Treating PTSD and Complex PTSD
Contents
PTSD Treatment
The International Society for Traumatic Stress Studies publish very comprehensive treatment guidelines, along with a separate set for treating Complex PTSD, which is designed to address the additional symptoms found in those with many different types of traumas or repeated trauma. Many other professional organizations also publish treatment guidelines.
A variety of treatments are available for treating "simple" or normal posttraumatic stress disorder.[1] These treatments are designed to address the "core symptoms" of PTSD: re-experiencing, avoidance/numbing, and hyper-arousal. [2]
Talking Therapies
Forms of psychotherapy which have been proven to be effective include:
- Early Cognitive-Behavioral Interventions
- Trauma-focused Cognitive Behavioral Therapy (CBT) including Stress inoculation training (SIT)
- Psychodynamic Therapy
- Group Therapy
- Prolonged Exposure Therapy
- Eye Movement Desensitization and Reprocessing (EMDR)
- Psychosocial rehabilitation
- Psychopharmacotherapy (medication)
- Hypnosis (as an adjunct treatment, which can reduce intrusions and re-experiencing symptoms in the shorter term)
- Creative Therapies[3][1]
Psychosocial Rehabilitation
Psychosocial rehabilitation focuses on the larger community as well as the person with PTSD, and is most relevant to those who have experienced multiple traumas or particularly severe PTSD. Many people with PTSD have impaired functioning in multiple areas of life, for example romantic relationships, family and friends, and employment; psychosocial rehabilitation aims to address these. Areas typically included in this are:
- health education/psychoeducation
- supported education
- self-care/independent living skills
- supported housing
- supported employment
- family skills training
- social skills training
- employment rehabilitation
The effects of this form of treatment have mostly been studied in people with several mental illness rather than specifically PTSD. This form of treatment typically involves the person with PTSD getting their own goals, and lasts for months, sometimes years or indefinitely, for example in the case of supported employment programs. It may involve the clinician liasing with other organizations to help the person access treatment, for example the Veterans' Association or a community college. The timing of this treatment should be planned in a way that avoids overwhelming the person with too many treatment goals or carrying out too many treatment activities at once.[1]:583-591 More evidence exists for education about PTSD than other interventions in this form treatment, however a symptom of Complex PTSD is experiencing difficulties in relationships, including withdrawal and helplessness. [4]
Medication and PTSD
According to the ISTSS treatment guidelines many people with PTSD prefer medication to psychotherapy, yet the overall effectiveness is not as high as that achieved by some cognitive-behavioral treatments. Medication is particularly appropriate if there is a lack of CBT specialists to provide therapy, and the typical comorbid conditions of depression and anxiety also respond to medication. However, discontinuing medication which produced a positive response frequently leads to relapse. [1]:567 Medication can be used in addition to psychotherapy, not just as an alternative.
Complex PTSD Therapy
Complex PTSD, also known as Disorders of Extreme Stress Not Otherwise Specified (DESNOS) is caused by repeated traumatic events, which are typically prolonged in duration. Is not a separate diagnosis in the DSM-5 psychiatric manual but was referred to as "PTSD and its Associated Features" in the previous DSM-IV version, and is likely to be diagnosed as "PTSD with Dissociative type" in the DSM-5. Complex PTSD is called Enduring Personality Change after Catastrophic Events (EPCACE) in the World Health Organization's ICD-10 manual. [4]
Treatment for complex PTSD differs from treatment for PTSD because it both the core symptoms (re-experiencing, avoidance/numbing, and hyper-arousal) and additional symptoms, which are not resolved by processing the trauma alone. These symptoms include:
- persistent and pervasive emotion regulation problems
- disturbances in relational capacities
- alterations in attention and consciousness (e.g., dissociation)
- adversely affected belief systems
- somatic distress or disorganization[4]: 3-4
Flexible, patient-tailored treatments are needed, with interventions matched to the prominent symptoms of each patient. This section covers the differences in individual psychotherapy recommended for people with Complex PTSD. Other treatments such as medication are described in the previous section.
Stage 1: Safety
For Phase 1, the clinician should observe and consider reduction in symptoms along with the patient’s demonstrated ability to reduce unhealthy coping or emotion-regulation strategies (such as drug abuse, self-injurious behaviors, and risk-taking or aggressive behaviors), as well as to demonstrate an increase in executive functioning and life skills. [4]:11
Stage 2: Processing unresolved trauma memories
Phase 2 processing of trauma memories should be initiated when there is agreement between the clinician and patient that the patient has enough skills and life stability to safely engage in trauma-focused work. During this phase, relapses are expected and planned for, with the patient sometimes returning to Phase 1 tasks to re-learn or re-consolidate skills before continuing with trauma processing. The movement to Phase 3 occurs when symptoms have been generally and consistently remitting over time and is a decision that is made in a collaborative fashion between therapist and patient. [4]:11
Stage 3: Consolidation of treatment gains
Appointments will steadily become less frequent during this phase. This phase covers the transition out of therapy to greater engagement in community life and involves the therapist and patient working collaboratively. This includes:
- consolidating the gains in "emotional, social and relational competencies" (including in building healthier relationships)
- The therapist supporting and guiding the person in applying their skills to strengthen safe and supportive social networks
- The therapist supporting and guiding the person in building and enhance intimate and family relationships
- planning for and organizing "education, employment, recreation and social activities or meaningful hobbies"[4]:10
The treatment guidelines also state that
Phase 3 planning also includes proposed use of “booster” sessions to refresh skills or address a life challenge, an articulation of relapse prevention interventions, and identification of alternative mental health resources. Phase 3 is essentially a plan for follow-up care, a part of treatment that is routine for other psychiatric disorders associated with significant personal and social resource loss but may be overlooked in the treatment of Complex PTSD.[4]:10
Duration of treatment
Treatment for complex PTSD involves long-term therapy, and the International Society for Traumatic Stress Studies (ISTSS) recommend three phrases to treatment in their treatment guidelines. [4] Research shows a treatment length of 4 to 5 months has brought considerable benefits to patients but ISTSS experts have recommended longer courses of treatment than those used in clinical trials. [4]:10
While there was no consensus on an ideal treatment duration, the majority of experts considered 6 months a reasonable length of time for Phase 1, and 3 to 6 months for Phase 2, producing a combined treatment duration of 9 to 12 months for the first two phases. [4]:10 However, some people will need these two intensive treatment phases to be significantly longer.[4]:11
Phase 3 was suggested as 6-12 month interval involving weekly visits which tapered off over time, depending on the patient's progress. [4]:10
References
- ^ a b c d Foa, Edna B., Keane, Terence M., Friedman, Matthew J., Cohen, Judith A. (Eds) (2009). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. Guilford Press..
- ^ American Psychiatric Association, (2013). Desk Reference to the Diagnostic Criteria from DSM-5. APA.
- ^ Youngner, Cole G.; Gerardi, Maryrose, Rothbaum, Barbara O. (2013). PTSD: Evidence-Based Psychotherapy and Emerging Treatment Approaches. FOCUS, volume 11, issue 3, page 307-314. (doi:)
- ^ a b c d e f g h i j k l m Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A., Van der Hart, O.. The ISTSS Expert Consensus Treatment Guidelines For Complex PTSD In Adults. Journal of Traumatic Stress, volume 24, issue 6, 5 November 2012, page 615-627.
