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Chapter 9 Post Traumatic Stress Disorder (PTSD)

Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T

LEARNING OBJECTIVES FOR

POST TRAUMATIC STRESS DISORDER (PTSD) and

RELATED ANXIETY DISORDERS

After reading this section you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for PTSD and Related Anxiety Disorders?
  2. What are the clinical descriptors for PTSD and Related Anxiety Disorders?
  3. What are the common symptoms for PTSD and Related Anxiety Disorders?
  4. What are the common populations which are treated for PTSD and Related Anxiety Disorders?
  5. What are the common treatment settings for PTSD and Related Anxiety Disorders?
  6. What are the Evidence Based Practices for treating PTSD and Related Anxiety Disorders?
  7. What are the common psychopharmacological treatments for PTSD and Related Anxiety Disorders?
  8. What are some common manuals, guideline books and client workbooks for treating PTSD and Related Anxiety Disorders?
  9. What are some good references you can use to learn more in-depth information about PTSD and Related Anxiety Disorders?

ICD-10-CM Codes for Trauma and Stressor-Related Disorders in DSM-5

F43.10 Acute Stress Disorder

F43.10 Posttraumatic Stress Disorder (includes Posttraumatic Stress Disorder for Children 6 years and Younger) Specify whether with dissociative symptoms and specify if with delayed expression

F94.2 Disinhibited Social Engagement Disorder

 

ICD-10-CM Codes for Related Anxiety Disorders

F41.0 Panic Disorder

F40.00 Agoraphobia

F41.1 Generalized Anxiety Disorder

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.

Ruby and Mike: Posttraumatic Stress Disorder


Ruby returned home from two tours of duty in Iraq and one from Afghanistan two years ago. Since that time her husband Mike reports that she has had a horrible time sleeping getting up in the middle of the night with nightmare about IED (Improvised Explosive Device) which blew up the Humvee in convoy while in Iraq in which four of her fellow troop members were killed. She also has recurring nightmares or flashbacks of young Iraqi children who were killed in a terrorist bombing in Bagdad when she was stationed there. Ruby refuses to go for help since she fears her security clearance would be affected and she is still enlisted in the Army and hopes to stay in until she has her 20 years in.


Mike is seeing you (because you are a mental health professional in private practice) today because he has begun to experience similar nightmares and flashbacks even though he did not experience directly what Ruby has but her traumatic response and fears have been so dramatic that now Mike is bogged down with what he suspects is are similar symptoms which he caught from Ruby as if her condition was a contagious disease. You explain to Mike that he has secondary trauma from that trauma which Ruby experienced and you can treat him and in the process help him to convince Ruby to come into you privately under the cover of the military insurance system.


He agrees to begin treatment after you explain to him that the Cognitive Behavioral Therapy approach you are going to train him in has been well researched and documented as an effective treatment for his condition. You tell him he will be given at least 12 sessions over the next six months which will involve in:

1) Learning to counter his negative catastrophic thinking when he sees the images in his mind of the IED explosion; the remains of the children’s bodies in Bagdad and most importantly of viewing his wife Ruby as she reacts to her own dreams and flashbacks.

2) He will learn progressive muscle relaxation so as to help keep him relaxed and more capable of dealing with his stress filled images and worries

3) He will learn to use “thought stopping” to stop himself from thinking about the horrors which his wife has brought into his life

4) He will be able to be a strong encouragement to his wife to get herself the help she needs to address her PTSD once can demonstrate to her his success and how he has not experienced any consequences in that he is a Lieutenant in Army himself who has had two tours in Afghanistan and one in Iraq and also intends to remain in the Army until his 20 years are up.


You then give Mike his first homework assignment which is to be brought back to his next appointment.

Post-Traumatic Stress Disorder (PTSD) is a trauma related disorder which may develop after a person experiences a distressing or threatening event. Unfortunately, it has become one of the two hallmark conditions which the veterans of the Afghanistan and Iraq wars have brought home with them (Turek, Steenkam and Rauch, 2010).


