Treating Acute Stress Disorder, Simple and Complex PTSD
Betty Everett, PhD
UAMS Walker Family Clinic
The treatment of acute stress disorder, simple PTSD (one event), and complex PTSD require different treatments. What follows is a discussion of some key elements, drawn from literature, workshops and personal experience working with children and families. The Majority of these principles are tailored to adult treatment, but many are the same and can be adapted to the developmental level of a child. With children, issues of safety are paramount and may be the primary goal in treatment.
Acute stress disorders are most helped with an emphasis on self-regulation and rebuilding. This means re-establishing a sense of security and predictability in adaptive action. They need help reconnecting with ordinary, supportive networks and engaging in activities that re-establish a sense of mastery. The role of mental health professionals in these initial recuperative efforts seems to be limited according to research from Critical Incident Debriefing studies.
“Simple” PTSD requires an evaluation of their levels of functioning prior to the traumatic event and the level of distress during the moments of the event. The safety phase is often more easily achieved, which can lead to fewer complications during the exposure treatment process.
The treatment of PTSD has three principal components.
1. Processing and coming to terms with the horrifying, overwhelming experience
2. Controlling and mastering physiological and biological stress reactions
3. Re-establishing secure social connections and interpersonal efficacy
When treating PTSD, it is helpful to use a phase oriented approach. Initially help the patient establish a sense of safety, sleep and a decrease in autonomic arousal. Drugs that decrease autonomic arousal will decrease nightmares and flashbacks, promote sleep, and may prevent the kindling effects that are thought to underlie the long-term establishment of PTSD symptoms. These patients are sometimes resistant to medications and sleep. Helping them understand this as part of the hyper arousal and fear response, and seeing sleep and medication as safe and effective choices, can be helpful.
For more complex trauma, skills training is frequently used during initial stages to help with self-regulation and safety. Skills such as those taught in DBT (Dialectical Behavior Therapy) have empirical support. With more complex PTSD, the drugs noted above are useful, but may be only palliative. Serotonin re-uptake inhibitors seem to have little immediate benefit, but can be immensely helpful in reducing avoidance, allowing individuals to attend to their current life contexts.
Abreaction is effective early in the progression of the disorder. Later, when intrusive fragments are predominant, exposure and desensitization are important. The “working through,” or exposure treatment phase, is difficult for some and may increase symptoms. The relationship with the therapist is paramount in this phase of treatment. When a patient’s life is organized around avoidance, clinicians should help them pay attention to and stabilize their social realm.
In the working through, or exposure phase, key elements are the establishment of a sense of safety, a working, trusting, therapeutic environment and integration of the experience. The massive defenses initially established as emergency protective measures must be relaxed and come under volitional control, and the ability to be present here-and-now established. The ability to be in control of affect, to be in charge of response-choice, and to be able to think at the point of stimuli rather than having an automatic response, are part of reclaiming life.
Initially, the memories may be somatosensory, and the clients need help putting what is going on into verbalizations. As they can tell their story without dissociation at any level and without overwhelming pain, help them know this is an important goal. Help support their affective expression and be compassionate with the events. Therapeutic interventions can include reprogramming negative thoughts and beliefs that are coded with abuse, grieving losses and moving forward, so health can return.
Two fundamental issues include the deconditioning of anxiety and the pervasive effects that trauma has on the way victims view of themselves and the world. Reconditioning anxiety, changing beliefs, developing a cognitive system that somehow allows one to continue to cope effectively in a world that now is known to be capable of great destructiveness, are core issues for psychotherapy.
Provide the patient with a capacity to feel safe while accessing traumatic material, so they are able to deal with the challenge of confronting the trauma. Psychopharmacology is often an important piece of this. Help them identify feelings by verbalizing somatic states. Emotion’s function as signals to readjust one’s expectations of the world and to take adaptive action. In PTSD, emotions seem to loose their alerting function with a dissociation set up between emotional arousal and goal directed action. The patient then loses the capacity to interpret the meaning of emotional arousal that thus becomes irrelevant as a current signal. Feelings become a negative occurrence because no release can be found in adaptive actions as they merely remind one of the inability to affect the outcome of one’s life. So feelings tend to be somatic states, and affective states are a reliving of the trauma. STAY with the patient through suffering, so suffering can be meaningful and bearable and helpful in mastering the trauma, putting the experience into symbolic communication, such as thoughts.
2. Deconditioning of traumatic memories and responses.
The critical issue is to introduce the capacity to flexibly remember the trauma. New information that is incompatible to the traumatic memory must be introduced. This can lead to the confronting of memories in the safety of the therapeutic relationship. Secure attachment helps with regulating emotional arousal. Maintain emotional connection with the patient to help provide the container. The patient must attend to the memory to activate his own fear memory, so the fear structure can be modified. The patient needs to relive the experience while staying present, dual awareness, so it is not just reliving. However, excessive arousal interferes with new learning and strong feelings often evoke avoidance responses, so again dual awareness is critical for reprocessing. Our job is to help the patient in re-structuring the trauma related schemes of internal and external reality perceptions of self and the world, helping to build self-efficacy, capacity for trust and intimacy, ability to control self, and to control responses, thoughts and beliefs. Exposure helps by letting them know they have gotten through the trauma. It assists in the building of mastery and can lead to the ability to experience pleasure.
3. Recognize the need for affiliation. Emotional attachment is the primary protection against trauma. This third phase is moving forward into life in the present- learning to deal with relationships and learning new skills.
Psychopharmological interventions may prove important during this phase. Tricyclics cause decrease in overall PTSD primarily by decreasing avoidant symptoms (amitriptyline) or decreasing intrusive symptoms (imipramine). Serotonin re-uptake inhibitors are likely to be the most effective drug by helping to patients feel less numb and more in tune with their surroundings.