Identifying and describing the numerous types of interventions to treat post-traumatic stress disorder (PTSD) can be a daunting task especially with the numerous therapeutic models and techniques with published case study support. This article will explore the physiology and neurobiology of PTSD. Additionally, it will discuss some of the most common categories of interventions and examples of each (e.g., prolonged exposure therapy, cognitive processing therapy, emotional freedom techniques, reprocessing therapy). Data on d-cycloserine, nabotulinumtoxin A, and methylenedioxymethamphetamine will also be elucidated.
In attempting to describe the catalog of post-traumatic stress disorder (PTSD) interventions, one quickly gets lost in hundreds of therapeutic models and techniques with published case study support. Three recent attempts to boil down the options to the best available identified over 70 separate therapies to choose from authors Figley, Shciraldi, and Shapiro.1,2,3 The situation is confused further by the many techniques suggested as treatment without any clear sense of what type of PTSD or population of PTSD sufferers they target, whether they focus on symptom relief, healing, or supportive intervention.
Attempting to clarify the situation by turning to evidence-based lists does not help much, either. Over a dozen organizations have created such guidelines, with surprisingly frequent disagreements about what is—and is not—evidence based treatment. Just a few years ago, experts spoke of THE evidence-based therapy for PTSD as if one particular therapy had been crowned above all the others. Heated debates occurred between proponents of competing therapies, each proponent waving overhead their favorite study proving their point.
Unfortunately for those seeking the Gold Standard of PTSD interventions, recent research has begun to demonstrate that the solution actually lies in common underlying patterns instead of specific techniques. This was recently highlighted in a Veterans Affairs and Department of Defense (VA-DoD) sponsored training on incorporating the latest “best evidence” into clinical protocols for PTSD. Instead of recommending a specific therapy as had been done in the past, the protocols were updated to suggest that adopting any one of many therapies, as long as they were centered on general treatment concepts of exposure or cognitive processing, were appropriate.
What we have learned is that in spite the dozens of therapies with positive data, these all are just a few basic patterns with idiosyncratic variations—much the same as we might say we have a recipe for chocolate cookies and not that we have THE recipe for chocolate chip cookies. There are many chocolate chip cookie recipes, but most are just variations of the same basic recipe. Additionally, as more studies compare these various therapies [i.e. Prolonged Exposure Therapy (PE) compared to Cognitive Processing Therapy (CPT), CPT compared to Present Centered Therapy (PCT), CPT compared to Trauma-centered family therapy (TCFT), PE compared to Eye Movement Desensitization Reprocessing Therapy (EMDR), EMDR compared to Emotional Freedom Techniques (EFT), PE compared to Imagery Rescripting and Reprocessing Therapy(IRRT) ], the main conclusion is that most appear equally effective as long as they use basic patterns of intervention.
This paper will explore the common categories of interventions and offer the most common examples of each.
First, one needs an understanding of how the physiology of PTSD shapes the symptoms that patients experience, and that there is a limited role of cognition in the development PTSD. Secondly, one must identify how crucial concepts from recent developments in the field of neurology form a basis for understanding successful PTSD intervention. This paper will review some common categories of intervention and examples of each.
PTSD has largely been viewed as a psychological struggle, currently identified as one of the anxiety disorders. However, the growing evidence is that the cognitive and emotional symptoms of PTSD are just the final side effects of a body out of control. Work with single-photon emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) scans, along with measures of physiology and neurological tracers have demonstrated PTSD has wide-ranging impacts on the body. There is evidence of altered functioning of steroids and disruption of adrenergic and glucocorticoid systems.4,5 These changes can lead to shifts in brain functioning, especially in the fear and memory centers of the brain.6,7 Eventually, these changes become a permanent part of how the brain operates and remembers and given enough time, these changes become reified in the brain structure.8,9,10,11
It is known that trauma re-shapes the brain. But it is also understood that trauma therapy re-shapes the brain. Just as trauma has specific chemical and steroidal actions in the body, and even a specific electrical signal in the brain wave, so too can the results of effective trauma therapy be seen in normalization of those same steroidal, structural and brainwave patterns.12,13,14 How do we understand this? Two key concepts demonstrate how psychotherapy heals the brain. These concepts lay the foundation for understanding the trauma therapies we will be discussing.
