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Treating PTSD, Part Two

Natalie Staats Reiss, Ph.D. Updated: Nov 9th 2007

Dr. Dombeck's previous essay about the the "looming PTSD bubble" /poc/view_doc.php?type=doc&id=13700 made a convincing argument that more research is URGENTLY necessary to help us understand how to effectively treat Post Traumatic Stress Disorder before a significant number of troops with this disorder come home from Iraq and Afganistan. I second his suggestion that we be as proactive as possible to address this potential crisis in the mental health field.

Along these lines, I was interested to read a new preliminary study published in the November issue of the American Journal of Psychiatry (Volume 164, Number 11, pages 1676-1683). This article suggests that an Internet-based form of cognitive behavioral therapy called "DE-STRESS" might be an effective and cost-efficient strategy that could help address this issue. This form of therapy combines highly effective exposure techniques (referred to in Dr. Dombeck's article) and cognitive strategies for a "one-two punch" against the symptoms of PTSD.

The study involved a group of individuals who developed PTSD in response to the Pentagon attack on September 11, or being in combat in Iraq or Afganistan. Participants were randomly assigned to one of two groups. Group one (24 individuals) received the active treatment. First, participants learned the tools necessary for change via an in-person session with a psychotherapist. During this two-hour session, clients developed a graded hierarchy of stressful situations (i.e., situations that were more stressful were put at the top of the hierarchy and things that were less stressful were put at the bottom) and learned two different stress management techniques: diaphragmatic breathing (a practice of highly controlled, deep, slow, and rhythmic breathing) and progressive muscle relaxation (a practice of tensing and releasing subsequent muscle groups to decrease tension). They were also taught cognitive reframing techniques (how to monitor, challenge, and restate unhelpful thoughts that perpetuate their feelings of anxiety and stress).

The active therapy group then moved to an Internet-based, self-help module. During the first two weeks of the self-treatment mode, participants completed a series of homework assignments. These assignments involved monitoring trauma-related situations that caused distress. Then, the therapist (via e-mail) helped them generate a final stress-related hierarchy. During week 3, clients were instructed to confront the situations on their hierarchy (the exposure component) while using their relaxation techniques. During week 7, participants had to complete 7 on-line trauma writing sessions (writing and re-writing detailed, first person, present-tense accounts of a troubling traumatic experience). The last week included a review of progress, education regarding relapse prevention techniques, and creating an individualized plan for future challenges. Throughout all weeks of therapy, members of group one received therapist contact via e-mail and phone calls.

Group two received supportive therapy (21 individuals). This group also received an initial two-hour meeting with a therapist, who discussed PTSD causes and symptoms, and stress management techniques. Participants in this group were instructed to read educational materials about PTSD and related conditions (such as depression and sleep problems), monitor feelings/moods, and write about non-trauma related concerns and hassles. Group two also received the same amount of email and phone contacts with their therapist as group one. During week 8, group two members planned ways to use the information that they learned to move forward.

Both groups had unlimited access to a special website with specific educational information about PTSD, stress and trauma, co-occurring conditions (e.g., depression, survivor guilt), anger management, and promoting good sleep habits.

The majority of participants in group one experienced decreased PTSD symptom severity, and saw specific gains in decreasing the avoidance of feared situations, as well as decreased hyperarousal (a constant state of being anxious and "hyped-up" and continually scanning the environment for danger). In addition, depression ratings also decreased. 1/3 of group one maintained treatment gains across 6 months.

Obviously, this was a rather small study, so I am not suggesting that this type of therapy is THE solution to treating PTSD. I know from my clinical experience that not all people would be able to stick with a self-directed therapy approach. Others might find the lack of ongoing interpersonal interaction with their therapist a huge negative. However, I find the idea of combining individual psychotherapy sessions and on-line self-help strategies intriguing for several reasons. First, it's cost effective, and can be used to target large groups of vets (or other individuals suffering from this disorder). Two, it can help to combat and decrease stigma, because the sessions (except for the initial meeting) can be conducted in the privacy of the client's home. Next, this format can circumvent the problems with having individuals with PTSD rely solely on self-help strategies. PTSD is usually a severe and complicating condition, and most people require contact with a trained mental health expert in order to obtain symptoms relief. Finally, this mode of treatment may be appealing for the convenience factor. Clients do not have to worry about making appointments, arranging transportation, and so on- they can log on at convenient times.

