Psychological trauma can occur in a brief moment, over a prolonged period of time or can occur in repeated episodes. We're all aware of the many examples that occur daily. Being near the explosion of a terrorist’s bomb that unleashes its destruction in a few seconds can leave psychological scars that last a lifetime. Soldiers involved in prolonged combat or civilians trapped in a city under siege may experience long and unrelenting periods of terror. A young child may be subjected to repeated episodes of neglect or abuse. Whatever the cause, these kinds of events have long-lasting and damaging effects on the people who experience them.
As I have discussed in the past several posts traumatic stress has prominent negative effects on both quality and quantity of sleep. It is also clear that poor quality sleep exacerbates other symptoms of traumatic stress. The treatment of PTSD is complex and time consuming. There are two strategies for approaching trauma and sleep. Treat the PTSD and the sleep problems will improve as well or treat the sleep problem and that may help the PTSD.
A number of therapies for treating PTSD are currently in use and have some degree of empirical support. The major treatment approaches are briefly described below as well as several new and controversial approaches.
Stress Inoculation training was developed in the 1980s to help patients master fear and anxiety by teaching skills for coping. This type of treatment is provided in phases. The first prepares patients for treatment by providing a psychoeducational framework for understanding and making sense of their reactions to the traumatic events. Patients are helped to understand that anxiety occurs on a physical level, a behavioral level, and a cognitive level. Patients are helped to identify their own physical, behavioral, and cognitive responses to trauma. In the second phase of treatment patients are taught coping skills for dealing with anxiety. These may include techniques such as relaxation and breath control methods. Other skills may include visualizing the anxiety-provoking situation and imagining successfully confronting and overcoming it. On the cognitive level, patients are taught to identify and challenge negative and maladaptive self-statements and to develop more accurate and adaptive ones.
Exposure techniques were first investigated as treatments for PTSD in the early 1980s. This is a challenging but effective therapy in which patients are supported through prolonged periods of exposure to imagined or actual stimuli that provoke vivid memories of the traumatic event. These techniques have even utilized virtual-reality by exposing patients to simulated situations such as driving a truck in Iraq through areas in which the patient experienced attacks. By in effect repeatedly reliving the traumatic event while focusing on breath control and paying attention to negative cognitive processes, over time patients can become desensitized to stimuli that previously caused anxiety related to the traumatic events.
Cognitive interventions have been used to help patients identify and challenge unrealistic or exaggerated negative thoughts about themselves and their world. Cognitive therapy may also focus on patients understanding of and beliefs about the traumatic events. Targets for such intervention include distorted beliefs of self-blaming for not preventing the traumatic event, which can result in low self-esteem and shame. Cognitive techniques may also be used to help patients reestablish a sense of control or safety.
Another cognitive approach is called cognitive processing therapy. This was developed specifically for survivors of sexual assault. It has now been extended to other forms of trauma. This comprehensive program helps people identify how the traumatic event has affected them and end any sense of self blame for the event. An effort is made to help them understand any distortion or overgeneralization about the meaning of the event that has compromised their functioning. Guilt might occur if a patient believed that they could've prevented the trauma. Training is given in labeling emotions and seeing how events, feelings, and thoughts are connected. Cognitive techniques are used to challenge maladaptive thinking patterns related to the traumatic event. Finally patients are assisted in finding more effective ways of thinking about core themes of traumatic experience such as trust, intimacy, power, and safety.
Combination treatment packages may include exposure therapy both with imagined situations and real-life reminders of the trauma, cognitive therapy techniques to challenge negative thought processes, relaxation training to help manage anxiety, and coping skills training to help master fear and negative behavioral patterns.
Skills Training in affective and interpersonal negotiation was developed to help patients who had survived child sexual abuse. It was designed to help ameliorate problems and affect regulation and interpersonal effectiveness. The program was designed to help patients learn methods for emotional management and to develop interpersonal skills. This helps remove barriers to further treatment of PTSD symptoms using exposure techniques.
Eye movement desensitization and reprocessing (EMDR) is a therapy that I was first trained in by Francine Shapiro in 1991. While it has become well-known it remains somewhat controversial because it was developed by Dr. Shapiro based on her own experiences rather than on prior theory or clinical technique. While walking she had noted relief from troubled thoughts when her eyes moved back and forth following the waving of leaves in a park. Based on this experience she developed a technique for using guided lateral eye movements to help cognitive processing of traumatic memories. This therapy has developed into a considerably more complex program than when I was first exposed to it. It now involves taking patient history, preparing patients for treatment, developing a target memory or image for intervention, desensitization of the target, installing more effective cognitive processing of the event, using a body scan, bringing closure, and evaluating treatment effects. This therapy thus utilizes imagined exposure, cognitive interventions, and lateral eye movements.
Both cognitive behavioral therapy and EMDR have been established as being effective and are recommended as first-line treatment for PTSD (Monson, Resick, & Rizvi, 2014).
Medications are often used to treat symptoms of posttraumatic stress disorder, including problems with sleep such as insomnia and nightmares. The FDA has approved both sertraline and paroxetine treatment of PTSD. These medications are used to treat depression, anxiety, concentration problems, and insomnia. Anti-anxiety medications can be used to help patients manage anxiety symptoms but have significant dependency liability and should only be used briefly. Prazosin is a medication that is sometimes used to help control PTSD related nightmares.
I will briefly mention two additional treatment approaches that are under active investigation and have often been used illicitly by people suffering from PTSD to manage their symptoms. In both Vietnam and in our wars in the Middle East soldiers have utilized cannabis both in the field and when returning to home to manage symptoms of PTSD. In fact, veterans’ groups have been very active in advocating for research into the potential benefit of cannabis for treatment of PTSD. The Multidisciplinary Association for Psychedelic Studies has been a leader in this effort and information about their proposed study is available online. After years of effort the DEA has recently agreed to allow this research to move forward.
The well-known club drug known as ecstasy is also being researched as a potential treatment for PTSD. Early results show that when supported by intensive preparation and psychotherapeutic interventions, MDMA can be safely administered with clinical benefit that is sustained over time (Oehen, Traber, Widmer, & Schnyder, 2013). It must be pointed out that taking unknown substances purchased through illicit sources with unknown contents, quality, or potency under uncontrolled conditions without psychotherapeutic support is highly unlikely to provide the kind of healing experience possible in well-controlled and supportive clinical settings. Further information about ongoing research in this area may be found on the MAPS website.
There is increasing evidence that treating sleep disorders such as insomnia helps ameliorate clinical conditions such as depression and posttraumatic stress disorder. It therefore makes sense to utilize standard cognitive behavioral strategies that have been previously discussed in this blog to specifically target and treat insomnia among patients with PTSD. In fact the most effective way to help reduce the negative effects of trauma may be by helping people sleep better so that they feel more safe and able to engage in the arduous work of trauma therapy.
Monson, C. M., Resick, P. A., & Rizvi, S. L. (2014) in Barlow, D. H. Clinical Handbook of Psychological Disorders 5th edition. New York: The Guilford Press.
Oehen, P., Traber, R., Widmer, V., & Schnyder, U., (2013). A randomized, controlled pilot study of MDMA (±3,4-Methylenedioxymethamphetamine)- assisted psychotherapy for treatment of resistant, chronic Post-Traumatic Stress Disorder (PTSD). Journal of Psychopharmacology, 27(1) 40–52.