Duration: 16 minutes, 10 seconds

KELLIE NEWSOME: Therapy is first line for PTSD, but what goes on in the session? And how do you prevent PTSD when your patient calls you after an assault or major accident? 

CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor-in-chief of the Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. We continue with our coverage of PTSD inspired by the American Journal of Psychiatry new review by Arieh Shalev and colleagues from NYU. Psychotherapy is first line for PTSD because it works better and lasts longer than medications (Storm MP and Christensen KS, Dan Med J 2021;68(9):A09200643). However, there is an exception to this rule: Patient preference. Naturally, you’re not going to force a patient to therapy if they don’t want to go. But, clinical trials of PTSD also find that outcomes are better when patients are randomized to their preferred treatment – whether therapy or meds.

There are several therapies that work for PTSD, and we’ll review them here, drawing from evidence in a Cochrane style review of 70 studies involving nearly 5,000 patients. 

CHRIS AIKEN: 

1. Trauma-focused CBT

First is Trauma-Focused CBT. This involves prolonged exposure sessions where the patient re-experiences the trauma in a new way. Yes, the exposure is bound to trigger anxiety, but if it is done in a structured, graded, and supportive way, it will also be paired with a sense of calm, such as by incorporating self-soothing exercises in the exposure. The patient needs to feel in control of the exposure process – not only to prevent flooding – but because a key part of the original trauma was the feeling of powerlessness and loss of control over the events. These exposure sessions are prolonged – often lasting 90 minutes – and involve imaginal exposure in the session where the patient recounts the trauma in full sensory detail. Outside of session, they work to reduce avoidance of everyday reminders of the trauma, such as slowly getting back on the highway after a traumatic car accident.

KELLIE NEWSOME: 

2. Next – and in fact closely tied – is EMDR or Eye movement desensitization and reprocessing therapy (EMDR), developed by Francine Shapiro in 1987. Like CBT, EMDR involves in-session exposure, but in this therapy, the patient moves their eyes side-to-side eye movements, often following an LED device, while recalling the traumatic events. Sometimes, hand tapping is used instead of eye movements – the idea here is that physical, bilateral stimulation helps connect brain regions that trauma has split apart.

You’ll often hear that EMDR is controversial, but the controversy is not over whether it works. It is as effective as CBT, and nearly all practice guidelines for PTSD recommend it. 

The controversy is about whether the fancy eye movements are a necessary part of the treatment, but we won’t get stuck on that. We could just as easily argue over whether other common accouterments of therapy are necessary for the healing: comfortable chairs, soothing artwork, complicated theories, and weekly, 1:1 sessions in an indoor environment that doesn’t much resemble the real world. 

Brainspotting is a recent offshoot of EMDR where the patient looks in a specific direction while recalling a traumatic memory. The specific eye position is determined by some trial and error, and it is thought to be associated in some way to an area of disturbance in the brain’s memory system. Evidence for brain spotting is much more preliminary.

CHRIS AIKEN: There’s another the American Journal left out: Narrative Exposure Therapy, perhaps because the studies are not as consistent and large. Although, a meta-analysis that wrapped up 18 of them concluded that it works with a medium to large effect size. In this treatment, the therapist helps the patient develop a more coherent and meaningful story of the trauma. In some ways, it’s an exposure-based treatment, but the focus is more on developing a more empowering narrative that is integrated into their entire life story. This therapy bridges the gap between exposure therapies and another avenue for PTSD, the therapies classified as “non-trauma-focused.”

KELLIE NEWSOME: What? How can a therapy for PTSD not focus on trauma? The answer is that these therapies focus on ways that PTSD symptoms are getting in the way of their current life rather than exposing people to the difficult memories. If your patient is unable to tolerate the intensity of exposure, this is the way to go.

Two examples are present-centered therapy and interpersonal psychotherapy. These focus on solving challenges in the patient’s current life that stem from the PTSD symptoms, challenges like asserting yourself at work or being open in close relationships. Another is cognitive processing therapy, which operates like traditional CBT, correcting the faulty attributions common in PTSD, like overgeneralization of fear and negative beliefs about the self. 

These non-trauma-focused therapies worked in controlled trials, but there is some evidence that TF-CBT and EMDR have more staying power. However, they seem to have fewer dropouts – exposure-based therapies are difficult and challenging. They sound simple, but it takes a lot of experience to develop the compassion and strength to guide people into areas that every nerve in their body is programmed to avoid. Secondary trauma can be part of the cost for therapists who go on that journey, causing some to limit the number of PTSD cases they see in a week.

