**8. Principles of management**

There are various semi-structured diagnostic interviews schedules used in research, however, to date, there is no single instrument accepted as a "gold standard" for making the diagnosis of PTSD or monitoring symptoms.

#### **8.1 Psychosocial treatment strategies**

Four strategies have been distinguished by both empirical evaluation and the development of treatment manuals. Currently, only the cognitive-behavioral approaches have been investigated sufficiently to make empirically based recommendations. According to the State of Washington's Task Force on Promotion and Dissemination of Psychological procedures (1995), the four strategies that meet criteria for either "probably efficacious" or "well-established" are briefly described as follows [38,39,40]:

#### **1. Prolonged Exposure (PE)**

Prolonged Exposure is a standard technique that has been used with various anxiety disorders and has now been adapted for PTSD in rape victims (Foa & Rothbaum, 1998). PE involves repeated imaginal re-living of the traumatic experience. Then it is followed up with subsequent real life exposure to situations that are unpleasant reminders of the cause of the fear. The theory posits that repeated pairing of the emotional memories, with a nondangerous environment will lead to reconditioning of the emotionally aversive associations to trauma memories [41]. Gradually being reminded or remembering the trauma will lose the intense negative quality. Breathing retraining to assist with relaxation is an initial component of the approach. The treatment ordinarily is carried out over ninety minute

symptoms are now three, due to slight changes in descriptions.

one modestly revised, one entirely new, and four unchanged symptoms.

month.

as before.

event(s).

**8. Principles of management** 

diagnosis of PTSD or monitoring symptoms.

"well-established" are briefly described as follows [38,39,40]:

**8.1 Psychosocial treatment strategies** 

**1. Prolonged Exposure (PE)** 

state.

 Criterion C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two

 New Criterion D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.

Criterion E (formerly "D"), which focuses on increased arousal and reactivity, contains

Criterion F (formerly "E") still requires duration of symptoms to have been at least one

Criterion G (formerly "F") stipulates symptom impact ("disturbance") in the same way

 The "acute" vs. "delayed" distinction is dropped; the "delayed" specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic

PTSD is a clinical diagnosis; there are no laboratory tests or brain-imaging studies currently used in clinical practice to diagnose PTSD. Brain imaging studies are under way to learn more about the brain in the PTSD condition, but these are not used in everyday medical practice. A physical exam and some blood tests may be necessary to rule out medical conditions that may mimic PTSD, such as hyperthyroidism which can create an anxiety

There are various semi-structured diagnostic interviews schedules used in research, however, to date, there is no single instrument accepted as a "gold standard" for making the

Four strategies have been distinguished by both empirical evaluation and the development of treatment manuals. Currently, only the cognitive-behavioral approaches have been investigated sufficiently to make empirically based recommendations. According to the State of Washington's Task Force on Promotion and Dissemination of Psychological procedures (1995), the four strategies that meet criteria for either "probably efficacious" or

Prolonged Exposure is a standard technique that has been used with various anxiety disorders and has now been adapted for PTSD in rape victims (Foa & Rothbaum, 1998). PE involves repeated imaginal re-living of the traumatic experience. Then it is followed up with subsequent real life exposure to situations that are unpleasant reminders of the cause of the fear. The theory posits that repeated pairing of the emotional memories, with a nondangerous environment will lead to reconditioning of the emotionally aversive associations to trauma memories [41]. Gradually being reminded or remembering the trauma will lose the intense negative quality. Breathing retraining to assist with relaxation is an initial component of the approach. The treatment ordinarily is carried out over ninety minute sessions that may occur twice a week. High-risk concerns such as psychosis, homicidal or suicidal tendencies should be addressed.

#### **2. Cognitive Processing Therapy (CPT)**

Cognitive Processing Therapy is an approach that focuses primarily on trauma-related attributions and cognition that are maladaptive. There is exposure to the trauma, but it occurs in a modulated fashion and is accomplished through having victims write descriptions of the trauma that are repeatedly reviewed and read. The description is analyzed to identify blocks and dysfunctional cognitions and cognitive therapy techniques are used to challenge and replace these distortions with more appropriate, accurate and adaptive views. Themes of safety, trust, power, esteem and intimacy are specifically addressed. Coping skills are taught to assist victims in predicting and managing stress responses. CPT has been proven effective with female rape victims. Resick and Schnicke (1995) provide the theory underlying the approach and a detailed description of the various techniques. The treatment occurs over 12 sessions.