For most of existence, the science field has considered the adult brain as static, mature, and unchanging except for its inevitable annual decline in size and functional capacity. However, by the 1990's, there was growing evidence this was a mistaken interpretation. It turns out common sense was right—our brain changes as often as we do and we have an unheralded ability to change, grow, and reboot our brain.
Neurogenesis is the concept that brain cells grow and replenish throughout the entire mammalian life cycle and it plays a crucial role in therapies designed to change traumatic memories. Although the information about the role of neurogenesis in the cerebral cortex is still largely big picture instead of detail, the firmer case can be made that neurogenesis is the core process in adult humans for learning and memory.15 Neurogenesis has been demonstrated to actively shape the size and function of the adult hippocampus.16,17 The hippocampus plays a role in trauma by acting as both the memory center of the brain as well as the mediator of the fear center (important functions in trauma formation and healing).
Neurogenesis paves the way for the second foundational concept—neuroplasticity. Neuroplasticity refers to the ability of external activity (movement or behavior) or internal activity (thoughts, imagery, emotions) to make permanent change in neuronal pathways and reorganize the structure or function of specific brain regions.18
Once again, this concept appears particularly relevant in PTSD treatment through the ability of neurogenesis in the hippocampus to allow humans to actively restructure memories. Particularly relevant is the ability to add new information to old memories, specifically new information about safety, meaning, time orientation.19 Two other salient points rise from research about neuroplasticity. First, neuroplasticity is not neither limited to cognition-based triggers nor limited to verbal understanding. In particular, we note that exercise-mediated neurogenesis plays a role in reformation of memory structures.20,21 Also, spatial memory is available for restructure and spatial movement may be a key to speeding up the neurogenesis process in the hippocampus.22
This is important information in light of current confusion with research data indicating the effectiveness of certain movement-based or non-verbal therapies such as yoga, therapeutic touch, and somatic experiencing. It also demonstrates the reported positive effects of interventions such as the Neurolinguistic Programming Rapid Phobia Protocol (NLP RPP or VKD), which require the subject to remember traumatic events with a different timeline than that encoded in the original memory and do not require the subject to recall painful affect during treatment. Further, there does not appear to be just one channel for neuroplasticity. Changes in the fear structure of the brain can be accomplished through multiple channels.23
Lest one thinks neuroplasticity is just another nifty new age concept with no reality outside the laboratory, there are a growing bundle of studies demonstrating neuroplasticity in therapy. Across many populations and therapeutic techniques, evidence is growing that therapeutic interventions have dramatic impact on brain structure and function in even the most persistent and developmentally basic of conditions. Recent research demonstrates therapy-driven neuroplasticity even in conditions long considered frozen in human brain structure. Two studies this year, each of a different type of behavioral therapy, demonstrated that in children with autism, psychotherapy can lead to observable, measurable brain change in both SPECT scans and observable behavior changes.24,25
The findings, however, are not just limited to behavioral interventions. Research has long supported that specific mental activities without behavioral activation, such as structured mantra meditation, can make changes in both brain structure and function.26,27 Even more enticing is the burgeoning evidence that one does not need a lifetime of therapy and that interventions and mental practice can trigger neurogenesis and neuroplasticity in short periods of time such as 8 sessions or 11 hours of effort.28
Although there are case studies supporting that behavioral change can happen in even fewer than 8 sessions, and research supports that chronic distress and even cortisol changes can happen within a couple of sessions, the support is not there to believe structural change happens quicker than 11 hours of intervention.29,13
BASIC INTERVENTION PATTERNS
So, how does one translate these neurological precepts into tools for identifying potential successful therapy techniques? The basic groundwork can be found in the works of several pioneers who formulated theories of action before the terms neurogenesis and neuroplasticity were available in the clinical lexicon.
As seen in the work of Edna Foa, Bessel VanderKolk and John Briere some general guidelines were developed by each in their own theoretical language.30–32 The four basic steps postulated here are:
The traumatic memory needs to be recalled or activated or felt in the body.
The emotional distress related to this activation must be adequately controlled so that there is a maximally beneficial balance between activation and stress.
The activated memory, emotion, or felt sense is then pared with either an incompatible emotion or corrective information.
