Special Features Influencing Treatment
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.
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.
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.
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.
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.
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