Treating Post Traumatic Stress Disorder
Multi-modal therapy is proving the most effective treatment

by Barry Belt, MA
and Robert W. Rothrock, PA-C

A sudden accident on the job, on the highway or at home; human-induced traumas resulting fom physical and sexual abuse, military combat, concentration camp incarceration, prisoner of war atrocities and hostage-taking; a single traumatic event that is beyond the range of usual human experience often results in Post Traumatic Stress Disorder (PTSD). The most frequent-occurring stressor that results in PTSD is an accident, but a host of natural catastrophes such as floods, earthquakes and fires can also be precipitating factors.

Over the past ten years, my colleagues and I have evaluated psychological symptoms and disabilities occurring as a result of an accident or other traumatic experience. One of the most common disorders that we diagnose and treat is Post Traumatic Stress Disorder. The American Psychiatric Association recognized PTSD for the first time in the Diagnostic and Statistical Manual of Mental Disorders (APA, 1987). Symptoms of PTSD usually begin immediately following the trauma. Often they increase in severity if left untreated. Victims relive the incident through flashbacks and dreams either during sleep or in the waking state, and may also experience withdrawal and a numbing of responsiveness. In addition, a variety of cognitive autonomic and dysphoric symptoms can occur. Often, victims report a feeling of a loss of control over their lives.

ONE WOMAN'S EXPERIENCE

Ms. J. is a 45-year-old woman who works as a secretary for a large corporation. One day she was seated in the passenger seat of a car on her way to work when she suddenly became aware of a car approaching from her right which was going too fast to stop at the red light. The patient anticipated the collision for several seconds before the oncoming car swerved and struck the right fender of the car. The shock of impact stunned her, and for several minutes she was unable to move. Within minutes, police officers and paramedics arrived at the scene and assisted the patient and the driver from the car.

On the way to the hospital, Ms. J. began to exhibit signs of anxiety. She replayed the accident in her mind and began to tremble as she realized the situation had been beyond her control. Examination in the emergency room revealed no serious physical injury. The patient was discharged to her home.

Once back at home, Ms. J.'s episodic bouts of pain in the neck, shoulder and lower back began. The pain was described as a spasmodic, tension-like pain or numbness, present about 25 to 50 percent of the time. The pain interfered with her falling and staying asleep, significantly reducing her activity level.

Emotionally, rather than returning to a state of equilibrium following the accident trauma, Ms. J. continued to experience a state of heightened arousal (flight or fight response), with no means to discharge it. She experienced nightmares, flashbacks, continued rumination, feelings of panic, loss of libido, difficulty falling and staying asleep, and irritability with family and friends. Her fearfulness and anxiety increased to such a degree that she was unable to continue driving. Additionally, when she was a passenger in a car, the patient would experience increased pain in her neck and back which she described as a pulling, gripping and tightening sensation. Her physical and emotional state prevented her from driving, or being driven, to work.

Because her symptoms appeared to be worsening after several weeks of treatment by her family physician, she was referred to the Pennsbury Pain Center of Morrisville, Pennsylvania with a diagnosis of a mild cervical and lumbar strain and sprain. The pain and symptoms were out of line with its findings and the fact that stress appeared to greatly exacerbate her pain behavior.

PHASES OF EVALUATION AND TREATMENT

Phase I - Evaluation: The purpose of the evaluation is to increase our understanding of the patient's pre- and post-accident coping skills and any family, social or occupational problems. Overall, the goal of therapy should be to help the patient regain his or her previous level of activity and prior psychological balance. The evaluation should consist of the following: a comprehensive psychosocial intake form, symptom intensity scale, an in-depth interview and a meeting with the patient's spouse. In addition, the following personality tests are often helpful: the Beck Depression Inventory, the Holmes Life Events Scale and the Cattell 16 Factor Personality Inventory.

The results of the evaluation should confirm the diagnosis of Post Traumatic Stress Disorder. However if the diagnosis still remains in doubt, other etiologic entities should be ruled out.

Phase II - Developing a therapeutic alliance: Following the completion of testing, a meeting is held with the patient to discuss his or her treatment and to strengthen the therapeutic alliance. The therapeutic relationship is the cornerstone of any treatment plan; therefore, establishing a relationship of empathy, trust, and support is a necessary prerequisite for successful intervention.

