Psychotherapeutic Interventions for Post-traumatic Stress Disorder

Affiliations: ¹Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL; ²Department of Medical Education, University of Central Florida, Orlando, FL

Abstract: There is a wealth of information about psychological treatment for post-traumatic stress disorder (PTSD), with the greatest number of studies supporting the use of cognitive-behavioral therapy (CBT), in particular prolonged exposure (PE) therapy and eye movement desensitization reprocessing (EMDR). While there is much evidence to support CBT therapies in persons with PTSD, few studies have examined their viability and effectiveness in older adults, especially nonveterans. In this article, the authors discuss some of the main psychotherapies for PTSD, including CBT, PE therapy, EMDR, psychodynamics, group therapy, and combination therapy. They also present some of the key considerations for clinicians when deciding which therapy or therapies to advise to their older adult patients with PTSD. 

Article series summary: This is the fourth and final article in a series on post-traumatic stress disorder (PTSD) in older adults. The first article in the series, “Post-Traumatic Stress Disorder: A Historical Perspective of an Evolving Diagnosis” was published in the June issue online, the second article in the series, “Prevention and Screening of Post-Traumatic Stress Disorder in Older Adults,” was published in the July issue online, and the third article in the series, “Biological and Pharmacological Treatment of Post-traumatic Stress Disorder in Older Adults,” was published in the August issue online.

Key words: Post-traumatic stress disorder, treatment of PTSD, cognitive-behavioral therapy, prolonged exposure therapy, eye movement desensitization reprocessing, psychodynamic therapy, PTSD group therapy, PTSD combination therapy.  
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The main approaches to treating post-traumatic stress disorder (PTSD) include medication, psychotherapy, or a combination of both, with many of these options having shown benefit in individuals with PTSD. The biggest challenge is making sure these treatment options are used effectively, as many patients with PTSD drop out of psychotherapy before completion.¹ Although many psychotherapists will identify a specific therapeutic approach, all effective psychological therapies involve some form of exposure and reprocessing of the trauma. Much of the research conducted on psychotherapy of PTSD has involved younger patients; however, the limited data available for older patients generally shows similar outcomes to younger cohorts, assuming that older adults have the physical and cognitive abilities to participate in these treatments in some meaningful way. Many patients respond well to some form of psychotherapy alone, but in severe refractory cases of PTSD, medication and psychotherapy can be used synergistically.

By some counts, there are over 200 schools or forms of psychotherapy; however, not all are necessarily appropriate for the treatment of PTSD. In this fourth and final article in the PTSD series, we review several forms of psychotherapy used to treat PTSD, including different techniques of cognitive-behavioral therapy (CBT; ie, prolonged exposure therapy [PE] and eye movement desensitization reprocessing [EMDR]), psychodynamic therapy, group therapy, and combination therapy, and provide the level of evidence supporting these therapies (Table). We also offer some of the key considerations before recommending any of these treatments to older adults and discuss how our understanding of PTSD is evolving and how it may be more effectively treated in the future.  

Cognitive-Behavioral Treatment

The most well-studied psychotherapeutic treatment for PTSD is CBT.^2-6 Developed in the 1960s, the traditional approach to CBT focuses on identifying dysfunctional thoughts and correcting them through a structured program, which involves working with a therapist as well as engaging in self-directed exercises between sessions for a limited period of time. For example, in cognitive-restructuring, one of the more traditional forms of CBT, the first step is to identify automatic thoughts (ie, negative thoughts or generally negative thought patterns), followed by schemas (ie, mental representation or set of rules that are stored in one’s memory and used for organizing one’s world view based on experience⁷). A person who develops a cognitive schema in response to a traumatic event may believe the world is overly dangerous (eg, distorted threat appraisal); that he or she is incompetent to minimize danger; and that he or she is to blame for the traumatic event.⁸ Once automatic thoughts are identified, the next step of therapy is to identify how the automatic thoughts lead to negative moods and behaviors, which then further strengthen or justify the patient’s negative cognitive schema. The third step of the treatment is to break the cycle of negative automatic thoughts by replacing them with more positive, reality-tested thoughts and behaviors. If symptoms recur after the treatment period has ended, patients can repeat these exercises at home or participate in “booster” sessions to help refresh the techniques and identify any new negative automatic thoughts that may have developed.   

