 200 feet with the father chasing the car on foot. The boy luckily suffered only bruises and contusions.

The dog-bite victim and the helpless father experienced similar psychological and physical stresses. The father experienced guilt, thinking that he should have either picked up his son at the friend's home or been closer to the friend's car. The woman—who never liked animals—thought that she should have crossed the street when she saw the dog and its owner approaching.

In an objective sense, the woman's trauma was more intense than that of the father. But in terms of subjective perceptions, each suffered PTSD.

For each patient, I used my Learning, Philosophy, and Action (LPA) technique. One visit was used to help the patient understand PTSD. The second visit was used to reach a global philosophical understanding, based on patient history, of what might have precipitated such an emotional response. In both patients' cases, the events were of such magnitude that the philosophical model was hardly necessary. But such exploration is important.

The action phase introduced ways to alleviate the disorder. The father was seen 2 days after the trauma, and the woman 3 months after the event, but I used the same technique with both patients. First, I taught the patient self-hypnosis, which took about 30 minutes. Then, I used an in vitro combination of systematic desensitization and reciprocal inhibition processes based on a split-screen movie technique.

While the patient was relaxed—and using hypnosis to achieve this—I introduced the concept of a large movie screen. As the patient visualized the screen, I asked him or her to imagine a thick, black line down the screen's center. On the left side of the line, I asked the patient to project the events leading up to the traumatic exposure, such as walking down the street or waiting for the son. On the right side of the screen, I asked the patient to visualize the expected happy ending, such as arriving home safely in the woman's case, or safely picking up the son in the father's case. The split-screen approach allows the patient to look from left to right and from right to left on the screen, an important part of the desensitization/inhibition process's next step.

As the process moves forward, the patient gets to see the traumatic event on the left side of the screen—not the real event, but a review of it. By doing this, the event gets out of the patient and onto the screen. The patient sees it, but does not reexperience the event. This is therapeutic.

We then move to the right side of the screen and use it to imagine any pleasant experience that the patient wishes. We link the two images. The traumatic events are linked to perceived pleasure. This desensitization/reciprocal inhibition process did negate the PTSD in both patients.

After three visits, the father was just fine 6 months later. The woman went on for about 3 months with a combination of learning and desensitization. About 70% of her PTSD problem was resolved.

She opted to continue in traditional talk psychotherapy. She was fine 1 year later, and treatment ended. Follow-up after 1 year was good.

Dealing with PTSD is challenging, and we need to be ready with the proper treatments. It is up to us to recognize this disorder and identify the treatment that works best for each patient.

Write me at cpnews@elsevier.com, and let me know about your treatment approaches to PTSD. I'll try to pass your approaches along to my readers.

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