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Treatments of PTSD
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The normal stress response occurs when healthy adults who have been exposed to a single discrete traumatic event in adulthood experience intense bad memories, emotional numbing, feelings of unreality, being cut off from relationships or bodily tension and distress. Such individuals usually achieve complete recovery within a few weeks. Often a group debriefing experience is helpful. Debriefing begin by describing the traumatic event. They then progress to exploration of survivors' emotional responses to the event. Next, there is an open discussion of symptoms that have been precipitated by the trauma. Finally, there is education in which survivors' responses are explained and positive ways of coping are identified.Neuroimaging research on the neurobiology of chronic PTSD (post-traumatic stress disorder) has revealed structural and functional alterations primarily affecting areas of the medial temporal lobe (hippocampus, amygdala, and parahippocampal gyrus) and the frontal cortex known to be associated with the disorder. Using functional magnetic resonance imaging (fMRI), the present study studied the functional neuroanatomy of traumatic and non-traumatic emotional memory in two surgical patients who had sustained severe accident trauma. While patient 1 had developed acute PTSD following the traumatic event, patient 2 (control) did not. When confronted with traumatic (relative to negatively valenced non-traumatic) memory, the PTSD patient exhibited evidence for increased neural activity in the right and the left superior temporal lobe, the amygdala, the left angular gyrus, and the medial frontal gyrus, while the non-PTSD patient exposed to identical conditions showed increased activations in frontal and parietal regions. Both patients exhibited identical activation patterns when recalling non-traumatic memories relative to neutral memories. It is concluded that the pronounced activation patterns in the PTSD patient may be considered specific for acute PTSD, involved with the emotional arousal and the vivid visual recollections typical for the acute phase of the disorder.
Acute stress disorder is characterized by panic reactions, mental confusion, dissociation, severe insomnia, suspiciousness, and being unable to manage even basic self care, work, and relationship activities. Relatively few survivors of single traumas have this more severe reaction, except when the trauma is a lasting catastrophe that exposes them to death, destruction, or loss of home and community. Treatment includes immediate support, removal from the scene of the trauma, use of medication for immediate relief of grief, anxiety, and insomnia, and brief supportive psychotherapy provided in the context of crisis intervention.
Uncomplicated PTSD involves persistent re experiencing of the traumatic event, avoidance of stimuli associated with the trauma, emotional numbing, and symptoms of increased arousal. It may respond to group, psychodynamic, cognitive-behavioral, pharmacological, or combination approaches.
Group treatment is practiced in VA PTSD Clinics and Vet Centers for military veterans and in mental health and crisis clinics for victims of assault and abuse. A group of peers provides an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material with the safety, cohesion, and empathy provided by other survivors. It is often much easier to accept confrontation from a fellow sufferer who has impeccable credentials as a trauma survivor than from a professional therapist who never went through those experiences first-hand. As group members achieve greater understanding and resolution of traumatic themes, they often feel more confident and able to trust. As they work through trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one's story (the "trauma narrative") and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to go on with their lives rather than getting stuck in unspoken despair and helplessness.
Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event. Through the retelling of the traumatic event to a calm, empathic, compassionate and non-judgmental therapist, the patient achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the patient identify current life situations that set off traumatic memories and worsen PTSD symptoms.
There are two cognitive-behavioral approaches, exposure therapy and cognitive-behavioral therapy. Exposure therapy involves therapeutically confronting a past trauma by either (a) repeatedly imagining it in great detail, an example of this treatment is called Eye Movement Desensitization and Reprocessing , or (b) going to places that are strong reminders of the trauma experience(s). Exposure therapy is intended to help the patient face and gain control of the fear and distress that was overwhelming in the trauma, and must be done very carefully in order not to re-traumatize the patient. In some cases, trauma memories or reminders can be confronted all at once ("flooding"), while for other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stressor's or by taking the trauma one piece at a time ("desensitization"). Cognitive-behavioral therapy involves learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"), managing anger, preparing for stress reactions ("stress inoculation"), handling future trauma symptoms and urges to use alcohol or drugs when they occur ("relapse prevention"), and communicating and relating effectively with people ("social skills" or marital therapy). Exposure and cognitive-behavioral therapies are often used together, although it is important not to use too many different therapy methods because this can cause the patient to feel overwhelmed and confused.
Finally, drug therapy can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases may help relieve the distress and emotional numbness caused by trauma memories. Several kinds of antidepressant drugs have achieved improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. At this time no particular drug has emerged as a definitive treatment for PTSD, although medication is clearly useful for symptom relief thereby making it possible for patients to participate in group, psychodynamic, cognitive-behavioral, or other forms of psychotherapy.
PTSD comorbid with other psychiatric disorders is actually much more common than uncomplicated PTSD. PTSD is usually associated with at least one other major psychiatric disorder such as depression, alcohol/substance abuse, panic disorder, and other anxiety disorders. The best results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol/substance abuse. The same treatments used for uncomplicated PTSD should be used for these patients, with the addition of carefully managed treatment for the other psychiatric or addiction problems.
Complex PTSD (sometimes called "Disorder of Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. These individuals often are diagnosed with borderline or antisocial personality disorder or dissociative disorders. They exhibit behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), extreme emotional difficulties (such as intense rage, depression, or panic) and mental difficulties (such as fragmented thoughts, dissociation, and amnesia). The treatment of such patients often takes much longer, may progress at a much slower rate, and requires a sensitive and highly structured treatment program delivered by a team of trauma specialists.
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