Prolonged Exposure Therapy
PE therapy exposes the patient to reminders of the trauma until the autonomic responses and perceived level of anxiety subjectively diminishes by at least half, indicating extinction/desensitization of the fear pathways. PE therapy involves frequently re-exposing the patient to the trauma during a structured course of therapy, usually in 8 to 15 sessions, each lasting 90 minutes.^2,9,10 PE therapy sessions may be held once or twice per week, during which the patient verbally recounts the traumatic event multiple times in the present tense and provides progressively more detail on each retelling.^2,10,11 The exposure sessions start with the patient recounting the events with his or her eyes closed using “imaginal exposure” (eg, repeated revisiting, recounting, and processing of the traumatic event, which helps the patient obtain a realistic perspective of the trauma) and in-vivo exposure (eg, confrontation with situations, activities, and places that remind him or her of the event). As the exposure sessions progress, the patient begins recounting events with his or her eyes open, usually as he or she regains more comfort and control with the memory. The patient is expected to engage in exercises and stimulus exposures between sessions, such as writing an account of the trauma and rereading it multiple times or making an audiotape and listening to it repeatedly.^9-12 Consistent and repeated PE is thought to habituate the fear pathways in the brain, making it easier for the person to work through the trauma and be less avoidant of thoughts and emotions associated with it.¹⁰

PE and CBT are particularly appealing approaches from a public health perspective because they offer several advantages of the more typical “talk” therapies. First, both of these therapies are short-term therapeutic interventions (requiring 8-20 sessions) that teach techniques that can be used by the patient after therapy is completed. Second, these techniques can be taught to and provided by therapists of varying backgrounds (eg, social workers, licensed mental health counselors, psychiatric nurses, physicians) in a relatively short period of time.^13,14 Finally, the formulaic approach and limited duration of these therapies make them easy to study and report on in evidence-based outcome measures. For such reasons, PE with CBT is currently being implemented as the primary psychotherapeutic approach by the VA hospital system.^15,16

The PTSD literature indicates that 40% to 60% of individuals report a significant symptom reduction, if not full remission, with CBT and PE therapy^13,17,18; however, a 2011 “real world” treatment study of veterans reported that only 33% of individuals who entered psychotherapy at a VA hospital completed eight or more sessions.¹⁹ Although many factors can lead to an individual discontinuing treatment, two key factors make it particularly difficult to keep PTSD patients compliant: (1) the autonomic arousal and fear avoidant symptoms experienced during “re-exposure”; and (2) the high level of comorbid conditions, such as substance use.¹³ Therefore, it is imperative for the treatment team to consistently emphasize the importance of psychotherapy compliance with PTSD patients. 

There has been a debate in the literature about whether elderly subpopulations (eg, those with dementia, those at high risk for cardiovascular events, the physically frail) can derive benefit from traditional CBT or PE therapy.^13,20,21 Of particular concern is the possibility of re-emergence of PTSD or of new delayed-onset PTSD as a result of neurocognitive changes (eg, dementia, normal age-related decrease in brain volume).^22-25 In individuals with mild to moderate dementia, there is question regarding whether CBT and PE will be helpful if the individual is unable to remember the sessions or is unable to strengthen pathways due to another disease process (eg, beta amyloid plaques). To our knowledge, this has not been directly studied; however, a 2012 article by Wolf and colleagues¹⁴ that examined the use of PE in veterans with PTSD and cognitive difficulties caused by mild to moderate traumatic brain injury did benefit from and respond to therapy. Although there are clearly differences between individuals with traumatic brain injuries and dementia, this study shows that individuals with cognitive deficits can have significant improvement in depression and PTSD symptoms when treated with PE.  

The patient’s physical health during therapy is also an area of concern.  Autonomic arousal, one of the cardinal features of PTSD, causes heart rate and blood pressure elevations. As a result, it has been hypothesized that subjecting older adults to prolonged periods of autonomic arousal during therapy could increase their risk of developing arrhythmias, myocardial infarction, or stroke^13,20,21; however, these concerns appear to be more hypothetical than real. Since the autonomic effect is already present with or without therapy, many seniors are already on medications that reduce arousal (eg, beta blockers), and, if needed, biofeedback techniques (eg, pulse rate) can be used to help gauge their level of arousal.^13,21,26 When patients are thought to be at risk due to frailty or unstable cardiac function, a graduated exposure can be instituted.^13,27

Another major concern is the use of abbreviated PE therapy for patients who do not have the mental focus or physical reserves (eg, people with COPD) to engage in a full 90-minute session. Hypothetically, it might be possible to “retraumatize” or strengthen the fear response instead of diminishing it if the treatment ends prematurely; however, this remains an unanswered question since there has been little direct study of these techniques to treat PTSD in the elderly.

