PTSD: treatment

Understanding what is happening in PTSD takes away some of its power over you. It demystifies the condition and checks maladaptive coping strategies – intentional or otherwise. In general, understanding your health condition improves outcomes. Read our article “PTSD – Defined” for more information.

A quick summary:

1. Trauma memory needs elaboration and integration into autobiographical memory.
2. Problematic appraisals (ways of thinking of yourself or the way you relate to various situations) need to be identified and modified.
3. Dysfunctional behaviour and cognitive strategies need to be dropped.
   • Many of the ways in which patients have dealt with trauma memory may have been useful for other, milder stressors but, paradoxically could be maintaining symptoms now;
   • They may directly produce PTSD symptoms;
   • They may prevent change in negative appraisals of the trauma and its consequences;
   • They may prevent the necessary change in the nature of one’s memory of the trauma.

Look after yourself and re-establish social relationships! Looking after yourself can involve sticking to an exercise regimen, not taking on too much work, managing any added stress in your life, looking after your diet, getting back into the activities you enjoy, etc.

If problematic beliefs are stopping you from doing this, then these need to be identified and evaluated.

As the majority of people don’t develop PTSD (See Does everyone who experiences trauma develop PTSD), the first month is an important time to reintegrate into a normal schedule and live a healthy lifestyle (i.e., good diet, good sleep regimen, social engagement). Talking about the trauma before you are ready is not necessary. Treatment for PTSD cannot realistically begin until you no longer feel traumatized.

An analogy for this would be coming up from deep sea diving; it needs to be done in a gradual albeit timely fashion.

• There is a high incidence of sleep disturbances in PTSD. In fact, even after evidence-based treatment for PTSD, insomnia is one of the most common persistent symptoms (Belleville et al., 2011).
• CBT-i is considered first-line therapy for insomnia treatment in PTSD. (Talbot et al., 2014)
• Improving sleep will go along way to make you feel more rested and able to reintegrate into your activities.

What are your life’s aspirations? Now, more than ever, it is helpful to keep them in mind.

A horse is so sensitive that it will take you where you are looking; and normally, you look where you want to go. Like that, keep your eye on where you want to go. Keeping in mind what you would like out of life in the next week, month, year, etc., and visualizing it as if you were experiencing it (e.g., taste, smell, feel, thought, emotions, etc.) will provide you with positive emotions that can provide the leverage you need over PTSD roadblocks.

An example of a practice that many successful people employ is one of a visualization board. Here, you create a detailed movie in your mind of how you envision yourself. This can be made more concrete by using crafts and handing up a collage somewhere in your house. It’s important that this “detailed movie” contains positive things as opposed to the absence of negative things (i.e., symptoms, problems).

• This exercise can give us strength when we face tough times.
• It can keep us on track: “What can I do this week to help me realize my aspirations?”

Some areas to consider in which people commonly have aspirations are:

1. Social interactions
2. Productivity/career
3. Household mx
4. Leisure activities/fun
5. Spiritual/cultural/intellectual activities
6. Exercise/health
7. Daily relaxation

Try filling out the Aspirations Diary so you are clear on where you want to get.

Coping strategies are general strategies people use to help reduce the effects of stress. These are commonly used in the treatment of PTSD as the rehabilitation can in and of itself present one with stress. An analogy would be when one makes an investment, they have to make some budgeting changes and perhaps change their lifestyle a bit until the investment shows returns. These coping strategies are not treatment strategies specific to PTSD.

• Role playing
• Assertiveness training
• Stress management
• Relaxation exercises
• Biofeedback (e.g., using electromyography, heart rate, or respiration rate)
• Exercise
• Mindfulness-Based Stress Reduction

1. The fear memory must be activated. The patient must be helped in evaluating the trauma-related information in a therapeutic manner.
2. New, corrective information must be appreciated that don’t quite fit in to the new fear structure. That is, information was overlooked that changes the perception of either what happened; and/or the consequences of what happened; and/or one’s ability to live life the way they would like. Corrective information means having a decreased fear responses while in the presence of trauma reminders.

Generally, PTSD-specific treatments are started when the patient is ready as the exercises can be challenging, emotionally and physiologically. Ideal candidates will have a stable lifestyle and support network; and will have put into place many of the things mentioned in the section above “WHAT ARE SOME NON-SPECIFIC (GENERIC) TREATMENT STRATEGIES FOR PTSD?”.

Imaginal Exposure

This is a technique that is about helping one habituate to the memory of the trauma. It allows one to think about it, visualize it, verbalize it and tolerate distressing information about it. In the process, often patients are able to integrate important information that was overlooked or ignored. One can audio record an account of the trauma and listen to it repeatedly to help in processing the trauma. Patients often will eventually learn that they can think about the trauma without reliving it or getting anxious. They will remember that the trauma happened in the past and they are just as capable as they were before; they can control the memories rather than the memories controlling them. Practicing this technique serves as an opportunity to correct unhelpful beliefs that may have developed as a result of the trauma.

The process involves recalling the memory with one’s eyes closed and then imagining that the trauma is happening right now. Tap into the feelings that go with the memory. Describe the trauma in the present tense and give as many details as you can including the events that happened, your thoughts and feelings. Every once in a while, rate how distressed you feel without losing touch of the memory.

Remember,

1. Memories and many of the situations that trigger PTSD symptoms (e.g., loud noises) are note dangerous;
2. Anxiety/distress decreases after repeated and prolonged exposure;
3. Exposure reduces PTSD symptoms.

Prolonged Exposure

We have discussed how one has to face PTSD in order to process and integrate memories. We have also discussed many of the symptoms (emotional, cognitive, physical) that happen after PTSD; and that many people avoid cues that trigger these symptoms. Prolonged Exposure therapy is not concerned with talking about the therapy or thinking about how you are thinking as a result of the trauma. Prolonged Exposure is a behavioural therapy. Here, we systematically desensitize patients to things to which they are afraid like reminders of the trauma, situations they avoid, situations that are viewed as dangerous and situations that help return the survivors to living the lives they are wishing to lead. So just like when skiing down a hill, one starts with the bunny hill and slowly works up to higher heights. Like that, a hierarchy of fears are developed and then patients systematically confront each level until it no longer terrifies them.

The premise to the exercise is fairly simple:

1. The patients must put themselves in the situation that triggers fear.
2. They have to stay their course (usually 30-40 minutes immersed in the situation) until they learn from their own experience that it isn’t as bad as they feared. That is, the anxiety has to subjectively drop by 50%. Eventually acute stress responses do tire out and there is a calm that is restored, it’s a matter of hanging in there until this happens. Some people inadvertently switch to “avoidance mode” and not fully engage in the challenge for that level; this will be counterproductive and be a common reason for a plateauing of progress.
3. Patients need to compare this experimental exposure to the traumatic one to separate fear from the trauma in their minds. What are the similarities and differences between then and now? Is there anything new noticed/experienced that changes beliefs you had regarding this activity? Do you need to avoid it? What’s the worst that could happen in doing this activity nowadays?

Gradual Exposure

This is similar to Prolonged Exposure in that it’s a behavioural a therapy and it is based on a hierarchy of fears where a patient has to progressively pass one level to get to the next. However, the approach is different. Where Prolonged Exposure elicited fear to habituate the patient to the stimulus, gradual exposure has the patient as calm as can be and slowly introduces them to a situation on the fear hierarchy with the focus on remaining calm using relaxation strategies. There is a procedure which is followed to help guide the patient up the hierarchy.