Treatment Options for Posttraumatic Stress Disorder: An Analysis of Peer-Reviewed Evidence
Written by Emma Queen – Clinical Hypnotherapist, Psychotherapist, EMDR Therapist, Meditation and Breathwork Practitioner.
Posttraumatic stress disorder (PTSD) manifests in various characteristic symptoms because of exposure to one or more traumatic events. Symptoms can be delayed, and range from dysphoric mood states to dissociation. Diagnosis of PTSD can be through witnessing or experiencing an event or learning of a traumatic event experienced by a relative or friend. Symptoms can vary in severity and can include (but are not limited to): intrusive thoughts, a difference in mood and cognitive behaviour, avoidance of people/locations, talking about the event (s), issues with sleep, outbursts (reactivity) and arousal. Symptoms lasting longer than a month that cause substantial anguish for the person’s day-to-day functionality will result in a PTSD diagnosis for adults, adolescents, and children older than six years (American Psychiatric Association, 2013). This paper will focus on treatments for individuals over age six and will argue that these treatments are all effective therapies for PTSD and that the use of medications for patients with PTSD will only lengthen or create more problems. Varied treatments will be explored with their limitations and challenges. It will be concluded that while no single treatment works for everyone, tailor-made strategies suited to the individual will allow for greater success and recovery with non-medication interventions is the way forward.
Cognitive Behavioural Therapy (CBT) is a psychotherapy approach that helps patients recognise unresourceful behaviours, negative thoughts and behaviour patterns. CBT includes Trauma-Focused CBT (TF-CBT) and Internet Based/Web Based (i-CBT) therapies as safe and effective for individuals with PTSD. CBT is the preferred therapy for people with PTSD in the United Kingdom and internationally (Murray et al., 2022). This cost-effective therapy is beneficial due to PTSD being a major public health issue and a high economic burden on all countries mentioned in the systematic review article by von der Warth in 2020 (von der Warth et al., 2020). CBT is also successful for the longer-term mental health of individuals with exceptional results in sustainability. A valuable study of 90 trials utilising 6560 people and 22 interventions concluded that “TF-CBT … [was] effective at sustaining symptom improvements beyond treatment endpoint” (Mavranezouli et al., 2020, pp. 542-555). A 2004 study found CBT was applied to twelve Vietnamese refugees whose PTSD symptoms were still relevant after 12 months of being on selective serotonin reuptake inhibitors (SSRIs) and receiving counselling. The study participants were practising Buddhists and were considered treatment-resistant; most respondents also had panic attacks. The results of the therapy indicated significant improvements in all areas. This adds to the argument for using non-drug-based treatments for PTSD because these individuals were on SSRIs for over 12 months with no significant change in their PTSD symptoms. It also must be noted that the same therapist contributed to the sessions with the individuals. Hence, a limitation of the therapy was potentially the fact that it could have been the “therapist effect” rather than the treatment being effective and the examined progress of the group (Hinton et al., 2004). With the progress of using the Internet for telehealth this decade and the idea that this concept will progress, a pilot study of the use of peer-supported web-based CBT (i-CBT) compared to self-managed web-CBT with PTSD-affected veterans with Hazardous Alcohol Use was executed in 2019 with 30 patients in a programme called Thinking Forward. The statistic behind the study mentioned, “… among veterans with a new diagnosis of PTSD, only 34% initiate psychotherapy, and only 9% receive eight or more sessions”. All individuals achieved good outcomes and had notable progress with their resiliency. Supporting the argument that CBT is an effective therapy for PTSD in a more current case study based upon the ramifications of the COVID-19 pandemic with a male age 46 who had Intensive Care PTSD (ICU-PTSD) because of ongoing Covid life-threatening symptoms and being disconnected from his family during his time in the ICU. Over five months, he attended online sessions for TF-CBT for 16 sessions (60-90 minutes each); after the treatment, he displayed no clinical symptoms of PTSD. This was sustained at the 3-month evaluation mark. This intervention was successful for this patient, and naturally, more research utilising CBT for PTSD, using cohorts of ICU-PTSD and COVID-19 survivors, will be beneficial in the future. Additionally, it is salient that this patient’s case study was not controlled, nor did it eliminate the potential for naturally progressing towards a healthy outcome (Skilbeck & Byrne, 2022). One limitation to using CBT for PTSD is the role and experience of the therapist. For fear of re-traumatising the patient, a therapist can often hold back on treatment strategies due to their confidence levels; furthermore, patients use their sessions for their day-to-day crises. Thus, the treatments are less TF than required (Murray et al., 2022). Another limitation is the availability and cost of treatment, TF-CBT is not available on national health services, and waiting lists are lengthy (Simon et al., 2019). This, however, does not mean that this cost-effective treatment is not valuable for people with PTSD. Creating individualised treatment plans for clinically diagnosed PTSD utilising this therapy and other treatments will allow for greater achievement and long-term success without needing medication.