Before initiating CBT and PE therapy, seniors should be carefully evaluated to determine if they are appropriate candidates for this approach. If they are, they will most likely benefit from it. A study by Thorp and colleagues²¹ that examined the efficacy of PE in eight “older veterans” (mean age, 63 years) with PTSD following military traumas found that all eight had greater improvement in PTSD symptoms than observed in a control group receiving usual treatment (ie, medication and/or supportive therapy). Patients (n=3) who received a combination of PE and psychopharmacologic treatments had the greatest reduction in symptoms.²¹

Eye Movement Desensitization Reprocessing
Similar to PE, EMDR is a structured approach to PTSD treatment and has been validated in the medical literature.^4,5,12,28,29 According to its founder Francine Shapiro, PhD, the philosophy behind EMDR is that unprocessed information resulting from distressing or traumatic experiences is the root cause of dysfunctional reactions seen in PTSD, so by forcing the mind to process these memories and creating new associations, physiological anxiety can be reduced.³⁰ EMDR is different from other CBTs in that the individual does not need to talk about the traumatic memory, but instead can just think about it. For this reason, individuals who have difficulty verbalizing their experience may do better with this type of therapeutic encounter. While thinking about or verbally recounting the trauma, the individual follows moving lights with his or her eyes, or engages in other bilateral brain stimulation techniques (eg, listening to audio tones, tactile stimulation). It has been hypothesized that the back-and-forth eye movements help to activate isolated and defective memory networks at a cortical level.^31-33

A small study by Lansing and associates²⁹ showed that EMDR produced clinical improvement and brain imaging changes (using high-resolution single-photon emission computed tomography of the brain) in a small cohort of police officers; changes in the occipital lobe, left parietal lobe, right precentral frontal lobe, and left inferior frontal gyrus were noted in individuals who reported improvement with EMDR treatment. Although multiple studies show improvement in patients who undergo this style of treatment, it is unclear whether the eye movement itself produces these effects or whether the other elements that are inherent to this treatment, including psychodynamics, CBT, and imaginal exposure/re-experiencing, contribute to these effects in some way.^12,28 The use of EMDR presents an option for older adults with PTSD, but it has not been extensively studied in this population.

Psychodynamic Therapies

Psychodynamic therapies, also referred to as insight-oriented therapies, are more traditional talk-based interventional therapies that may include psychoanalysis, ego strengthening, hypnosis, and supportive psychotherapy, among other approaches. Historically, these types of interventions have been difficult to assess in an evidence-based manner due to the variability of approaches used by different practitioners and the ongoing personal nature of the treatments. Although psychodynamic therapy does not have the same evidence-based research data to support it as are available for CBT approaches, there are several outcome case studies to support its efficacy in individuals with PTSD, and more large-scale evidence-based research (eg, meta-analyses) studies are on the horizon.^15,34-37

The core goals of psychodynamic therapy include identifying, understanding the meaning of, and addressing the impact of traumatic events on the patient’s life and function. The impact of PTSD on interpersonal (ie, existing or occurring within the individual self or mind) and intrapersonal (ie, existing or occurring between the person and others) relations and the patient’s need to clarify and find meaning in the event are the traditional focus of this style of therapy, rather than on the patient’s specific PTSD symptoms. Individuals with lower levels of autonomic arousal tend to benefit the most from this style of therapy.³⁴

Group Therapy

Group therapy takes many different forms, including family therapy, supportive group therapy, and group CBT.³⁴ In general, it is best to use group therapy as an adjunctive therapy to existing individual psychotherapy.³⁸ It is more difficult to discern the effectiveness of group-based therapy because of the inherent differences among members within a group, more heterogenic focus on varying complaints and life situations, and different levels of skill exercised by the therapists who run the groups.^5,34,38 In addition, questions arise as to whether some group therapies, especially those run by individuals with limited training (eg, layperson rape support groups), may be detrimental to patients with PTSD because a group setting can enforce the notion of permanency, make patients feel they need to “one up” each other when describing symptoms, implant factitious memories or symptoms, and detract from patients’ recovery goals, especially if groups have outspoken or disruptive members (eg, persons with personality disorders).^39,40 The elderly may have more difficulty participating in group therapy because sessions may be long, requiring them to sit, talk, and listen longer than some individual therapies. They may also have difficulty hearing other members and attending scheduled sessions (eg, cannot drive at night, have fatigue at the end of the day).²⁰

Combination Therapies

Although there are many different schools of therapy for the treatment of PTSD, no single treatment approach is ideal for all cases.¹⁵ Many of the more substantive therapeutic reviews find CBT and PE to have the best empiric and replicable support.^{17,34,35,41-43} Most studies, however, have found some improvement using all forms of therapy (eg, psychodynamic, hypnotherapy, supportive) versus no therapy.^15,34,41,42 In actual practice, most therapists use aspects and techniques from several forms of therapy during the treatment period.⁴⁴ Therefore, even though a therapist may principally use one primary approach, such as CBT or PE, most, at some point, employ concepts and techniques from other therapeutic schools, such as supportive and/or psychodynamic therapy.