Phase III - Discussion of treatment components and results: In cases of Post Traumatic Stress Disorder, it is our experience that multi-faceted cognitive behavioral therapeutic techniques are most effective. These techniques are directed toward empowering the patient by modifying and alerting dysfunctional perceptions and conditions concerning the trauma. The patient plays an active and collaborative role in all phases of treatment and homework assignments are routinely given.

MS. J.'S TREATMENT PLAN

The cognitive behavioral techniques incorporated into Ms. J.'s treatment plan are reviewed below and include individual and couple psychotherapy, biofeedback-assisted relaxation, desensitization and an aerobic exercise program. There is often overlap from one strategy to another, but each treatment modality is designed to reinforce and support the other. Our patient experienced the following:

1. Psychotherapy—cognitive orientation: During this phase of treatment, the patient worked on changing her internal representations and negative self-talk about driving and increased pain behavior while in an automobile. One belief that impaired her functioning was the overwhelming feeling that another accident would occur and increased pain was inevitable each time she entered an automobile. She was soon able to reframe her view to the reality of her situation, which was that her accident was one isolated event in a long history of safe and trouble-free driving. This return of focus to her many years of accident-free driving (in which she felt in control on the road) reduced her fearfulness and increased her self-confidence.

2. Computerized biofeedback-assisted relaxation training: Computerized biofeedback-assisted relaxation included EMG training to lower muscular tension and thermal training to reduce sympathetic arousal. The patient was taught a variety of relaxation techniques, both brief and extended, to use in various situations so that she could regain a sense of self-control and confidence. Techniques such as autogenic training, calming images and self-hypnosis were directed specifically to the patient' problems to help her to return to a state of equilibrium. Specially prepared relaxation tapes for PTSD, produced by our Center, were used for home practice along with a daily monitoring sheet for charting progress. Special emphasis was focused on transferring her ability to calm and quiet herself from an office setting to real life events.

3. Desensitization: The desensitization phase of treatment was also geared toward teaching Mrs. J. to cope with her increased muscle tension, tightness and fear of driving. During desensitization, she was asked to imagine several driving scenarios in which she was either a passenger or a driver. Whenever she felt an increase in tension or discomfort in her neck and back, she relaxed herself using the techniques learned during biofeedback-assisted relaxation. After Mrs.  J. was able to imagine driving scenarios and maintain a relaxed physical and emotional state, the next step in desensitization was watching a specifically produced driving video which includes scenes of various degrees of driving difficulty, traffic intensity and road conditions. Through the use of biofeedback instrumentation (thermal and EDG), she was able to observe, monitor and finally control her physical and emotional reactions to the various driving scenarios. Once Ms. J. could comfortably imagine driving scenes, she was ready for a few driving lessons with an instructor experienced in working with post traumatic patients. These driving lessons, along with the other coping techniques she learned, enabled her to resume driving after the tenth session.

4. Couples therapy: We met with the patient and her husband separately and then both together to enlist the spouse's support and cooperation in the treatment process. During the individual meeting, the husband agreed not to reinforce her fear of driving and to help her empower herself to begin driving again.

5. Aerobic exercise: As part of treatment, the patient was encouraged, under medical supervision, to begin an aerobic exercise program, such as a daily brisk walk. Aerobic exercise is an excellent means of discharging stress and tension and increasing energy.

THE RESULTS

The Center's staff saw the patient for a total of 15 sessions during which the multi-modal approach outlined above was implemented. Symptomatology and pain behavior decreased; she was able to drive comfortably and resumed complete functioning with few, if any, residual effects. An essential ingredient in the treatment plan was the patient's own active involvement. Throughout therapy, the need for the patient to assume responsibility and control was emphasized, and she was given a great deal of support and positive reinforcement when goals were achieved and homework and home practice completed. It was very helpful to have her husband's active assistance in reinforcing and supporting his wife as she eliminated maladaptive behavior patterns.

This multi-modal treatment plan is one mode of therapy that has proven very effective in the treatment of chronic pain and Post Traumatic Stress Disorder. Psychotherapy with a cognitive orientation, desensitization and relaxation training are always incorporated into the treatment plan, but specific coping skills and strategies vary according to the patient's personality traits and needs.