This new memory or experience—made of both the old experience and the new experience—needs to be stored in order to replace the old.
It can be further stated that not only must the memory be recalled, but the therapist's primary job is to make sure the emotions are properly regulated in and out of session.
Neuroplasticity can only occur while a memory is in conscious awareness. Additionally, if the memory is recalled but nothing new is added then the old memory is either reinforced or restored. However, if while the memory is being recalled, the therapist and client change something (of the memory, the experience of the memory, the emotions felt during the recall, then felt sense in the body, the action followed by the body, the cognitive interpretation of the event, the sense of meaning of the event) then the memory will be stored differently. It will be stored with new, essentially healthier, information. This is how the memory will be recalled in the future.
Here presents a puzzle for many people. Many therapy options are considered “talk therapy”. Yet “trauma informed talk therapy” is certainly different than general “talk therapy”. Many people mistakenly believe—most likely from being raised in a therapy friendly society and watching too many episodes of Bob Newhart—that when a client experiences a trauma, what they need is to talk about what happened. In actuality, this can often only lead to further traumatization without lasting relief. “Talk therapy” will only work for trauma if during that talk, new information is incorporated into the client's perception or understanding of the situation. Venting, griping, getting it out, looking for support, and avoiding the pain are not methods which by themselves lead to neuroplasticity.
Trauma therapy is not “talk therapy” even though some trauma therapies use talk as one of their tools. Trauma therapy—through whatever method used—is attempting something deeper and more complex than support, sharing, or venting. This then is the common theme of trauma therapies: helping the client reactivate the trauma while regulating the experience so that it is stored as a new, more adaptive experience. Each therapy uses a different technique or style, but in the end they all are following this basic formula. A review of multiple studies and the best evidence leads to strong recommendation not for a specific therapy but rather any therapy which includes the components of exposure and/or cognitive restructuring; or stress inoculation training.33 Further, the general criteria of successful therapy outlined by Foa have been found to not be specific to a particular theoretical school of therapy, found in such diverse models as hypnosis, behavioral intervention, prolonged exposure, cognitive therapy, interpersonal therapy, and even specific models of psychodynamic therapy.30
Recall the previous discussion of somatic, sensory and spatial alternatives to cognition in the neuroplasticity process. Now, one can see that many body-based or somatic interventions can be used to store a new spatial understanding with the remembered experience. For that matter, several techniques do not even use conscious recall of trauma in the neuroplasticity process, instead repeatedly combining a felt sense of being in the body with comfort, or being in the present with awareness to gradually decondition the trauma response (Yoga, Healing Touch, EFT, Present-Centered Therapy, Interpersonal Therapy, Acceptance and Commitment Therapy, Meditation, Guided Imagery, Hypnosis). In many of these there is a process of somatic activation and multiple sensory channels of memory formation, thus supplanting the need for the client to either verbalize or have cognitive awareness of the process.
But this is still a bewildering array of options. One way to simplify is to sort interventions by their general purpose on the continuum of trauma healing. Let's consider the following Classification of Interventions as a first step:
Coping/supportive management. These interventions are designed to assist the person in adapting to the symptoms and minimizing their damage in his/her life. There are many tools in this area.2,34 The most common of these would be forms of relaxation training, breath training, support groups, peer to peer intervention. Medication is most often used in this category, as medications are not typically prescribed to treat PTSD per se as much as to control specific symptoms related to PTSD: depression, anger, anxiety, sleep disturbance, nightmares. For most coping techniques, relief tends not to last much past the last dose of these treatments.
Strengthening, Tone work. These are particular interventions utilized to improve a person's ability to tolerate negative affect or physical discomfort. Without this ability therapy cannot stay in the productive zone and clients either retreat to avoidance/substance use or the move into a state of overwhelm and crisis. The skills taught in this category are often referred to as Affect Regulation or Distress Tolerance skills. These interventions are often used to prepare a person for the more challenging work of healing/resolution. Many types of affect regulation therapies and body work techniques begin in this category and then cross over to the next category of healing/resolution. EMDR, affect regulation training, ego-strengthening hypnosis and yoga are often utilized for this purpose. Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT) also often start in this category.