CHRIS AIKEN: In the first episode of this series, we talked about subtypes of PTSD, and we might consider military trauma to be one of those subtypes. Actually, military trauma was where the idea of PTSD came from, so maybe I should say that civilian trauma is the subtype. Compared to civilian trauma, military trauma is less responsive to treatment – both to therapy and to medication treatment. The reasons why are unknown, but there are many possibilities. Most veterans are men, and women respond better to therapy and to SSRIs in general. Veterans go through unique training that bonds them to their unit but can separate them from society upon return. Some PTSD symptoms, like hypervigilance and even anger, can be functional for soldiers. Veterans are more likely to have traumatic brain injury and more cognitive problems, and soldiers also have higher rates of ADHD. And then there’s the problem of benefits and secondary gain. In one study, veterans who were undergoing evaluation for PTSD-related benefits did not respond to psychotherapy, while others who weren’t undergoing evaluation did. Moral injury may play a role in worsening the syndrome, particularly in unpopular wars like Vietnam.

Still, therapy helps combat PTSD, bringing about around 60% improvement for the average veteran. But dropout rates are even higher for this group, and incomplete recovery the norm, with more than two-thirds still meeting PTSD criteria after treatment. Non-trauma-focused treatments offer a reasonable option for veterans who drop out of exposure-based therapies.

KELLIE NEWSOME: Time for a preview of the 2-question CME quiz for this episode. Earn CME through the link in the show notes

1. Which treatment is first line for PTSD?

A. Psychotherapy

B. SSRI Antidepressants

C. Either Psychotherapy or Pharmacotherapy

D. Combined Psychotherapy and Pharmacotherapy

What about PTSD in children? Therapy works well in children, according to a review of 14 controlled studies involving close to 1,000 participants. Among them, trauma-focused CBT has the best evidence for childhood PTSD.

In our next episode we’ll look at what the corner pharmacy has to offer, but first, let’s see what we can do to prevent PTSD when patients contact us after a trauma.

CHRIS AIKEN: We rarely get the chance to implement preventative therapies in practice, but here you might. Each year I get a few emergency calls from patients who just experienced a trauma – maybe a sexual assault, a car accident, or they found their loved one dead. 

Propranolol used to be the go-to med for these cases, but the studies have not panned out on the positive side, and the data is more consistent for a hormonal intervention: hydrocortisone. The idea is that hydrocortisone aids extinction learning. In animals, it increases synaptic plasticity and connectivity and BDNF after a trauma and reduces adrenergic overload. Ideally, give it within 12 hours after a trauma for a 10-day course. The dose is Hydrocortisone 20mg 1 po bid for 10 days.

Outside of that, we don’t know much about medications to prevent PTSD. Alcohol and benzos probably make things worse after a trauma, but opioids may help if physical pain is involved. In several retrospective but controlled trials, patients who received prescription opioids after a trauma had lower rates of PTSD.

KELLIE NEWSOME: Psychotherapy can also prevent PTSD from setting in after a trauma – and here, the prize goes to specific forms of CBT. Importantly, the field has moved away from debriefing, a once popular educational and supportive therapy that was given in group or individual form after trauma exposure. But, the Cochrane group found it wanting in 1997. And in some studies, it even seemed to raise the risk of PTSD, possibly because the more vulnerable people felt triggered or invalidated by the group approach or people felt pressured to talk about their feelings before they were ready.

Many of your patients are not going to start psychotherapy to prevent PTSD after a trauma, but you can still give them sound advice from what we know about PTSD. Avoid alcohol. Bump up the sleep hygiene and do anything that improves sleep quality. Exercise. Keep a journal. Use deep breathing or mindfulness to manage anxiety – I might recommend an app to guide them in these practices. And keep a list of evidence-based apps at chrisaikenmd.com/apps.

Don’t avoid reminders of the trauma, but don’t rush in so much that you get flooded – patients need to regain a sense of control here. Most importantly, be around your community – family, friends, and faith communities – that support you. Do things that bring you joy. And that restore a sense of purpose and meaning, like helping others. If nightmares are a problem, try imagery rehearsal therapy. It’s simple intervention with a big effect size where the patient recalls the bad dream in full detail each day but changes the ending in anyway they like. Look to our August 2021 Carlat interview with the founder of this therapy – Barry Krakow.

Join us next week where we conclude this series with pharmacotherapies for PTSD. And no, we’re not just going to tell you to give everyone sertraline and paroxetine.

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