Controversies about Post-traumatic Stress Disorder

Authored by Henry Strick van Linschoten

Post-traumatic stress disorder (PTSD) was first included as a diagnosis in DSM-III in 1980, and since then there has been substantial growth in studies relating to this condition, both in the research and clinical contexts. There is now considerable consensus on key questions regarding the treatment of PTSD, although much research still remains to be done. This summary highlights some of the main conclusions which have been reached, as well as some of the remaining unresearched or controversial points.

The effectiveness of different kinds of psychotherapy for PTSD

Major sources are the International Society for Traumatic Stress Studies (ISTSS) guidelines for the treatment of PTSD (Cloitre et al., 2012; Foa et al., 2009b) the summary guidelines are available online), the NICE Guidelines (NICE – CG26, 2006) and the Cochrane review (Bisson & Andrew, 2007). There is a useful overview article about the available guidelines by Forbes et al. (2010), which also discusses other guidelines and gives a wider perspective on methodology and the strength of evidence.

Major types of psychotherapy that have been studied repeatedly in randomised controlled trials are:

• Trauma-Focused Cognitive-Behavioural Therapy (TFCBT)
• Eye Movement Desensitisation and Reprocessing (EMDR)
• Stress management therapy
• Group TFCBT

As the terms indicate, these are mostly specially modified therapies dedicated to working with PTSD. There is a widely-held assumption that PTSD is sufficiently special to require adaptation of the major standard therapies, in order to be fully effective.

Although the guidelines are based on the same universe of studies and similar methodologies, there are slight differences in the details of their recommendations. These can be summarised as follows.

TFCBT and EMDR have the strongest research backing. They have a large effect size (major statistical measure of how strong, rather than how significant a relationship is), and are about equally effective. TFCBT includes a number of variants – exposure therapy, Stress Inoculation Training and cognitive processing therapy – which show similar effectiveness. There is reasonable, but thinner and less convincing evidence for the effectiveness of stress management and Group TFCBT.

A number of studies support the idea that the standard way of working of major kinds of psychotherapy needs to be adapted to be effective with PTSD (see especially Bisson & Andrew, 2007).

There is no substantive research evidence for other types of therapies, although some studies have been done. This includes psychodynamic therapy (Kudler et al., 2009), sensorimotor psychotherapy (Ogden et al., 2006; Fisher & Ogden, 2009), acceptance and commitment therapy (Cahill et al., 2009) and dialectical behaviour therapy (Cahill et al., 2009). This does not mean that these therapies are not effective, but only that high-quality research evidence is not available.

All guidelines report the result that the once-popular first-day debriefing (sometimes called ‘stress debriefing’ or ‘psychological debriefing’) is not effective and can be harmful, and that such debriefing should not be done (NICE – CG26, 2006; Bisson et al., 2009).

NICE – CG26 (2006) proposes that for adults in general 8 to 12 sessions, starting with several sessions without formal trauma work to strengthen the therapeutic relationship, scheduling longer sessions (1.5 hours) for specific work with trauma, and being flexible about extending the number of sessions when the trauma is more complex.

For children with PTSD there is substantially less evidence overall but clear evidence in favour of TFCBT with adaptation for children (Cohen et al., 2010 and references). The studies in which this has been demonstrated most conclusively involve trauma consisting of sexual abuse. There is a lack of evidence for other types of trauma and other kinds of psychotherapy, including EMDR.

Eye Movement Desensitisation and Reprocessing; its special status in working with PTSD

EMDR (Shapiro, 2001, 2002) is a psychotherapy that focuses on working with trauma. It has a major following, and professionals such as van der Kolk state that every psychotherapist working with clients with PTSD should be trained in EMDR. Unpacking studies of EMDR (that is, trying to ascertain which of the different components of EMDR are more effective than others) suggest that eye movements or equivalent bilateral stimulation can be dispensed with, without lessening its effectiveness (Spates et al., 2009; Chemtob et al., 2004). However, EMDR practitioners consider a number of studies to have demonstrated that the eye movements have certain specific effects that are considered to be beneficial (Schubert & Lee, 2009). From the start, the EMDR protocols and training have been uniquely focused on trauma work, and there is a great deal of experience embedded in practitioners, trainers and publications on the subject.

There are similarities found between the theory and practices of EMDR and ‘energy therapies’ (Mollon, 2004, 2008; Feinstein et al., 2005), but also clear differences. Research evidence formally supporting the use of energy therapies for PTSD has yet to be published. Energy therapies focus fundamentally on working with the memories and impact of past trauma, as does EMDR, and in that respect they are forms of therapy that are especially adapted to trauma work.

Is PTSD a unitary phenomenon?

Practitioners distinguish different manifestations and intensities of PTSD on a number of dimensions. Since the early 1990s, PTSD and dissociation experts have proposed a new diagnostic category called ‘complex PTSD’ (Herman, 1992; Chu, 2011), at times also referred to as Disorder of Extreme Stress Not Otherwise Specified (DESNOS). This recommendation was not implemented for DSM-IV in 1994, and was rejected for DSM-5. The concept of complex PTSD does not form a part of existing diagnostic and research nomenclature.

If a person is seen as having symptoms corresponding to the profile of complex PTSD, it may be considered necessary to decide how they fit into the established diagnostic categories. In many cases they would be likely to qualify for diagnosis under the dissociative disorders, perhaps dissociative identity disorder (DID) or Dissociative Disorder Not Otherwise Specified (DDNOS). Sometimes they also have a comorbid personality disorder diagnosis, and would be likely to be diagnosed with PTSD according to its established definition. For treatment approaches, it is often recommended to focus on the dissociative aspects of their problems, in addition to working with the PTSD. In this module the term PTSD will follow the standard definition, and not include complex PTSD (Courtois & Ford, 2009; Van der Kolk et al., 2005; Cloitre et al., 2012)

Evidence for pharmaceutical interventions in treating PTSD

There is not much first-quality research evidence for the use of pharmaceutical drugs in treating PTSD. Friedman et al. (2009) and Donnelly (2009) give a lengthy summary of research. They recommend the use of selective serotonin reuptake inhibitors (SSRIs) and second-generation anti-psychotics as likely to be effective. A British summary article (Bisson, 2007) only recognises trials for amitriptyline, mirtazapine and paroxetine as showing statistically significant effects, and states that these were small trials and constitute only limited evidence. Forbes et al. (2010) contains evaluation of the strength of evidence for SSRIs. The NICE Guidelines (NICE – CG26, 2006) state that psychotherapies are preferred to drugs as a treatment for PTSD.

Research evidence is not the only factor

While there is an unusually rich availability of high-quality formal research studies in the field of PTSD, the practitioner will need to put this in the context of his or her wider training, clinical experience and general understanding of human beings and their personal physical, temperamental, cultural and spiritual make-up and influences, with an eye to the unique characteristics of the individual client. There is an extensive literature about trauma treatment, much of which is clinically focused. Van der Kolk et al. (1996) offers one such example, which is out of date as regards research findings but continues to offer much clinical wisdom. Other sources for treatment methods based on clinical experience are Rothschild (2000, 2003), Briere & Scott (2012) and Foa et al. (2009a).

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