Healing/Resolution. Techniques which utilize neurogenesis or neuroplasticity to directly attempt to either return the brain to pre-trauma functioning or allow a new integration of the trauma, most often by directly dealing with traumatic memories in session. This is the category where most evidence based therapies fall.
Co-mediation/augmentation. New interventions have been emerging all which appear to work by allowing psychotherapy to be more effective. These are usually pharmacologically based interventions paired with another psychotherapy. They are also quite controversial.
d-cycloserine: this medication is building support for being able to block traumatic re-experience during recall. When combined with therapy this allows for a faster processing to resolve painful affect. Additionally there is some brain scan evidence to suggest d-cycloserine promotes neurogenesis directly, even when not paired with a psychotherapy and that it acts to enhance the fear extinction process.
MDMA (Methylenedioxymethamphetamine): Ecstasy has begun in clinical trials and currently has one study released. It was used with a combination of exposure/interpersonal therapy in which the MDMA was used similar to d-cycloserine—it was administered before therapy session to trigger intense pleasurable feelings while the patient processed the traumatic event. This approach has not been compared to other therapies at this point. Although the first study had positive results, the design has been questioned and it included a very small number of patients. A significant concern to this approach is whether the risks of using the drug are worth getting results similar to approaches which do not use the drug.
Stellate ganglion block: At this time there is no evidence except one anecdotal report for this technique, which involves injecting the epidural anesthetic bupivacaine in the neck. It has received criticism but at this point is proceeding with a limited clinical trial to attempt to define benefits and potential side effects to this approach.
Botox (nabotulinumtoxin A): Also a technique with no research evidence at this point, Botox is being used in a limited trial to assess if injections into facial nerves will have a positive side effect of decreasing negative affect associated with PTSD. This work is proceeding due to antidotal reports that Botox injections has sometimes decreased depressive emotions in those diagnosed with Major Depressive Disorder.
Rebuilding/Establishing Meaningful Life. Interventions which seek to move a client back into life, including occupational therapy interventions, spiritual explorations, and interpersonal / vocational interventions.
Technology Assisted. This category at this time currently consists of taking therapies from #3 and applying them through technology. The two most common applications include virtual reality therapy and Telephonic/remote video intervention.
Virtual Reality. This is primarily a version of prolonged exposure. Evidence is beginning to support this as a possible intervention for PTSD when combined with PE or other types of exposure intervention.
Telephonic and Remote Video Intervention. These are increasingly being used to allow traditional interventions to reach clients who cannot easily travel to the clinic for service.35 To date, two approaches have research supporting their use remotely: Prolonged Exposure and EFT. In both cases the research delivered a mixed finding that using these approaches by phone or video is more effective than no treatment, but less effective than the same treatment delivered in person. In spite these findings, the amount of progress in symptom reduction makes this a valid and valuable approach especially in rural, remote areas.
Group Intervention. Just as was discussed previously about the “technology assisted” options, group intervention for the most part serves as a subset of #3 in that most group models are actually group versions of other techniques. Cognitive Processing Therapy appears the most researched though trauma-focused CBT variations account for significant research. Additional research support exists for behavioral family group interventions for child abuse related trauma.
Present Centered Group therapy is a model of intervention with PTSD which does not process past traumas but rather assists group members in learning to separate PTSD symptoms and trauma experience from their present life. Based loosely on the group work of Irvin Yalom, this group approach has considerable research support for an evidence-based treatment for groups.36
There is another similarity between group therapy and telephonic/video therapy. Group therapy also in general appears to be not as effective as the same model when it is offered individually. A recent meta-analysis demonstrated this as a consistent finding across many studies. An additional finding of that meta-analysis was that there was no basis to consider “evidence-based therapy” delivered in groups to be any more effective than any non-evidence based group in directly treating the symptoms of PTSD.
The above categories are helpful, but are in some ways incomplete. This becomes apparent when one begins to consider some of the very recent additions to “evidence-based” therapy taxonomies such unlikely techniques as EFT, EMDR, yoga, mindfulness, meditation, hypnosis and guided imagery. These are techniques which really stretch the definition of “talk therapy”, instead relying on touch, eye movement, acupressure, guided body movement, manipulated mental images and other non-traditional ways to produce “dual attention”.
