Preventing PTSD After Trauma
A brief review of psychological and technology-based approaches.
Posted March 5, 2017
Psychological interventions aimed at preventing PTSD following exposure to trauma—overview of research findings.
A 2013 review (AHRQ Pub. No. 13-EHC062-1-EF April 2013) compared the efficacy, effectiveness, and adverse effects of interventions aimed at preventing PTSD in adults. 13 studies on efficacy included diverse populations including victims of sexual assault, accidents, terrorist attacks and others. Significant findings hold no evidence for debriefing in preventing PTSD, some evidence for a collaborative care (CC) model combining pharmacologic management and CBT, no evidence for comparative effectiveness of escilatopram (an SSRI) over cognitive therapy (CT) and prolonged exposure (PE), no evidence for the comparative effectiveness of CBT over supportive counseling (SC). There was insufficient evidence for other interventions in preventing the development of PTSD following trauma exposure, including CBT, CBT combined with hypnosis, CT, PE, psycho-education, SC and the medications escitalopram and hydrocortisone. There was also insufficient evidence to determine the role of timing, intensity and dosing of specific psychological or pharmacological interventions aimed at preventing PTSD. Findings of studies were limited by small study sizes, high attrition rates, methodological problems including absence of randomization in many studies and poor statistical methods, and a high risk of bias. There was insufficient evidence to determine whether significant differences in the risk of developing PTSD following trauma exposure are present in diverse sociodemographic or diagnostic groups following early interventions. There was insufficient evidence for adverse effects caused by early interventions aimed at preventing PTSD. Based on studies reviewed the authors concluded that CC effectively reduces the risk of developing PTSD in civilians following injuries that require surgery, debriefing following exposure to trauma does not reduce the incidence or severity of PTSD and may even be harmful, CBT may be more effective than SC, and the effectiveness of psychological interventions does not differ between men and women. The authors cautioned that findings of studies on interventions used in groups exposed to specific types of trauma may not generalize to other trauma types including terrorist attacks, natural disasters, sexual assault and combat, and commented that these groups are under-represented in PTSD prevention studies. Finally, there were too few studies to determine whether cultural differences played a significant role in response to interventions aimed at preventing PTSD following exposure to trauma.
Prevention studies are limited by difficulties identifying individuals at high risk of developing PTSD shortly after exposure to trauma. The authors emphasized the importance of developing a "prediction rule", taking into account personality factors, events and immediate post-trauma response patterns that may help predict who is more likely to develop PTSD following exposure to trauma. Such a rule could be tested in a controlled intervention trial to determine its potential impact on the rate of new PTSD cases following exposure to trauma. The majority of interventions used to prevent PTSD are supported by weak evidence. Based on limited available evidence brief trauma-focused CBT may be the most effective intervention for reducing PTSD symptom severity following exposure to trauma and collaborative care may reduce the severity of PTSD symptoms following injury.
A 2013 systematic review of studies on interventions aimed at preventing PTSD following exposure to trauma included 16 studies on psychological interventions and two studies on pharmacologic interventions (Forneris et al 2013). Psychological interventions aimed at preventing PTSD included debriefing, CBT (alone or in combination with hypnosis), cognitive therapy, debriefing, prolonged exposure therapy, psychoeducation, and supportive counseling. Only one study ("battlefield training") was done on combat veterans. Limited evidence supported use of any particular psychological therapy in preventing PTSD following exposure to trauma. The authors noted that these findings may not generalize to military combatants diagnosed with PTSD, are limited by small study size, methodological problems and imprecise outcome data.
Technology-based treatments may reduce symptom severity in chronic PTSD and prevent PTSD following exposure to trauma.
Many forms of psychotherapy incorporate imaginal or in vivo exposure to achieve desensitization to memories of trauma in individuals diagnosed with phobias and PTSD. Emerging findings suggest that desensitization training employing advanced technologies may also be an effective preventive intervention in individuals or groups who are at risk of encountering traumatic events by increasing emotional resiliency in coping with stress and reducing the risk of developing PTSD. Virtual reality graded exposure therapy (VRGET) is a rapidly evolving form of exposure therapy that employs real-time computer graphics, advanced visual displays and body tracking devices to create computer-generated ‘virtual’ environments that provide intense ‘immersive’ experiences for patients with the goal of minimizing avoidance and facilitating emotional processing of traumatic memories. VR technology expands the paradigm of exposure therapy by permitting individuals suffering with PTSD who avoid trauma cues or cannot evoke vivid mental images to experience vivid life-like scenarios simulating remembered trauma (Rizzo et al 2011). Sessions are guided by a therapist who regulates the virtual scenario to achieve the appropriate intensity of arousal for the patient. Repeated exposure results in habituation to a particular fear-inducing environment (ie, reduced autonomic arousal), extinction of fear response and reduction in severity of PTSD symptoms. A recent review of studies on VRGET for treatment of established cases of PTSD yielded promising findings (Botella et al 2015).
