Post Traumatic Stress Disorder: Special Features Influencing Treatment

Special Features Influencing Treatment

Psychiatric Features

Several important issues of comorbidity need to be considered in the treatment of PTSD. These may suggest either a contraindica-tion to a particular treatment or the need first to treat the comor-bid state before embarking energetically on the PTSD problems. Thus, comorbid depression needs to be treated, as it is likely to interfere with the benefits of behavioral therapy or other psycho-therapies. In fact, as mentioned earlier, in some instances guilt-bound issues may worsen with exposure. A suicidally depressive individual with PTSD needs to be adequately treated before deal-ing with issues of PTSD, which may in fact worsen suicidality in some instances.

Occasionally, severe depression comorbid with PTSD may need to be treated with electroconvulsive therapy. Although this form of treatment has no proven place as a major interven-tion for PTSD per se, in comorbid cases it has been noted that PTSD symptoms may also abate when they are tied to the pres-ence of depression. Amitriptyline is less likely to help combat veterans with PTSD if they have been exposed to more severe forms of combat trauma, and also if they have more severe symp-toms of depression, anxiety and PTSD. Antisocial and severe borderline personality disorder may be contraindications to vari-ous forms of psychotherapy and are unlikely to respond well to pharmacotherapy.

General Medical Comorbidity

PTSD patients have been shown to have an increased risk of physical conditions, with particular conditions perhaps being more prevalent (gastrointestional disease and cardiovascular disease). There is also evidence that chronic pain and PTSD are commonly associated, even when PTSD has not followed serious physical injury.

Demographical Features

It is not known to what extent sex or age is likely to determine treatment outcome. However, it is generally believed that lack of psychosocial supports can interfere with successful adaptation to trauma and response to treatment.

Nonresponse to Treatment

A stepwise sequence of approaches may be used in the treatment of PTSD but it must be said that there are no definitive guidelines currently in place. As a result, the particular order in which treat-ments are considered varies based on individual circumstances. Also, no uniform definition exists as to what constitutes a good or poor response to treatment. In general, some symptoms of chronic PTSD persist, albeit at a considerably reduced level, in people who have undergone treatment. A summary of the limited information available for predicting response to pharmacother-apy and behavioral therapy in PTSD arising from combat trauma is given elsewhere (Davidson and Fairbank, 1993).

Management problems are likely to occur as a result of both therapist-related factors and factors related to the patient. With regard to the therapist, it must be recognized that much of the material offered by the patient is charged with affect and, at times, may strain credibility and lead to high levels of doubt. The therapist may fall into the error of being unable to accept such an emotionally charged experience and thus rejecting or denying its validity. Equally, the therapist may fall into the error of overi-dentification with the patient such that impartiality is lost. It is important for therapists not to become overinvolved with rescue or to break down customary therapist–patient boundaries.

Although not unique to PTSD, powerful violent urges may arise in the patient during treatment, which may chal-lenge the therapist’s feeling of safety. Simple strategies, such as where the patient and therapist sit with respect to proxim-ity of escape, merit attention. For example, a female therapist dealing with a highly hostile and threatening male patient would do well to be sure that she can exit the room quickly if necessary and not be trapped behind a desk with the patient having control of the exit. Another simple yet important issue calling for attention is whether there is an available alarm if the therapist is dealing regularly with violent or threatening patients.

With respect to the patient, there are times when decom-pensation occurs to such an extent that the provider will have to judge whether hospitalization is indicated. Denial of particu-larly painful issues can lead to avoidance of therapy and missed appointments. Similarly, the emergence of unpleasant or trou-bling side effects with medication may also lead to treatment discontinuation. At all times, it is advisable for the therapist to remind the patient that difficult issues will arise periodically and that, rather than the patient taking unilateral action to drop out of treatment, these issues are best discussed with the therapist, with the hope that they can be resolved and further treatment progress can be made.

At times, it is helpful to engage the spouse or signifi-cant family member in treatment because of the difficulties and stresses to which they may be subjected. Furthermore, they can provide information that might help the therapist to acquire a better grasp of the severity of symptoms as well as their effects on the lives of others. For example, sleeping partners can give a more graphic account of the nocturnal disturbances that may oc-cur in symptomatic patients with PTSD. They may also provide important supplementary information as to the effects of poor impulse regulation or impaired memory or concentration on day-time behaviors in an individual.

Given that many patients with PTSD are receiving more than one treatment, coordination of effort between providers is important. At times, different philosophical persuasions may re-sult in one provider being somewhat less supportive of another’s efforts, a situation in which everybody loses. Mutual respect for each other’s efforts is essential if optimal progress is to be made by the patient.

Summary of Treatment

Whatever the type of treatment administered, a number of goals are common to all and can be summarized as follows: 1) to re-duce intrusive symptoms; 2) to reduce avoidance symptoms; 3) to reduce numbing and withdrawal; 4) to dampen hyperarousal; 5) to reduce psychotic symptoms when present; and 6) to improve impulse control when this is a problem.

By reducing troublesome symptoms, a number of other important goals can also be accomplished as follows: 1) to de-velop the capacity to interpret events more realistically with re-spect to their threat content; 2) to improve interpersonal work and leisure functioning; 3) to promote self-esteem, trust and feelings of safety; 4) to explore and clarify meanings attributed to the event; 5) to promote access to memories that have been dissociated or repressed when judged to be clinically appropri-ate; 6) to strengthen social support systems; and 7) to move from identification as a victim to that of a survivor.

The three major treatment approaches, pharmacothera-peutic, cognitive–behavioral and psychodynamic, all emphasize different aspects of the problem. Pharmacotherapy targets the un-derlying neurobiological alterations found in PTSD and attempts to control symptoms so that the above treatment goals can be more effectively accomplished. Cognitive–behavioral treatments emphasize the phobic avoidance and counterproductive reenact-ments that often occur, along with the identification of faulty be-liefs that arise owing to the trauma, and replace them with more adaptive beliefs, usually in association with direct therapeutic exposure. The psychodynamic approach emphasizes the associa-tions that arise from the trauma experience and that lead to un-conscious and conscious representations. Defense mechanisms that lead to lack of memory, and the contributions from early de-velopment, are also brought into play in psychodynamic therapy.