#### **3. Stress Inoculation Training (SIT)**

SIT is a CBT approach that has a primary focus on teaching the identification and management of anxiety reactions to stressful situations. Michenbaum (1985) first developed this intervention for use with a wide variety of populations suffering from anxious response including trauma. SIT involved explaining the physical, cognitive and behavioral components of fear and anxiety reactions. Then victims are taught various coping strategies to address dysfunctional thoughts and unpleasant feelings that come up with exposure to certain trauma reminders. These include relaxation, shifting attention and self-coaching dialogues. The goal is that victims learn to manage trauma related anxiety with confidence and efficacy. SIT has been found effective with various stress-related conditions and for female rape victims. Typically this approach consists of 8-14 sessions.

#### **4. Eye Movement Desensitization and Reprocessing (EMDR)**

Shapiro (1995) developed the Eye Movement Desensitization and Reprocessing (EMDR) approach. Like SIT, this approach has been advocated as a treatment for a variety of psychological problems involving intense emotions and intrusive thoughts. It is generally considered a form of imaginal exposure accompanied by cognitive re-framing, which are standard elements of CBT. Victims are encouraged to imagine a stressful scene and replace dysfunctional cognitions with more adaptive ones while engaging in lateral eye movements. Therapists move fingers back and forth to facilitate this process. The unique aspect of the treatment is the eye movement component. The currently available research has established EMDR is as effective as CBT treatments [42]. However, the eye movements have not been found to be necessary and they do not explain symptom reduction. Initially, it was claimed that EMDR could cure PTSD in one or two sessions. The developer of the method now takes the position that up to 12 sessions may be necessary in some cases to achieve full effects.

#### **8.2 Pharmacotherapy of adult PTSD**

Though seldom the sole, or even primary treatment for PTSD, pharmacotherapy can alleviate suffering, help restore immediate functioning, and be a supportive adjunct to psychotherapy [43,44]. The scientific literature on PTSD pharmacology is relatively sparse. Most studies have been trials of different medications, only a few randomized trials have been conducted and they have had equivocal results. Treatment guidelines are largely developed on the basis of clinical experience and expert opinion. Antidepressants are the

Post Traumatic Stress Disorder – An Overview 15

Empirical evidence from controlled treatment-outcome studies provides strongest support for the use of trauma-focused cognitive-behavioral treatment (CBT) to resolve PTSD symptoms in children[42]. Therefore, CBT may be considered as the first line approach, either alone or in conjunction with other forms of therapy. CBT usually involves the following components: direct discussion of the trauma, emotional and cognitive coping skills, corrective cognitive distortions, and contingency reinforcement programs for children displaying behavioral problems. The current consensus is that it is not necessary that children be diagnosed with PTSD to receive this treatment, only that they have identifiable posttraumatic stress symptoms that interfere with functioning. CBT approaches are based on the interrelationships between thoughts, feelings, and behaviors [50,51]. In many cases thoughts can lead to emotional states which in turn produce behavioral responses. For example, traumatized children may have over generalized or inaccurate beliefs derived from the traumatic stress experience that triggers anxiety responses. Anxiety is expressed as intensely uncomfortable or may be expressed in appropriate behaviors. In addition, avoidance coping may temporarily reduce anxiety but lead to maladaptive behavior

Stress management techniques such as progressive muscle relaxation, thought-stopping, positive imagery, and controlled breathing are often taught to accompany direct traumafocused discussion in treatment. It is usually recommended that these skills be taught to children prior to detailed discussions of the trauma. With practice, relaxation strategies can help the child gain confidence to approach the direct discussion of the trauma without overwhelming fear, as well as handle other stressful situations outside of the therapeutic context (i.e. flashbacks at school). Because stress management is a useful skill and is easy to master, this component of treatment can facilitate a more positive association to therapy to

