psychological therapy in post traumatic stress disorder (PTSD)
Last edited 01/2019
psychological therapy
Trauma focused procedures have been shown to be effective in ameliorating the symptoms of PTSD. Specific types of include:
- cognitive-behaviour therapies (CBT)
- exposure therapy - confronting the traumatic memories through written and verbal narrative. During this process the therapist encourages the patient to describe their traumatic experience and expose them repeatedly to the trauma related situations that were being avoided or evoked fear but are now safe e.g. - driving a car through the same road where the road traffic accident occurred, walking in the busy park where an assault occurred
- cognitive processing therapy - designed to
- correct misinterpretations (mostly overestimation) the patient had regarding current threat e.g. - patient who are under the impression that they will get assaulted each time they leave the house
- modify the beliefs and their behaviour during the traumatic event (e.g. - patients guilt and shame)
- eye movement desensitization and reprocessing (EMDR)
- includes an exposure-based therapy (with multiple brief, interrupted exposures to traumatic material), eye movement, and recall and verbalization of traumatic memories of an event or events
- individual trauma focused CBT and EMDR have been shown to be effective equally (1,2)
Non trauma focused CBT can be used as an alternative in cases where trauma focused therapy is poorly tolerated, contraindicated, or unavailable. Methods of non trauma focused CBT are:
- grounding techniques to manage flashbacks e.g. - focusing on the here and now by describing items in a room
- relaxation training e.g. - controlled breathing and progressive muscle relaxation
- positive thinking and self talk e.g. - repeating positive phrases such as “I can deal with this”(1,2)
NICE suggests that (3):
- psychological treatment should be done in a regular and continuous (usually at least once a week) manner and should be delivered by the same person (3)
- non-trauma-focused interventions such as relaxation or non-directive therapy should not be used routinely since these do not address traumatic memories (3)
- offer an individual trauma-focused CBT intervention to adults with a diagnosis
of PTSD or clinically important symptoms of PTSD who have presented more than
1 month after a traumatic event.
- these interventions include:
- cognitive processing therapy
- cognitive therapy for PTSD
- narrative exposure therapy
- prolonged exposure therapy
- these interventions include:
- Eye movement desensitisation and reprocessing
- consider EMDR for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a non-combat-related trauma if the person has a preference for EMDR
- offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a non-combat-related trauma
- Supported trauma-focused computerised cognitive behavioural therapy
- supported trauma-focused computerised CBT should be considered for adults
with a diagnosis of PTSD or clinically important symptoms of PTSD who
have presented more than 3 months after a traumatic event if they prefer
it to face-to-face trauma-focused CBT or EMDR as long as:
- they do not have severe PTSD symptoms, in particular dissociative symptoms and
- they are not at risk of harm to themselves or others
- supported trauma-focused computerised CBT should be considered for adults
with a diagnosis of PTSD or clinically important symptoms of PTSD who
have presented more than 3 months after a traumatic event if they prefer
it to face-to-face trauma-focused CBT or EMDR as long as:
- Cognitive behavioural therapy for specific symptoms
- consider CBT interventions targeted at specific symptoms such as sleep
disturbance or anger, for adults with a diagnosis of PTSD or clinically
important symptoms of PTSD who have presented more than 3 months after
a traumatic event only if the person:
- is unable or unwilling to engage in a trauma-focused intervention or
- has residual symptoms after a trauma-focused intervention
- consider CBT interventions targeted at specific symptoms such as sleep
disturbance or anger, for adults with a diagnosis of PTSD or clinically
important symptoms of PTSD who have presented more than 3 months after
a traumatic event only if the person:
Do not offer psychologically-focused debriefing for the prevention or treatment of PTSD
For full details then consult NICE guideline (3)
Reference:
- (1) Bisson JI et al. Post-traumatic stress disorder. BMJ. 2015;351:h6161
- (2) Ursano RJ et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004;161(11 Suppl):3-31.
- (3) NICE (December 2018).Post-traumatic stress disorder (NG116)