Post Traumatic Stress Disorder (PTSD): What it is, how it can be treated and how treatment outcomes can be measured

PTSDThe public is rarely confronted with sufferers from PTSD. The stories of Iraq war veterans returning back home as broken men unable to find their way back into ordinary life are among the best-known examples publicized in the media. PTSD however extends far beyond the effects of traumatizing war experiences – time to shed some light on the phenomenon.

PTSD is a recognized mental disorder and develops after a terrifying event that has involved physical harm of the threat of physical harm (NIMH, 2013). Symptoms include re-experiencing the traumatic event such as in nightmares and flashbacks, detachment and estrangement from others, emotional numbing, hyperarousal symptoms and hypervigilance (Bisson & Andrew, 2009).  PTSD can be the result of ordeals such as rape, child abuse, bombings, natural disasters, severe accidents or combat experiences and tends to start immediately after the catastrophic event. PTSD is regarded as a treatable disorder even if it has been unreported for many years (NICE, 2005).

Recommendations for treatment in the Cochrane Systematic Reviews

A query in the Cochrane database presented three relevant systematic reviews:

(a)    For psychological treatment, trauma-based therapy appears more effective than non-trauma based interventions. The authors conclude that “There is evidence that individual trauma focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation reprocessing (EMDR), stress management and group TFCBT are effective in the treatment of PTSD.” (Bisson & Andrew, 2009).

(b)     For pharmacotherapy 59% of PTSD patients in 17 out of 35 trials showed significant improvement while the placebo effect was relatively highly effective at 39%. Stein and colleagues (2009) mention the high drop-out rate in patients using SSRIs and emphasize that effect-size statistics in trials do not translate into clinical efficacy. It is mentioned that pharmacotherapy is usually only used in combination with psychotherapy (Stein et al., 2009)

(c)     For combined psychotherapy and pharmacological treatment: Inadequate methodology of trials and a wide lack of evidence-based data such as global functioning, suicide ideation and attempts, quality of life, cost of treatment, depression and substance abuse, rendered a final assessment of the submitted trials inconclusive. The authors conclude that “The consistency of results cannot be evaluated here given the small number of trials and the lack of usable data.” (Hetrick et al., 2010, p.14).

Critical assessment, clinical utility and alternative sources of information

Summaries in the Cochrane Collaboration database which appear focused on research reviews provided little data and help on clinical utility and application for PTSD, except for the identification of effectiveness of various psychological treatments.  A query in NICE, by comparison, gave a detailed account on assessment and coordination of care, social support and factors supporting patients, language and cultural issues as well as pragmatic, timeline-and decision making-based treatment guidelines (NICE, 2013). Explicit guidelines for treatment of comorbidity are provided. Pharmacotherapy is discouraged as a first-line treatment and, in agreement with findings from the Cochrane data-base; trauma-focused psychotherapy appears preferable. Drug therapy is only recommended if patients are unable to enter psychotherapy, e.g., for the severity of trauma and ability to engage in dialogue.

Measurement of outcomes

Outcome assessments of studies should investigate effects beyond mere symptomatology and address issues such as global functioning and quality of life. Significant effect size in trials does not necessarily translate into clinical efficacy and utility (Chamless et al., 1998, p.10-11). Furthermore factors such as cost-effectiveness and patient acceptance/ dropout-rates need to be taken into consideration. Lambert and colleagues (2004) add some compelling arguments supporting a preferably psychotherapeutic approach such as a lower relapse rates, fewer dropout rates, larger effects and maintenance of gains  as compared to pharmacotherapy (Lambert et al., p.143).

The reviews in the Cochrane Collaboration database (Bisson & Andrew, 2009) as well as the treatment guidelines of the National Institute for Clinical Excellence (2005) unanimously agree that trauma focused cognitive-behavioural therapy/ TFCBT is the treatment of choice when it comes to PTSD. NICE (2005) proposes TFCBT for older children within the first month of the event and adults within a timeframe of 3 months after experiencing a traumatizing event. For symptoms presenting themselves after 3 months of trauma individual TFCBT (8-12 sessions on individual outpatient basis) or Eye Movement Desensitisation and Reprocessing/ EMDR (Shapiro, 1989) is recommended.

Bisson and Andrews (2009, p.2) emphasize that TFCBT and EMDR are superior to any other therapy measured at 2-5 months following treatment, which appears congruent to the efficacy for both interventions quoted in the NICE treatment guidelines.

Primary outcomes have been measured by employing clinician rated psychometric instruments assessing the severity of stress symptoms, quoted is the Clinician Administered PTSD Symptom Scale. Secondary outcomes have been measured using self-report inventories such as the Impact of Event Scale (Horowitz et al., 1979), the Beck Depression Inventory (Beck et al., 1988) and the Spielberger State Trait Anxiety Inventory (Spielberger, 1994). Into account are taken dropout rates, diagnosis after treatment and adverse reactions.

It can be argued that currently listed outcome criteria are necessary, but insufficient. Lambert and colleagues (2004, p.148) point out the issue of social validity of clinical significance, meaning that after successful treatment a client’s post-intervention behavior does not differ from a normal reference group. The issue of including measures of functioning and quality of life has also been brought up by Chamless and Hollon (2001, p.10). Treatment goals need be maintained and relapse should be prevented, warranting a standardized long-term follow-up paving the way for a more holistic outcome-value definition.

As a last word of caution: returning to typical behavior does not entail ‘cure’ for the lifelong damage that PTSD sufferers have to deal with. Remaining lifelong vulnerability adds to an enormous subjective burden.

References

Beck, A.T. Steer, R.A, Garbin, M.G. J. (1988). “Psychometric properties of the Beck Depression Inventory Twenty-five years of evaluation”. Clin. Psych. Review 8: 77–100.

Bisson, J., Andrew, M. (2009). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic. Reviews 2007, Issue 3. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub3.

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7–18

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716.

Hetrick, S.E., Purcell, R., Garner, B., Parslow, R. (2010). Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007316. DOI 10.1002/14651858.CD007316.pub2.

Horowitz, M.J., Wilner, M. & Alverez, W. (1979). Impact of Events Scale: A measure of subjective stress. Psychosomatic Medicine, 41(3), 209-218.

Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 139–179). New York, NY: Wiley.

National Institute of Mental Health. (2013). Post-traumatic Stress Disorder. Retrieved from http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

National Institute for Clinical Excellence (2005). Clinical Guideline 26. Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. Retrieved from http://www.nice.org.uk/CG026distributionlist

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223

Spielberger, C.D., Sydeman, S.J. (1994). State-Trait Anxiety Inventory and State-Trait Anger Expression Inventory. In M.E. Maruish (Ed.), The use of psychological testing for treatment planning and outcome assessment. (pp. 292-321). Hillsdale, NJ: Lawrence Erlbaum Associates.

Stein, D.J., Ipser J.C., Seedat S. (2009). Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2.

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