In addition, the use of appropriate medications coupled with these psychotherapeutic approaches has shown synergistic benefit, particularly for refractory severe cases.^13,21,45,46 In a randomized controlled trial that involved adult survivors of the World Trade Center attack of September 11, 2001, 19 adults received PE therapy plus paroxetine while 18 adults received PE plus placebo.⁴⁶ Combined treatment resulted in greater improvement in PTSD symptoms and remission status than was observed in the placebo group. However, as we discussed in the previous article in this series, potential adverse effects of medications used to treat the symptoms of PTSD must be considered carefully when prescribing them to older adults.

Future Directions of PTSD Therapy

Future therapies for PTSD will largely be dependent on how PTSD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and by advances in our technical ability to further understand its pathophysiology. The latest criteria for PTSD, published in May 2013 in the fifth edition of the DSM (DSM-5), recognizes PTSD as a trauma- and stressor-related disorder, rather than an anxiety disorder.⁴⁷ It also proposes four diagnostic “clusters” of behavioral symptoms of PTSD, compared with the three outlined in the DSM-IV and some of the earlier versions of the DSM. The current clusters are re-experiencing, avoidance, negative cognitions and mood, and arousal. The number of symptoms that must be identified for the diagnosis depends on the cluster, and the criteria require the symptoms to persist for more than 1 month. The distinction between acute and chronic phases of PTSD has been eliminated.

In addition, the DSM-5 recognizes a dissociative subtype of PTSD.⁴⁷ This subtype was added based on three converging lines of research: (1) symptom assessments, (2) treatment outcomes, and (3) psychobiological studies.⁴⁸ As a result, the dissociative subtype of PTSD was established to specifically focus on depersonalization and derealization, with a goal to better treat and improve the outcome of PTSD in these patients.

Whether or not more PTSD subtypes exist or one even agrees with the need to subdivide PTSD, additional research to further define which symptoms and which types of patients will respond best to existing therapeutic approaches is needed.²⁵ In terms of lab/bench research, better neuroimaging and the development of new biological markers (eg, hormone responses, genetics) will hopefully lead to better tailored pharmacologic and psychotherapeutic treatments and improved diagnostic accuracy for both PTSD and its co-occurring conditions.^49-52 In addition, a better understanding of the physical changes produced by PTSD may help geriatricians better comprehend the future health risks their patients might experience.²⁴ For example, a study by Yaffe and colleagues²⁵ looking at a VA sample found that individuals with a PTSD diagnosis had a nearly twofold increased risk of developing dementia as compared with a cohort group without PTSD.²⁵ It is unclear at this time if dementia and PTSD share a common risk factor, or if developing PTSD is enough to increase the risk of developing dementia.²⁴

Finally, new technological advancements may further improve and refine psychotherapy treatments. Current research is exploring the effectiveness of using virtual reality technology as a stimulus for in-vivo exposure therapy.^53-56 In addition, the use of the Internet as a primary tool to provide therapy to individuals who drop out of traditional treatment or who are treatment avoidant is being investigated.^53,57-59

Conclusion

Our review has highlighted that few studies have provided evidence specifically on the different psychological treatments for PTSD in the complex older adult population. Much of the evidence supporting the use of these treatments, such as PE and EMDR, have included younger cohorts and military service personnel. Additional studies are needed to evaluate psychological and combination treatments in nonveteran older adults, as many older adults experience chronic and acute PTSD as a result of traumatic events other than combat, such as being a victim of sexual or physical abuse; being injured in a motor vehicle accident; and experiencing a natural disaster. Looking ahead to improve PTSD therapy in this age group, better neuroimaging and the development of new biological markers (eg, hormone responses, genetics) may lead to better tailored treatments and improved diagnostic accuracy for both PTSD and its co-occurring conditions in older adults.In addition, a better understanding of the physical changes produced by PTSD may help geriatricians better comprehend the future health risks their patients might experience.

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Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Ryan C. Hall, MD, 2500 West Lake Mary Blvd, Suite 219, Lake Mary, FL 32746; dr.rcwhall@live.com.