Systematic relaxation consists of a series of muscle tensing and relaxation exercises. progressive relaxation and guided tension releasing exercises are recommended for children above 10 years. Therapists may want to adapt exercises to the child's most problematic muscle groups or focus on head, torso and leg exercises separately. Image-induced relaxation is a strategy that may be more effective for younger children. They are taught to distinguish between tense and relaxed states. For example, a child is asked to stand like a "tin soldier" and conversely collapse like a "wet noodle" into a chair. Children are taught when confronted by distressing memories or cues to practice relaxed responding. Children are taught self-instruction such as "relax, hang loose, lighten up, or calm down" at these times and are encouraged to practice at home. Controlled/deep breathing consists of gradually breathing in and out on a count of four to restore normal breathing states and promote relaxation. This technique can be used in vivo for all types of stress inducing

Thought replacement consists of teaching children to interrupt upsetting or disturbing thoughts (e.g., imagines a stop sign and sub-vocalizes the word STOP), and focus on a positive experience or memory (e.g., getting hugged by a parent, going to Disneyland). Positive coping self-statements challenge the disturbing thoughts with self affirming or

patterns.

situations.

**8.3.1 Teaching stress management techniques** 

counterbalance some of the more difficult aspects.

**1. Relaxation techniques** 

**2. Cognitive coping techniques** 

backbone of PTSD treatment; they are particularly useful for their anxiolytic qualities and ability to reduce arousal. The newer selective seratonin reuptake inhibitors and related medications are generally safer, better tolerated, and possibly more effective than older formulations. SSRIs (selective serotonin reuptake inhibitors) are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline [45]. Atypical antidepressants like Nefazodone can be effective with sleep disturbance symptoms, and with secondary depression, anxiety, and sexual dysfunction symptoms. Trazodone can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety. Heterocyclic/Tricyclic anti-depressants like Amitriptyline has shown benefit for positive distress symptoms, and for avoidance, and Imipramine has shown benefit for intrusive symptoms. Monoamine-oxidase inhibitors (MAOs) like Phenelzine has been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.

A full psychopharmacologic approach can include the use of anticonvulsants and mood stabilizers, major tranquilizers and anti-psychotic medications of which newer drugs are well tolerated, and adrenaline blocking drugs [46]. Use of these combinations is usually best left to psychiatrists who are expert in the treatment of PTSD.

Beta blockers (Propranolol) has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances [47]. Also, post-stress high dose corticosterone administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD[48]. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland and Israel.

**Symptom prevention:-** Some medications have shown benefit in preventing PTSD or reducing its incidence, when given in close proximity to a traumatic event. These medications include: Alpha-adrenergic antagonists (e.g. clonidine), Beta blockers (e.g. Propranolol),Glucocorticoids and Opiates [49].

#### **8.3 General treatment components in children**

When clinicians offer assistance to traumatized children and their families, they should begin with: (1) Establishing rapport with the child and caregiver(s) and (2) Providing a rationale for treatment. The clinician should keep the following points in mind when providing a rationale for treatment. The child and caregiver(s) should separately or together receive information regarding the purpose and process of treatment. Caregivers should be informed about the common effects of traumatic experiences on children; that children can have a variety of different reactions. Most children do not have lasting psychological effects (although with some experiences long term effects are more likely, e.g., abuse by the parent, long-term abuse). Treatment will most often be relatively short term and will involve talking about what happened, learning to express feelings appropriately, and gaining an accurate perception of the event. The treatment rationale and concrete goals of therapy should be presented to the child in a clear and simple manner. In the case of certain crimes, such as sexual abuse or physical abuse, where there may be misinformation about children's roles in what happened or offender patterns, it is important to provide corrective information. Educating caregivers and their children about healthy sexuality and personal safety skills is also important during the initial phase of treatment with victims of sexual abuse.