I look forward to reading about expanded trials of the DE-STRESS approach.





Reader Comments
Discuss this issue below or in our forums.

Will I Ever Be Normal Again? - Allan N. Schwartz, PhD - Apr 28th 2009

Hi Trish,You should have every reason to believe that you will feel normal again but it is important that you start getting help for your PTSD. It is important that you see a clinical psychologist or psychiatrist who are trained and expert in the treatment of PTSD. There are now a variety of approaches used to treat this problem. One of them is called "EMDR," but there is also "Exposure Therapy," and other approaches. Sometimes medication is used to help suffers sleep because solid sleep is part of the recovery process. I want to urge you to start getting help as fast as possible.Dr. Schwartz

sleepness nights - trish - Apr 27th 2009

i was hit by a car and was concious through the whole ordeal its been almost 4mnths now and i cant sleep at night i too have a reacurring nightmare ive awaken in the middle of it and im gasping for air ive been off work for 3mnths now and i have no energy or ambition to leave my home accept when i have to,i truly thought i was going to die that day and am so afraid to cross the street,when im waiting for the lights to turn red my legs shake and im see myself getting hit again and smashing my head into the windsheild and flying into the air i feel afraid to make any daily life desisions my carreer is flagging,i will never be able to flag again due to suffering PTSD,will i ever be normal again?

You're not a wimp - - Jun 12th 2008

It takes time to overcome trauma.  Be understanding with yourself but also be prepared to challenge yourself.  I found that if I gave myself permission to stop pushing myself for a given amount of time that I was better able to function.  I set recovery goals for myself.... reasonable goals.  Leaving the house next week to walk your dog may not be a reasonable goal.  But opening the door to look outside for 10 minutes may be.  Then maybe sitting on the porch for increasing amounts of time... etc.  You may need a therapist with whom you can talk about your trauma and perhaps they can help you to set behavioral goals.  On the other hand, your symptoms will likely fade with time and the doctor you have now may be making the symptoms bearable while you wait.  If your trauma is fairly recent I would bear with myself, be patient, and be aware of how you are feeling... is the fear still constant and as intense? are there short breaks in the fear that are getting longer? etc.  If it has been awhile (I don't know the exact amount of time, but if it's been 6 months and nothing has changed) Then you may want to consider a therapist who can help you get started.  Again.. patience..  but also persistance.

I am sorry for what happened to you.  I hope that this helps you to find ways to help yourself,


Living with PTSD - Wendy - Dec 21st 2007

I am a 36 year old married female. My husband and I owned a small Collections & Repossession business. On March 26th of this year I was walking our dogs (as I did everyday) when a neighbor called me over next door. I thought nothing of it, was "neighborly" & went to say hello. Well, to make a long story short the neighbor that called me over --- up and ran...then this large woman whom I had never met before threw me to the ground, began kicking me in the head, stomping on my face, suddenly a pitt bull dog appeared. This woman called the dog by name & took him by the scruff of the neck & commanded him to "Kill", REPEATEDLY. FINALLY I managed to get up off the ground, I still had my little shih-tzu puppy on her leash! As we all know, anytime you have a head injury you BLEED....ALOT! I remember wiping the pouring blood from my eyes and at that point was just thinking to myself,"What on Earth just happened? Who in the world is this person? Why did she do this to me?Etc., etc"

As I stood up I overheard her say, "Go on you b@#$ch, take your blank, blank home." All I could say was, "Lady, you just messed with the WRONG B@#$ch !" I walked to our home and called out to my husband. He was coming down the hallway, saw me, stopped--opened mouthed, & asked me very calmly if I had been hit by a car. The dog had completely ripped into my skull and I required over $100,000 in reconstructive surgeries & hospital bills.

The WORST thing of all is that I only have 2 years left of my education to become a Vetinarian. Now I stay in the house, afraid of everything, have been rushed to the E.R. more than once due to SEVERE panic's like I would just forget how to breathe, my hands would draw up, etc. My brother is on his 2nd tour in Iraq, he is a Sgt in the U.S. Marine Corp. He pretty much thinks I'm a wimp because I still get so upset and live like a prisoner in my own home. I couldn't imagine if something like War happened to me. Why can't I deal with this? I have nightmares all the time. I go to a psychiatrist, but he just writes me an Rx for Xanax & never discusses what happened to me or what I can do to overcome this.


WenCambron in AL

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