Data Back Cognitive-Behavior Therapy for PTSD Treatment

Suddenly, after the September 11 terrorist onslaughts against the United States, it was no longer just combat soldiers and victims of crime, rape, and abuse who were experiencing psychological trauma, but thousands if not millions of Americans. An untold number of them not only experienced acute stress disorder but also are at risk for developing posttraumatic stress disorder (PTSD)—the ultimate psychological blow following death or injury.

Thus, Psychiatric News spoke with some authorities on PTSD treatments to learn which treatments are considered to be the most effective, what PTSD treatments being researched look especially promising, and what PTSD treatments might be like a few years from now.

In terms of psychotherapies for PTSD, the various cognitive-behavioral therapies, particularly exposure therapy and cognitive restructuring, seem to be the most solidly evidence-supported treatments. So said Matthew Friedman, M.D., executive director of the National Center for Posttraumatic Stress Disorder at the Department of Veterans Affairs in White River Junction, Vt., and a professor of psychiatry and pharmacology at Dartmouth Medical School.

Exposure therapy helps a person confront the memory of a psychological trauma in a therapeutic manner and come to terms with it. Cognitive restructuring enables a person to identify negative, irrational beliefs having to do with a psychological trauma and to replace them with truthful, rational beliefs.

In the opinion of Barbara Rothbaum, Ph.D., a leading PTSD-treatment researcher at Emory University in Atlanta, exposure therapy is supported by the strongest scientific evidence. Twelve studies back it, she said.

As for psychotherapies for children who have PTSD, cognitive-behavioral therapies have the strongest empirical support, Judith Ann Cohen, M.D., a professor of psychiatry at MCP Hahnemann University in Philadelphia and an authority on PTSD treatment in children, pointed out. However, family therapy has also been found to be efficacious for youngsters who have been psychologically traumatized by physical abuse but who do not necessarily have full-blown PTSD, she added.

Regarding drug treatments for PTSD, the first drug expressly approved by the Food and Drug Administration (FDA) for treating the disorder was the SSRI sertraline. Another SSRI, paroxetine, is expected to receive FDA approval for treating PTSD very soon, Friedman said. “So for two drugs of the same pharmacological family to get FDA approval, with all the rigor that is demanded by the FDA for such approval, indicates that there is effective treatment for PTSD pharmacologically,” he added.

Of the PTSD treatments currently being tested, which look especially promising? There is favorable but relatively little evidence for stress inoculation treatment, Friedman pointed out. Stress inoculation treatment teaches a package of anxiety-management techniques.

There has been work on eye movement desensitization and reprocessing (EMDR), where the evidence is not as strong as for cognitive-behavioral therapies, but encouraging, Friedman reported. EMDR is used to access, neutralize, and bring to resolution traumatic memories, he explained.

“Virtual reality exposure,” a new medium for conducting exposure therapy, looks as if it might also be of value to PTSD patients, Rothman said. For example, a Vietnam veteran suffering from PTSD would be exposed to a “virtual Vietnam” while confronting painful memories from his days in Vietnam.

Still another PTSD treatment that does not yet have strong empirical support, but which Cohen and her colleagues are exploring, is a kind of cognitive-behavioral therapy for children who are suffering from both psychological trauma and grief. “This is unfortunately very relevant now for kids in Washington, D.C., and New York who lost a loved one in the traumatic events,” Cohen said. “They have grief issues and trauma issues that compound each other. So this is a lengthier cognitive-behavioral intervention that addresses both the trauma and the grief.”

Cohen and her colleagues are also conducting a trial to determine whether cognitive-behavioral therapy plus sertraline is more beneficial to children with PTSD than is cognitive-behavioral therapy alone.

And Edna Foa, Ph.D., a PTSD-treatment expert at the University of Pennsylvania, and her colleagues will be studying whether sertraline plus exposure therapy is more effective against PTSD than exposure therapy alone.

What treatments for PTSD may be emerging over the next few years? “New medications will be developed, and I think they will be more powerful than the ones that have already been approved,” Friedman predicted. The reason, he explained, is that “almost without exception, drugs tested on PTSD to date have been medications that were developed for other purposes, yet there is undoubtedly a unique pathophysiological profile to PTSD that really does differentiate it from major depressive disorder and many other anxiety disorders. It is thus reasonable to expect that in the future, drugs will be designed expressly to counter this particular profile.”

“What I think is going to be happening,” Cohen predicted, “is that we will be looking at not just what treatments work against child PTSD, but which treatments are most effective for which kinds of children. I don’t think there is ever going to be a one-size-fits-all treatment. For example, what treatment would most help children who have been traumatized by multiple traumatic events, say, foster care? I hope that in 10 years we will have some answers.” ▪