August 24th, 2012

Curing trauma: reality or myth?

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PHOTO BY Tom Croke
Terence M. Keane, Ph.D., says that online therapy may be especially appealing to veterans with PTSD.

Horrific events such as a divorce, serious motor vehicle accident, physical assault, a terrorist attack or military service in an active war zone hold the potential for inducing trauma in its victims. A variety of treatment options are available that can alleviate symptoms and restore psychological balance. Some recent news stories report the possibility of a “cure” for trauma. But is this optimism misplaced?

Simon A. Rego, Psy.D., ABPP, ACT, director of psychology training at Montefiore Medical Center/Albert Einstein College in the Bronx, explains that patients who are traumatized have developed widely distorted beliefs about the world, along with coping mechanisms – oftentimes avoidance – as a way to deal with the stress and fear. “Using avoidance with memories perpetuates the very disorder,” he says. “It’s necessary to learn on an emotional level that you can manage anxiety if you stay the course.”

That course usually begins with talk therapy, Rego notes. A proponent of cognitive behavioral therapy (CBT), he indicates that imagery rehearsal therapy (IRT), prolonged exposure (PE) and eye movement desensitization and processing (EMDR) are some additional commonly used, effective interventions.

Another therapy, critical incident stress debriefing (CISD) had fallen out of favor in recent years. But Rego points out that new research out of Emory University finds that a modified form of Prolonged Exposure, a form of cognitive behavioral therapy, may indeed yield good effect when used soon after a traumatic situation. The results of this research may have tremendous implications, particularly for returning war veterans, he suggests.

Regardless of which talk therapy option is used, patient cooperation is key to achieving positive results. “If the patient is unwilling to do the homework, he won’t get better. The therapy has to create a sense of understanding and motivation,” he says. “I let the patient lead the way. It’s part of what I call ‘informed consent.’ The clinician is the theorist and the patient is the applied scientist.”

When psychotherapy fails to produce the desired results, the addition of pharmacological agents may enhance treatment. Matthew Friedman, M.D., Ph.D., executive director of the U.S. Department of Veterans Affairs National Center for PTSD and professor of psychiatry and pharmacology at the Geisel School of Medicine at Dartmouth, notes that Prazosin, which blocks some of the effects of norepinephrine, shows promise for the treatment of PTSD-related nightmares. “It was first introduced as an anti-hypertensive, but was not top ranked,” he says, adding that while Prazosin is recommended for traumatic nightmares, the jury is still out on its effectiveness for all PTSD symptoms.

The Food and Drug Administration approved two selective serotonin reuptake inhibitors (SSRIs), Paxil and Zoloft, for the treatment of trauma, according to Friedman. “There is also good data to support Prozac and Effexor, a first cousin to the SSRIs. These four medications have the strongest efficacy for PTSD,” he says, adding that the anti-depressant Remeron or Serzone may be effective, although the latter comes with a black box warning because of possible liver toxicity. Small studies on the anticonvulsant Topamax may offer another viable treatment option.

Some studies looked at combination therapy with SSRIs and atypical anti-psychotics, such as Risperidone, Olanzapine and Quetiapine, Friedman says. “The results were quite negative. Based on that, I would recommend against that option.”

Friedman also strongly cautions against the use of benzodiazepines, including Valium, Ativan, Xanax and Clonopin. “These are ineffective and carry the risk of addiction. There is some evidence from an animal study and one human clinical study that it might interfere with psychotherapy,” he says.

One of the most exciting developments, still under investigation, involves D-cycloserine, an older medication originally used for tuberculosis. Friedman explains that animal studies show that this drug works effectively in a fear extinction paradigm. This paradigm has been adapted for clinical use as exposure therapy. “When D-cycloserine is given before a trial, research shows extinction happens more quickly,” he says. “We know that extinction is really new learning that works on the NMDA receptors.”

Terence M. Keane, Ph.D., president of Division 56 (Trauma Psychology), associate chief of staff for research and development at the VA Boston Healthcare System and director of the Behavioral Science Division at the National Center for PTSD, proposes a more high-tech solution. He indicates that therapy, either treatment-assisted or anonymous, delivered via the Internet may gain more favor in time. The VA recently completed a randomized online trial in which 600 subjects with alcohol abuse and PTSD were effectively treated in 43 days. “There are all kinds of implications [from this study]. Those effects are still good three months later,” he says.

While virtual therapy may seem challenging, it involves some of the same components as face-to-face treatment. “Patients do the same homework online and in the office. They keep a diary on their Smartphone or with a pen and paper and go through certain exercises,” Keene says. He  points out that online therapy may be especially appealing to returning veterans, since it eliminates the “shame piece.” He says, “For this segment of the population, they might do better anonymously.” Also, individuals who live in rural areas with few practitioners could also benefit from online treatment. “New media may be part of the solutions,” he says. “We are encouraged by the outcomes so far.”

One of the biggest issues surrounding trauma treatment is the dearth of qualified practitioners, according to Friedman. Approximately 10 years ago, A VA study found that 80 percent of its practitioners were not using an evidence-based psychotherapy and only 10 percent are using one routinely, he adds. Cognizant of the problem, in the last five years the VA has trained approximately 4,600 practitioners to utilized effective treatments for patients with PTSD.

As for a cure, Friedman prefers the term remission. He does concede that achieving virtual freedom from symptoms is possible with appropriate intervention, although recurrences can occur under certain circumstances. He says, “The data tend to indicate that on balance medications are not as effective as psychotherapy. As we learn more we can anticipate that more specific and effective medications will come on the market.”

By Phyllis Hanlon

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