Confronting trauma directly most effective for post-traumatic stress disorder

For patients suffering from post-traumatic stress disorder, psychological treatments that address the trauma directly are better than more general therapies, according to a systematic review of the subject.

The treatment approach known as trauma-focused cognitive behavioral therapy shows “a strong positive effect,” the study says. In this type of program, therapists address the distressing thoughts and feelings related to the trauma and help the survivor cope with unpleasant memories and reactions.

The analysis suggests that stress-management therapies may also be effective.

Limited evidence supports the value of anxiety-management techniques such as relaxation and deep breathing. Least successful are nonfocused treatments such as straightforward counseling or “psychodynamic” therapies that emphasize the emotional conflicts caused by the traumatic event, particularly as they relate to childhood experiences.

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Lead author Dr. Jonathan Bisson of Cardiff University in Wales hopes the findings will result in “more people seeing trauma-focused psychological treatment as the most appropriate approach for PTSD and hopefully with more therapists being trained in the specific techniques required to help people.”

PTSD is a medically recognized anxiety disorder that occurs in response to extremely stressful situations such as combat, sexual assault, traffic or industrial accidents, natural disasters or bereavement. Symptoms typically include distressing thoughts of the event, numbing of emotional responses, estrangement from other people, sleep disturbances, irritability and hypervigilance.

A survey by the National Institute of Mental Health in the early 1990s found that 29 percent of female assault victims suffered from PTSD. Among men with combat experience the figure rose to 39 percent.

The new review included 29 studies that compared the results of a specific therapy to those of another treatment approach or a control group. Controls comprised either patients receiving minimal care while on a waiting list for treatment or those already in treatment who continued receiving standard care.

All of the studies focused on adult trauma survivors. Seventeen took place in the United States, with the remainder in Australia, Canada, Germany, the Netherlands and the United Kingdom. The number of patients in each trial ranged from 16 to 360.

Small sample size was one of the disappointing aspects of the review, says Bisson, adding “Unfortunately, studies of psychological treatments tend to be bedeviled by that.” Nevertheless he notes, “The stronger methodological studies produced more positive results than the weaker studies, which gives us confidence in our findings.”

The authors note that the review did not address a promising therapy known as eye movement desensitization and reprocessing, which will be included in future updates of the review. Other Cochrane Collaboration reviews have analyzed immediate treatment of trauma-related symptoms to prevent PTSD and pharmacological treatments for PTSD.

Trauma-focused cognitive behavioral therapy is widely accepted and in widespread use in both the United States and the United Kingdom, says Bisson. The U.S. Department of Veterans Affairs’ National Center for PTSD notes, “In general, CBT has proven very effective and produced significant reductions in PTSD symptoms.…Furthermore, the magnitude of treatment effects appears greater with CBT than with any other treatment.” Likewise, the National Institute of Clinical Excellence has issued practice guidelines for England and Wales stating that trauma-focused psychological treatment should be provided as the first-line treatment for PTSD.

Nevertheless, says Bisson, “Some people do feel we’ve underplayed the importance of psychodynamic therapy, but this is a very objective study looking at the effectiveness of treatments, and the results are there for people to see: There’s more evidence for trauma-focused therapy than there is for the other therapies.”

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