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By THE CARLAT PSYCHIATRY REPORT

As you can see from this issue’s lead article, SSRIs help alleviate core PTSD symptoms, but hardly roar by the placebo response rate in clinical trials. And anytime the placebo effect is this robust, you can predict that psychotherapy will be very effective. This is certainly true in the world of PTSD.

The most well-studied therapy is exposure therapy, in which patients are encouraged to confront their demons in various ways in the hopes that this will gradually desensitize them to their symptom-inducing power. In this technique, therapists guide patients through a process of imagining and recalling the traumatic event (“imaginal exposure”), and they help patients come up with strategies allowing them to expose themselves to the feared place or situation (“in vivo exposure”). Sometimes, this means that the therapist will actually accompany the patient, for example, to the street where the assault occurred, doing “guerilla psychotherapy” where it needs to happen the most. (See this issue’s interview with Dr. Edna Foa for more information on a particularly effective version of exposure therapy.)

Anxiety management programs focus on teaching patients a range of coping skills to help them calm themselves when they experience PTSD symptoms. Most famously, these techniques include good old relaxation training, but creative therapists will add controlled breathing exercises, distraction techniques, positive imagery, and even some cognitive therapy.

There’s always straight-ahead cognitive therapy, in which therapists help patients identify dysfunctional thoughts and attitudes that may have been engendered by the trauma, guide them in challenging these beliefs, and then help them to replace them with more realistic cognitions.

No brief survey of PTSD therapy would be complete without mentioning EMDR (“eye movement and desensitization reprocessing”), a technique that raises everyone’s “hokeyness” antennae but appears to be effective nonetheless. The technique was developed by psychologist Francine Shapiro as a result of a personal experience: as her eyes tracked something that was moving back and forth rapidly, she realized that an upsetting thought that was preoccupying her had gone away (Shapiro and Forrest, EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma, New York: Basic Books, 1997). In EMDR, the therapist has the patient recount or remember the trauma while having the patient track side-to-side movements of the therapist’s finger. A bit of cognitive therapy is typically thrown into the mix, with the therapist helping the patient replace negative with positive self-beliefs (Shapiro and Maxfield, J Clin Psychol; 58:933-946).

Yes, these abstract explanations of therapeutic techniques are always a bit mind-numbing. So let’s get to the bottom-line: Are they effective, and how do they stack up against one another, and against meds?

Exposure therapy, stress inoculation training (a version of “anxiety management”), and cognitive therapy all appear to work better than the typical waiting list control group, and all three techniques are essentially equivalent when compared head-to-head (J Clin Psychiatry 2000; 61[suppl 5]:43-48). Of the three, exposure therapy may be the easiest to learn how to do, so one could argue that this would be the best of the lot to focus on if you intend to do much therapy with PTSD patients.
EMDR has been studied in controlled trials (J Consult Clin Psychol 2001; 69:305-16), and appears to be superior to waiting list. A big controversy among those who follow these issues is whether the eye movement part of EMDR is actually superfluous. The definitive meta-analysis of 34 studies of EMDR cited above reported that “no incremental effect of eye movements was noted when EMDR was compared with the same procedure without them.” This suggests that EMDR is simply a collection of traditional exposure and cognitive therapy techniques with eye movements thrown in for kicks, but there are many very devoted practitioners of EMDR out there who would have TCR quartered and roasted for saying so.

How does therapy compare to medication for PTSD? Sorry, there have been no head-to-head clinical studies of this. The closest we’ve found is a meta-analysis concluding that therapies tend to have larger “effect sizes” (which is equal to drug effect minus placebo effect, adjusted for the relative precision of whatever rating scale is used) than meds (Clin Psychol Psychother 1998; 5:125- 144), but this was published in 1998, before the big SSRI studies were done. It would certainly seem likely that a combination of therapy and medication would be better than either one alone. In fact, in this month’s interview, Dr. Edna Foa describes a study indicating that adding CBT to Zoloft enhances response, but this research has not yet been published.

TCR VERDICT: Get them into therapy! (Along with your favorite med)