backbone of PTSD treatment; they are particularly useful for their anxiolytic qualities and ability to reduce arousal. The newer selective seratonin reuptake inhibitors and related medications are generally safer, better tolerated, and possibly more effective than older formulations. SSRIs (selective serotonin reuptake inhibitors) are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline [45]. Atypical antidepressants like Nefazodone can be effective with sleep disturbance symptoms, and with secondary depression, anxiety, and sexual dysfunction symptoms. Trazodone can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety. Heterocyclic/Tricyclic anti-depressants like Amitriptyline has shown benefit for positive distress symptoms, and for avoidance, and Imipramine has shown benefit for intrusive symptoms. Monoamine-oxidase inhibitors (MAOs) like Phenelzine has been observed to be effective with hyperarousal and depression, and is especially effective with nightmares. A full psychopharmacologic approach can include the use of anticonvulsants and mood stabilizers, major tranquilizers and anti-psychotic medications of which newer drugs are well tolerated, and adrenaline blocking drugs [46]. Use of these combinations is usually best

Beta blockers (Propranolol) has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances [47]. Also, post-stress high dose corticosterone administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD[48]. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy") in conjunction with

**Symptom prevention:-** Some medications have shown benefit in preventing PTSD or reducing its incidence, when given in close proximity to a traumatic event. These medications include: Alpha-adrenergic antagonists (e.g. clonidine), Beta blockers (e.g.

When clinicians offer assistance to traumatized children and their families, they should begin with: (1) Establishing rapport with the child and caregiver(s) and (2) Providing a rationale for treatment. The clinician should keep the following points in mind when providing a rationale for treatment. The child and caregiver(s) should separately or together receive information regarding the purpose and process of treatment. Caregivers should be informed about the common effects of traumatic experiences on children; that children can have a variety of different reactions. Most children do not have lasting psychological effects (although with some experiences long term effects are more likely, e.g., abuse by the parent, long-term abuse). Treatment will most often be relatively short term and will involve talking about what happened, learning to express feelings appropriately, and gaining an accurate perception of the event. The treatment rationale and concrete goals of therapy should be presented to the child in a clear and simple manner. In the case of certain crimes, such as sexual abuse or physical abuse, where there may be misinformation about children's roles in what happened or offender patterns, it is important to provide corrective information. Educating caregivers and their children about healthy sexuality and personal safety skills is

also important during the initial phase of treatment with victims of sexual abuse.

left to psychiatrists who are expert in the treatment of PTSD.

psychotherapy are being conducted in Switzerland and Israel.

Propranolol),Glucocorticoids and Opiates [49].

**8.3 General treatment components in children** 

Empirical evidence from controlled treatment-outcome studies provides strongest support for the use of trauma-focused cognitive-behavioral treatment (CBT) to resolve PTSD symptoms in children[42]. Therefore, CBT may be considered as the first line approach, either alone or in conjunction with other forms of therapy. CBT usually involves the following components: direct discussion of the trauma, emotional and cognitive coping skills, corrective cognitive distortions, and contingency reinforcement programs for children displaying behavioral problems. The current consensus is that it is not necessary that children be diagnosed with PTSD to receive this treatment, only that they have identifiable posttraumatic stress symptoms that interfere with functioning. CBT approaches are based on the interrelationships between thoughts, feelings, and behaviors [50,51]. In many cases thoughts can lead to emotional states which in turn produce behavioral responses. For example, traumatized children may have over generalized or inaccurate beliefs derived from the traumatic stress experience that triggers anxiety responses. Anxiety is expressed as intensely uncomfortable or may be expressed in appropriate behaviors. In addition, avoidance coping may temporarily reduce anxiety but lead to maladaptive behavior patterns.

#### **8.3.1 Teaching stress management techniques**

Stress management techniques such as progressive muscle relaxation, thought-stopping, positive imagery, and controlled breathing are often taught to accompany direct traumafocused discussion in treatment. It is usually recommended that these skills be taught to children prior to detailed discussions of the trauma. With practice, relaxation strategies can help the child gain confidence to approach the direct discussion of the trauma without overwhelming fear, as well as handle other stressful situations outside of the therapeutic context (i.e. flashbacks at school). Because stress management is a useful skill and is easy to master, this component of treatment can facilitate a more positive association to therapy to counterbalance some of the more difficult aspects.