Reductions in the severity of PTSD may require at least seven sessions of virtual reality exposure therapy. (Schnurr et al., 2007). Findings of a study on combined multi-sensory exposure and VRGET reported significant reductions in severity of PTSD symptoms in active duty combatants who had failed to respond to other forms of exposure therapy (Reger et al 2011). Several patients in the study reported significant and sustained improvement following only 5 VRGET sessions however there was considerable variability between patients in the number of VRGET sessions needed to reduce symptom severity to the same level. These findings suggest that brief VR exposure therapy may result in rapid extinction when combined with multi-sensory exposure and D-cycloserine or other medications.
In addition to uses of virtual reality (VR) for exposure therapy in the treatment of established cases of PTSD VR applications are being developed for assessment of risk of developing PTSD and mental resilience training aimed at preventing PTSD in active duty soldiers and other high risk groups (Vakili et al 2013). Three HCI training systems are currently being prototyped to train at-risk individuals in effective coping and emotional self-regulation skills before or following exposure to trauma with the goal of reducing the risk of developing PTSD. A recently invented approach called Stress Inoculation Training (SIT) emphasizes cognitive restructuring and the acquisition and rehearsal of coping skills during graded virtual exposure to stressors that simulate the trauma. Emerging findings suggest that pre- or post-deployment stress inoculation training in groups of soldiers may reduce symptoms of autonomic arousal (Hourani et al 2011).
HCI systems based on cognitive-behavioral therapy CBT and biofeedback are also being developed for resilience training in individuals at risk of developing PTSD following exposure to trauma. STRIVE (Stress resilience in virtual environments) is a kind of ‘stress resilience training’ aimed at enhancing emotional coping strategies prior to active deployment (Rizzo, Parsons et al 2011). STRIVE employs an immersive VR environment to simulate combat situations that includes a ‘virtual mentor’ who guides the soldier through the virtual experience while coaching him or her in relaxation and emotion self-regulation skills. The intensity of the virtual stimulus used is determined by the individual’s habituation based on heart-rate variability (HRV) and other measures of autonomic arousal. The goal of STRIVE is to monitor allostatic load as a physiological indicator of stress. The STRIVE protocol might also provide a useful tool for predicting the risk of developing PTSD or other psychiatric disorders in new recruits prior to exposure to combat. Recruits who display high resilience and thus lower risk of developing PTSD would be more suitable for combat roles while conversely, individuals who display low resilience might preferentially be assigned to non-combat roles.
Combining VR environments with real-time feedback may speed the rate of recovery from PTSD
Emerging findings suggest that combining VR environments with real-time feedback based on neurophysiological responses to stress may permit each unique patient to optimize the level and type of VR exposure to enhance resiliency training, speed the rate of recovery from PTSD (Repetto et al., 2009). A study examined multiple physiological and neurophysiological variables to determine which ones correlate best with stress in virtual environments designed to desensitize individuals to traumatic memories. Measured variables included EEG, ECG and saliva cortisol level. Although VRET has been explored as a treatment of PTSD in combat veterans most findings are in the form of case studies (Rizzo et al., 2009; Wood et al., 2007). Reduced heart rate variability (HRV) takes place immediately after exposure to stress and may be a predictor of cortisol response 15 to 20 minutes later (Kallen et al., 2010). An individual’s unique response to stress may be correlated to asymmetry in functional brain activity (Verona et al., 2009; Crost, Pauls & Wacker, 2008) with relatively greater activity on the left or right frontal cortex depending on the coping strategy used (Harmon-Jones et al., 2010) or personality (Crost, Pauls & Wacker, 2008). Neurofeedback translates electrical brain activity into auditory signals that are used to modulate brain activity to achieve lasting therapeutic changes in psychological states or behaviors. Limited findings support that EEG biofeedback may reduce symptom severity in established cases of PTSD. (Hammond, 2005; 2006). Heart rate variability (HRV) and galvanic skin resistance (GSR) are other physiological signals used to provide feedback that can modulate responses to stress (Cukor et al., 2009; Repetto et al., 2009).
The interested reader can learn more about emerging approaches for preventing the development of PTSD following exposure to trauma or treating already established cases of PTSD in my e-book, PTSD--The Integrative Mental Health Solution.
Botella, C., Serrano, B, Banos, R, Garcia-Palacios, A., (2015) Virtual reality exposure-based therapy for the treatment of post-traumatic stress disroder: a review of its efficacy, the adequacy of the treatment protocol and its acceptability, Neuropsychiatr Dis Treat 11:2533-2545. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599639/