Populations treated for PSTD include:

  1. Children and Adolescent (Silverman, Ortiz, Viswesvaran, Burns, Kolko, Putnam. and Amaya-Jackson, 2008; (Cohen, Jaycox, Walker, Mannarino, Langley and DuCloss, 2009; Korn, 2009).
  2. Adults (non-specific) (Cloitre, 2009; Schubert and Lee, 2009).
  3. Victims of Sexual or Physical Abuse (Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin, 2005; Silverman, Ortiz, Viswesvaran, Burns, Kolko, Putnam. and Amaya-Jackson, 2008; Rauch, Grunfeld, Yadin, Cahill, Hembree and Foa, 2009; Najavits and Hien, 2013).
  4. Veterans of Conflicts including Afghanistan (OEF) and Iraqi (OIF) Wars. (Sharpless and Barber, 2010; Turek, Steenkam and Rauch, 2010; Tran, Kuhn, Waiser and Drescher, 2012; Foa, Gillihan and Bryant, 2013; McDowell and Rodriguez, 2013 Porter, Pope, Mayer and Rauch, 2013; Fisher, Sherman, Han and Owen, 2013; Schumm, Fredman, Monson and Chard, 2013; Sripada, Rauch, Tuerk, Smith, Defever, Mayer,  Messina, Venners, 2013).
  5. Victims of Natural Disasters (Cohen, Jaycox, Walker, Mannarino, Langley and DuCloss, 2009).
  6. Victims of Manmade Disasters (Ponniah and Hollon, 2009).


Clinicians have placed a major focus on the Evidenced Based Treatments for PTSD due to increased PTSD in returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. The EBPs for PTSD include:

1) Trauma Focused Cognitive Behavioral Therapy (FTCBT) or Cognitive Processing Therapy: (CPT) (Bradley, Greene, Russ, Dutra and Westen, 2005; Bisson, Ehlers, Matthews, Pilling, Richards and Turner, 2007: Cloitre, 2009; Sharpless and Barber, 2010; Foa, Gillihan and Bryant, 2013; Lewis, Roberts, Vick and Bisson, 2013).

2) Prolonged Exposure (PE) (Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin, 2005; Cloitre, 2009; Rauch, Grunfeld, Yadin, Cahill, Hembree and Foa, 2009; Sharpless and Barber, 2010; Steenkam and Rauch, 2010; Turek, Steenkam and Rauch, 2010; Foa, Gillihan and Bryant, 2013).

3) Eye Movement Desensitization and Reprocessing (EMDR) (Davidson and Parker, 2001; Bradley, Greene, Russ, Dutra and Westen, 2005; Bisson, Ehlers, Matthews, Pilling, Richards and Turner, 2007; Cloitre, 2009; Korn, 2009; Ponniah and Hollon, 2009; Schubert and Lee, 2009; Sharpless and Barber, 2010).

4) Pharmacotherapy (Sharpless and Barber, 2010).


The non-pharmacological models of treating PTSD have cognitive behavioral therapy as their basis because they all work to help clients confront those triggers in their life which remind them of trauma experiences by talking them out or confronting these triggering images. These treatments also attempt to get the clients to let go of their dysfunctional, irrational, unrealistic perceptions which had been stimulated by their traumatic experiences (Foa, Gillihan and Bryant, 2013). There has been an effort to develop online programs for self-help for those individuals with PTSD who are unwilling to deal with the stigma of coming into a clinic for treatment (Lewis, Roberts, Vick and Bisson, 2013).


The Veteran’s Administration (VA) has adopted three psychological interventions as their Evidenced Base Practices to use with patients with PTSD. They are Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE) and Eye Movement Desensitization and Reprocessing (EMDR). The VA’s manual gives specific instruction on how to conduct Cognitive Processing Therapy and Prolonged Exposure (Veterans Administration and Department of Defense, 2010).

Assignment for Mike after his first session


Here are some methods how people cope with stress in healthy positive ways while in recovery from traumatic events in their lives. People can cope with stress while in recovery in a variety of positive ways, such as these. Write down which positive coping strategies you can and are willing to use in your recovery efforts.