Eye movement desensitisation and reprocessing (EMDR) is a therapy that involves the patient thinking about the traumatic event and moving their eyes (bilateral stimulation) to desensitise the emotion and reaction around the event—developed in 1987 by Francine Shapiro, MD. specifically for the treatment of PTSD – due to the traumatic event not being processed appropriately and continuing to cause anguish for the individual. Since it was discovered, EMDR has reached beyond PTSD alone and is proven effective with patients with comorbid psychiatric disorders (Valiente-Gómez et al., 2017). In 2013 the World Health Organisation (WHO) issued a news release based upon EMDR (together with CBT) being the psychotherapy of choice for PTSD patients (Valiente-Gómez et al., 2017). They also warned against the use of benzodiazepines and stated that they “… should not be offered to reduce acute traumatic stress symptoms or sleep problems in the first month after a potentially traumatic event” (WHO, 2013). It is encouraging to see that the trends of mental health treatment are changing and being supported (utilising other therapies) in a forward momentum by WHO. The reasoning behind this theory is that medications like these can impede the recovery time of the trauma patient. (Campos et al., 2022). The rationale for raising this topic, together with the treatment of EMDR and CBT in this paper is due to mental health practitioners traditionally prescribing medication for mental health issues. It is again encouraging to find that research is backing this up. However, as recently as 2019, there was some confusion in studies around EMDR and PTSD when mental health professionals searched for evidence-based treatments (Opheim et al., 2019). This is relevant given that “[EMDR] is a proven therapy for treating PTSD, yet there is little to no consensus as to why this therapy is effective.” (Calancie et al., 2018) In Valiente-Gómez et al.’s study on EMDR Beyond PTSD, they again reiterated the same observation as mentioned in this paper about CBT, therapists not wanting to re-traumatise a patient, believing that “traumatic events might deteriorate the patient’s psychopathological state.” (Valiente-Gómez et al., 2017) So, further education and training are needed in this field and a more personalised approach to treatment plans. The same study confirmed that EMDR is a competent regime without side effects. This leads to further back up the argument that medications are not beneficial for PTSD patients due to side effects such as osteoporosis (Skjødt et al., 2019), weight gain (Hirschfeld, 2003), and sexual dysfunction (Rothmore, 2020). These issues can cause further impact on a person’s health, wellbeing and quality of life.
The practice of mindfulness characterised by an awareness of thoughts, feelings, bodily sensations and the surrounding environment. Paying attention to the moment without judgement has long been a practice from Eastern Meditation practices. It is increasingly becoming popular in today’s culture due to the accessibility of information on the internet and ongoing research on the benefits of relaxing the body without using medications. Mindfulness-based activities can range from meditation to yoga, breathing to gardening, walking to body scans, and other inward-focused activities. It is a cost-effective method allowing the recipient to become less reactive and more aware of their feelings and body. By exploring the topic of mindfulness and its effect on PTSD symptoms, we can discover its potential for its afflicted patients. Nolen-Hoeksema’s article discussed repeatedly focusing on negative feelings and ruminating on unfavourable emotions. It concluded that this led to greater depressive symptoms in individuals (Nolen-Hoeksema, S. 2000). The five facets of mindfulness had been used in various studies over the years, using the Psychological Model of the Mechanisms of Mindfulness – these include acting with awareness, non-judging of inner experience, non-reactivity to inner experience, describing and observing (Brown et al., 2014). In 2019 Reffi et al. used these facets to study PTSD symptom clusters in relation to emotional dysregulation (ED). They found that “non-judging may be the primary active component in the relationship between mindfulness and PTSD symptoms.” (Reffi et al., 2019) The article also suggests that mindfulness be provisional therapy for PTSD individuals. The limitation of studies like these and other psychological studies is the weight of the self-reporting element of participants. Results can be exaggerated due to embarrassment or biased due to the individuals’ self-awareness. In support of mindfulness being beneficial for PTSD symptoms, a study in 2021 utilised two sample studies on 99 predominantly female black participants living in low socio-economic areas and found that the PTSD symptoms suffered were lessened considerably using mindfulness and ED strategies (Powers et al., 2021). The apparent limitation of this study was the specificity of the sample size being predominantly black females. Mental health workers used further evidence of the ongoing practice of meditation with PTSD symptoms convincingly reducing in the aftermath of Hurricane Katrina. In this pilot study, ten weeks after the catastrophic event, 20 mental health workers undertook a 4-hour workshop and then an eight-week meditation program where the findings backed up the theory that “meditation intervention” (Waelde et al., 2008, p.497) was suitable for the treatment of PSTD and anxiety. However, the findings noticed that feelings of depression were not significantly different. (Waelde et al., 2008). Once again, mindfulness is another therapy that does not involve medications for the individual—of course, allowing for no side effects and being incredibly cost-effective and easy to access. It also allows the patient to take charge of their own healing, which empowers them. Assuming they learn the tools that are effective for them, they can also use them in the future to manage other life events. This shows how medications for PTSD patients are not beneficial. Lastly, the options for mindfulness are immense and can be adjusted from one person to another by either themselves or a mental health practitioner.
In conclusion, this paper has covered three medicine-free solutions and therapies for people with clinically diagnosed PTSD using peer-reviewed articles and journals. CBT is found to be the preferred therapy; however, accessibility, cost and waiting lists for trained professionals are constraining for the individual. EMDR, as approved by WHO, has demonstrated effectiveness yet is not yet researched enough to establish how or why it works. Mindfulness studies are ongoing and are yet to be conclusive for treating PTSD and other mental health concerns. However, mindfulness’s accessibility and cost-effectiveness make it a promising treatment tool. Importantly, these therapies are viable without medication and empower individuals to heal themselves. Tailor-made treatment plans incorporating all or some of these therapies are necessary due to the complexity of people’s symptoms, experiences and self-awareness. To ensure the long-term sustainability of patients’ mental health, healthcare practitioners must embrace a holistic medication-free approach to PTSD patients. This paper underscores the importance of training, education and research to refine practices for the wider population.
Printable version of this research paper here: https://fairymeadow-hypnotherapy.com.au/wp-content/uploads/2023/06/FMH-PTSD-Treatments.pdf
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