To incorporate all of these variations, one can consider three basic methods to take advantage of neuroplasticity to encourage neurogenesis.
Top-down: These are techniques which use a cognitive processing technique to address trauma. The most common of these is cognitive behavioral therapy. A variation of CBT specifically designed for trauma is Cognitive Processing Therapy (CPT) which targets both trauma recall and challenging of disordered cognitions.
Bottom-up: These interventions use body-based interventions to introduce incompatible sensations or spatial awareness as a tool for incompatible information. Somatic experiencing and other body approaches will often use dual focus of feeling the distress while also feeling other sensations. A partial list of these interventions with research support include yoga, mindfulness or moving meditation, Tai chi/Qi Gong, somatic experiencing, somatic therapy, acupuncture/acupressure. Multiple Studies with children showed a combination mind-body approach to be effective.
Neurofeedback, or EEG Biofeedback is actually one of the oldest techniques to be researched, with a PTSD protocol researched in the 1970's. Particularly in the area of dually diagnosed PTSD sufferer, the current research shows impressive results with higher symptom resolution rates and higher treatment retention rates than most evidence-based therapies. This approach can be daunting, however, due to the significant number of sessions many clients need to fully resolve their issues.
Dual focus: These are approaches use a dual focus during exposure to the traumatic recall. Although each has its own theory, the common element remains that there is a pairing of the trauma with activation of other parts of the brain. For many there is also a cognitive component. These approaches have the additional advantage of activating the pre-frontal lobe through heavy use of executive functions. This allows the dual focus approaches to also be top-down.
Mixed Approaches: These techniques use a combination of bottom up and top down. Hypnosis combines cognitive reframes with relaxation and incompatible sensations. Guided Imagery often does the same. Imagery combined with relaxation and then the introduction of reframing messages. EFT is an energy medicine techniques which combine cognitive processing with acupressure stimulation. This acts to trigger incompatible sensations so that the trauma is re-experienced without distress. EFT at this point is considered an evidence based intervention with studies showing it to be as effective as EMDR and CBT. Additionally IRRT, a form of guided imagery and exposure has been shown to be effective and also has one study demonstrating it to be a helpful method when prolonged exposure has not been successful no success.
Prolonged exposure is probably the gold standard of the evidence based approaches (in terms of having the most research studies behind it) and is a good example of a mixed approach. It effectively combines exposure (bottom up) with cognitive processing in session (top down). An extremely effect tool, the difficulties with PE are the high incompletion rate and the level of distress tolerance it requires from the client. Other approaches such as EFT, NLP and EMDR have developed “rapid exposure” as an alternative to prolonged exposure. Both EFT and EMDR have evidence to believe they are perceived as less intrusive and demonstrate lower dropout rates than PE.
There are studies showing no advantage of any one of these four over the others in terms of effectiveness but the studies do support that EMDR and EFT retain clients to completion at higher levels than other treatment approaches. NLP is perhaps the gentlest of all the exposure approaches, with clients often reporting the sessions to be relaxing and enjoyable. However NLP has limited studies at this time to support it.
A well supported mixed intervention for children is trauma-focused play therapy which often moves back and forth between top-down interventions and bottom-up interventions. EFT additionally has support as an intervention with children and teens with a trauma history. Both play therapy and EFT have the advantage of being able to be used with children who are not comfortable talking about the trauma.
There are many effective methods for addressing PTSD. Multiple avenues exist for intervention and each year more of these methods are producing adequate research findings to move into the category of evidence-based treatment. At the same time, there are common patterns among these well-supported methods and knowing these patterns can help clinicians select effective tools for their work. Additionally, although the research does not support any individual therapy over any other, there are a few basic guides to be gleaned from the research. One, if you have a choice, pick an individual trauma-focused therapy over the same therapy in group setting, but pick any trauma-focused group over just utilizing coping methods. Further, choose group over telephone or electronic media, but choose telephone/electronic intervention over coping alone. Therapy should be tried before trying a medication alone approach. Any type of focused time-limited group will likely be as successful as any other. Indeed, one of the strongest group models available is trauma-focused Present Centered Therapy. Although medication treatments receive a lot of attention, these should not be considered before existing psychotherapies.