Exercise: aerobic exercise, walking, swimming, dancing

Stress‑reduction Activities: stretching, progressive muscle relaxation, breathing, self‑hypnosis, yoga

Mental Relaxation Techniques: mindfulness meditation, centering, clearing mind, imagination, visual imagery

Spirituality: prayer, worship, letting go and letting God, valuing, commitment, one day at a time

Recreational Diversions: music, hobbies, movies, theater, reading, cards, sewing

Interpersonal Relationship Enhancement: affirmation, networking, assertiveness, setting limits, creating supportive structures, expressions of love, affection, and concern

Problem Solving: time management, brainstorming, priority setting, rational thinking, thought stopping, re‑labeling, organizing, and planning

Family Life Skills: esteem building, conflict resolution, togetherness, support, positive reinforcement

Intellectual Practices: learning new concepts, learning new behavior patterns and attitudes, developing new insights, making subjective data objective, creating new generalizations and rules based on a reasonable analysis of data

Sense of Humor: putting things into perspective, lightening up, reducing the intensity, having fun, joking, clowning around, being a little kid again


After reading these strategies for overcoming the stress in my life, I agree that I will work on some of these strategies as I work on my recovery from PTSD,

Signed:                                                              Date:

 

Adapted from: Section 3, Chapter 7: Coping with Stress in Recovery in: Messina, J.J. (2013). Self-Esteem Seekers Anonymous -The SEA's Program of Recovery, retrieved from www.coping.us

Medications that clinicians have found to be most useful with clients with PTSD include  Paxil (Paaroxetine), Sertraline, and Effexor (Venlafaxine) (Sharpless and Barber, 2010). Clinicians most commonly support SSRIs as first line interventions for PTSD (Steenkam and Rauch, 2010).


Medications used for PTSD

Classificaton

Drug name (Generic Name)

Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)

Effexor (Venlafaxine HCl) 
Cymbalta (Duloxetine HCI)
Pristiq (Desvenlafaxine)

Selective Serotonin Reuptake Inhibitors (SSRI)

Prozac (Fluoxetine)
Zoloft (Sertraline)
Paxil (Paroxetine)
Celexa (Citalopram)
Lexapro (Escitalopram)

A major issue in dealing with PTSD is the comorbidity of substance abuse disorder (SUD) and researchers have taken steps to develop EBPs which address these comorbid disorders (McDowell and Rodriguez, 2013; Litt, 2013; Najavits and Hien, 2013). The complexity of these issues is obvious in Najavits and Hien’s (2013, p 442) description of the population with these comorbid conditions. “In addition to co-occurring SUD/psychiatric disorders, most had experienced child abuse, been homeless, served jail time, and suffered interpersonal abuse in the past 6 months; SUD was primarily drugs rather than alcohol (with methamphetamine common).”


For veterans of OEF and OIF, Traumatic Brain Injury is a comorbidity which can make treating PTSD extremely difficult (Sripada, Rauch, Tuerk, Smith, Defever, Mayer, Messina, Venners, 2013). The VA and community agencies focused on this population have been active in promoting the importance of this fact and to gain better understanding for these veterans (CEEM, 2013).

Another major comorbid condition with PTSD is depression (Tran, Kuhn, Waiser and Drescher, 2012). It is for this reason that clinicians find antidepressants effective in lessening the depressive symtomotology which frequently accompanies experiencing PTSD symptoms (Sharpless and Barber, 2010).


Researchers have also found pain to be a comorbid condition present with PTSD and that clinicians need to handle cautiously the intervention in treating the pain so as not to have the client become addicted to the pain medication instead of dealing with letting go of the PTSD symptoms (Porter, Pope, Mayer and Rauch, 2013).

To insure good follow through for their clients with PTSD, therapists have conducted joint client and partner sessions (Schumm, Fredman, Monson and Chard, 2013) as well as sessions with their families (Fisher, Sherman, Han and Owen, 2013).


Foa and her colleagues addressed the reality that clinicians infrequently utilize EBP for PTSD and for other disorders.  They concluded that this is due to “a professional culture that does not support the use of EBTs, lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques and the cost associated with effective dissemination models” (Foa, Gillihan and Bryant, 2013).

Handouts for Mike to better explain the elements involved in his treatment

  1. TEA System
  2. ALERT System
  3. ANGER System
  4. LET GO System
  5. CHILD System
  6. RELAPSE System

All available online at: www. coping.us at: http://coping.us/seastoolsforrecovery.html

Treatment Workbook for PTSD


Foa, E.B., Hembree, E.A. and Rothbaum, B.O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences: Therapist guide. New York: Oxford University Press.


Foa, E.B., Chrestman, K.R., and Gilboa-Schnechtman, E. (2009). Prolonged exposure therapy for adolescents with PTSD: Emotional processing of traumatic experiences: Therapist guide. New York: Oxford University Press. 

 

Hinkling, E.J. and Blanchard, E.B. (2006). Overcoming the trauma of your motor vehicle accident, A cognitive-behavioral treatment program: Therapist guide. New York: Oxford University Press.

 

Reich, J.W., Zautra, A.J. and Hall, J.S. (2010). Handbook of adult resilience. New York: The Guilford Press

 

Resnick, P.A., Monson, C.M. & Chard, K.M. (2008). Cognitive processing therapy veteran/military version: Therapist’s manual. Washington, DC: Department of Veterans’ Affairs.

 

Turk, D.C. and Winter, F. (2006). The pain survival guide-How to reclaim your life. Washington, DC: American Psychological Association.

 

Williams, M. and Poijula, S. (2002). The PTSD workbook. Oakland, CA: New Harbinger.

 

Zehr, H. (2001). Transcending: Reflections of crime victims. Intercourse, PA: Good Books

Online Training In Treatment for Survivors of  PTSD and Trauma

 

CPTWeb is a web-based multi-media, training course for mental health providers seeking to learn Cognitive Processing Therapy (CPT) for PTSD. CPTWeb is specifically designed to teach clinicians about using CPT with military and veteran clients. It teaches all of the components of CPT using concise explanations, video demonstrations, and clinical scripts. Common clinical challenges and cultural considerations are discussed for each component. It can be accessed at: www.musc.edu/cpt

 

TF-CBTWeb is a web-based, multi-media training course for Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). It can be accessed at:  https://tfcbt2.musc.edu/ 

 

CTGWeb is a follow-up training course to TF-CBTWeb that teaches therapists how to apply TF-CBT to cases of child traumatic grief. It can be accessed at: www.musc.edu/ctg


Prolonged Exposure Therapy - Online Training provided by The Center for Deployment Psychology. Link to find notice of upcoming online training go to: http://www.deploymentpsych.org/training?field_training_access_value=2&field_training_type_value=All

References for PTSD


Bisson, J.I., Ehlers, A., Matthews, R., Pilling, S, Richards, D. and Turner, S. (2007).

Psychological treatments for chronic post-traumatic stress disorder Systematic review and meta-analysis. British Journal of Psychiatry, 190, 97- 104. doi: 10 .1192 / bjp.bp .106.021402 

 

Bradley, R., Greene, J., Russ, E., Dutra, L. and Westen, D. (2005). A multidimensional meta-

analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227. 

 

Center of Excellence for Medical Multimedia (CEMM ) (2013). Traumatic brain injury.

Retrieved at: http://www.traumaticbraininjuryatoz.org/

 

Cloitre, M. (2009). Effective psychotherapies for posttraumatic stress disorder: A review and

Critique. CNS Spectrum, 14 (1 Suppl. 1), 32-43.

 

Cohen, J.A., Jaycox, L.H., Walker, D.W., Mannarino, A.P., Langley, A.K. and DuCloss, J.L.

(2009). Treating traumatized children after hurricane Katrina: Project fluer-de lis. Clinical Child and Family Psychology Review, 12, 55-64. DOI 10.1007/s10567-009-0039-2

 

Davidson, P.R. and Parker, K.C.H. (2001). Eye movement desensitization and reprocessing

(EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69(2), 305-316. DOI: I0.1037//0022-006X.69.2.305

 

Fisher, E.P., Sherman, M.D., Han, X. and Owen, R.R. (2013). Outcomes of participation in the

REACH multifamily group programs for veterans with PTSD and their families. Professional Psychology, Research and Practice, 44(3), 127-134. DOI: 10.1037/a0032024

 

Foa, E.B., Gillihan, S.J. and Bryant, R.A. (2013). Challenges and success in dissemination of

evidence-based treatements for posttraumatic stress: Lessons learned from prolonged exposure therapy for PTSD. Psychological Science in the Public Interest, 14(2), 65-111. DOI: 10.1177/1529100612468841

 

Foa, E.B., Hembree, E.A., Cahill, S.P., Rauch, S.A.M., Riggs, D.S., Feeny, N.C. and Yadin, E.

(2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with or without congnitive restructuring: Outcomes at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953-964. DOI: 10.1037/0022-006X.73.5.953

 

Korn, D.L. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR

Practice and Research 3(4), 264-278. DOI: 10.1891/1933-3196.3.4.264

 

Lewis, C., Roberts, N. Vick, T. and Bisson, D.M. (2013). Development of a guided self-help

(GSH) program for the treatment of mild-to-moderate posttraumatic stress disorder (PTSD). Depresseon and Anxiety, 30, 1121-1128. DOI 10.1002/da.22128

 

Litt, L. (2013). Clinical decision making in the treatment of complex PTSD and substance

misuse. Journal of Clinical Psychology: In Session. 69(5), 534-542. DOI: 10.1002/jclp.21989

 

McDowell, J. and Rodriguez, J. (2013). Does substance abuse affect outcomes for trauma-

focused treatment of combat-related PTSD. Addiction Research and Theory, 21(5), 357-364. DOI: 10.3109/16066359.2012.746316

 

Najavits, L.M. and Hien, D. (2013). Helping vulnerable populations: A comprehensive review of

the treatment outcome literature on substance use disorder and PTSD. Journal of Clinical Psychology: In Session, 69(5), 433-479. DOI: 10.1002/jclp.21980

 

Ponniah, K. and Hollon, S. (2009). Empirically supported psychological treatments for adult

acute stress disorder and posttraumatic stress disorder: A review. Depression and Anxiety 26, 1086-1109. DOI 10.1002/da.20635 

 

Porter, K., Pope, E.B., Mayer, R. and Rauch, S.A.M. (2013). PTSD and pain: Exploring the

impact of posttraumatic cognitions in veterans seeing treatment for PTSD. Pain Medicine, 14(11), 1797-1805. 10.1111/pme.12260

 

Rauch, S.A.M., Grunfeld, T.E.E., Yadin, E., Cahill, S.P., Hembree, E. and Foa, E.B. (2009).

Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder. Depression and Anxiety, 26, 732-738. DOI 10.1002/da.20518

 

Schubert, S. and Lee, C.W. (2009). Adult PTSD and its treatment with EMDR: A review of

controversies, evidence, and theoretical knowledge. Journal of EMDR Practice and Research, 3(3), 117-132.  DOI: 10.1891/1933-3196.3.3.117 

 

Schumm, J.A., Fredman, S.J., Monson, C.M. and Chard, K.M. (2013). Cognitive-behavioral

conjoint therapy for PTSD: Initial findings for operation enduring and iraqi freedom male combat veterans and their partners. The American Journal of Family Therapy, 41, 277-287. DOI: 10.1080/01926187.2012.701592

 

Sharpless, B.A. and Barber, J.P. (2011). A Clinician's guide to PTSD treatments for returning

veterans. Professional Psychology: Research and Practice 42(1), 8-15.

 

Silverman, W., Ortiz, C.D., Viswesvaran, C., Burns, B.J., Kolko, D.J., Putnam, F.W. and

Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child and Adolescent Psychology, 37(1), 156-183. DOI: 10.1080/15374410701818293 

 

Sripada, R.K., Rauch, S.A.M., Tuerk, P.W., Smith, E., Defever, A.M., Mayer, R.A., Messina, M.

and Venners, M. (2013).. Mild traumatic brain injury and treatment response prolonged exposure for PTSD. Journal of Traumatic Stress, 26, 369-375. DOI: 10.1002/jts.21813

 

Tran, C.T., Kuhn, E., Waiser, R.D. and Drescher, K.D. (2012). The relationship between

religiosity, PTSD and depressive symptoms in veterans with PTSD residential treatment. Journal of Psychology and Theology, 40(4), 312-322. DOI: 0091-6471/410-730

 

Turek, P.W., Steenkam, M. and Rauch, S.A.M. (2010). Combat-related PTSD: Scope of the

current problem, understanding effective treatment, and barriers to care. Developments in Mental Health Law 29 

 

Veterans Administration and Department of Defense (2017). VA/DoD Clinical Practice

Guideline for Management of Post-Traumatic Stress: Washington D.C., VA/DoD  at: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal.pdf

WHERE DO I GO FROM HERE?

CONCERNING POST TRAUMATIC STRESS DISORDER (PTSD)

 Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning PTSD in my clinical practice?
  3. Why is it important that I learn more about PTSD?
  4. What more do I need to know about PTSD?
  5. Where can I go to obtain more information about PTSD?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on PTSD?