#### **1. Relaxation techniques**

Systematic relaxation consists of a series of muscle tensing and relaxation exercises. progressive relaxation and guided tension releasing exercises are recommended for children above 10 years. Therapists may want to adapt exercises to the child's most problematic muscle groups or focus on head, torso and leg exercises separately. Image-induced relaxation is a strategy that may be more effective for younger children. They are taught to distinguish between tense and relaxed states. For example, a child is asked to stand like a "tin soldier" and conversely collapse like a "wet noodle" into a chair. Children are taught when confronted by distressing memories or cues to practice relaxed responding. Children are taught self-instruction such as "relax, hang loose, lighten up, or calm down" at these times and are encouraged to practice at home. Controlled/deep breathing consists of gradually breathing in and out on a count of four to restore normal breathing states and promote relaxation. This technique can be used in vivo for all types of stress inducing situations.

#### **2. Cognitive coping techniques**

Thought replacement consists of teaching children to interrupt upsetting or disturbing thoughts (e.g., imagines a stop sign and sub-vocalizes the word STOP), and focus on a positive experience or memory (e.g., getting hugged by a parent, going to Disneyland). Positive coping self-statements challenge the disturbing thoughts with self affirming or

Post Traumatic Stress Disorder – An Overview 17

The process of gradual exposure begins by confronting the least anxiety provoking stimuli first and works its way through more distressing stimuli (e.g. the child might identify hearing the word "rape" as upsetting, but less so than remembering what actually happened). Talking, writing, speaking into a tape-recorder, responding to "mock interview," or drawing a picture with explanation can be used to accomplish exposure. Role-playing, puppet play, and doll-play can be helpful especially with young children. Some children may choose to create books, poems or songs about their traumatic

**Direct Exposure:** This method is appropriate for an older child with good visualization skills. The child is asked to recall specific sensory details of traumatic event, focusing on visual memories. Fantasy is discouraged when recalling the account. This approach should not be confused with hypnotic suggestion or guided imagery. For example, a therapist asks the child to close her eyes (if comfortable) and recall a scene of the traumatic event as if she were there. The therapist poses some specific questions to help the child stay focused like, "describe the room you were in, the time of day, or what the child smells, hears, feels, and thinks at the time." Too many questions may interfere with the child's visualization. The therapist should only ask as many questions as they feel necessary to help the child visualize the scene. The session should not end until the child's anxiety level has decreased

**In Vivo Exposure**: this technique is most used in the later stages of the exposure therapy. The child is helped to identify situations for in vivo practice of exposure to fear inducing stimuli. This should occur in a situation where there is no actual danger or risk thus enabling the child to experience mastery and competence (e.g., confronting fear of the dark by turning off the light during the session, sleeping alone in her room, walking to school).

Most interventions for traumatized children also involve the evaluation of cognitive assumptions children may have made relating the traumatic experience. Children make sense of their experiences in the world by developing belief systems. Like adults, most children have a generally positive view of themselves, other people and the world. Being the victim of a traumatic stress situation can conflict with those beliefs. In order to resolve the conflict, children may change their ideas and thoughts about themselves and others or develop inaccurate, distorted and confused beliefs about the trauma[]. Examples of faulty attributions are "Nothing is safe anymore", "It was all my fault", "I must be a bad person for this to have happened." For some children, unfortunately, a traumatic event can serve to confirm already existing negative perceptions. When treating children with PTSD, it is important to explore and correct these distorted thought patterns related to the trauma. The maladaptive assumptions or beliefs must first be identified. This means it is important initially to allow children to express beliefs even though they may be inaccurate (e.g. self blame-"I asked for it because I went to his house" – or thinking that drinking caused the offender to abuse). Then through various therapeutic exercised, like role playing, telling stories, and providing corrective feedback, these negative or inaccurate thoughts can be disputed. The therapist helps the child generate positive thoughts to replace negative distorted ones instead of just telling children what they should think. With younger children, play therapy using toys and dolls, art materials, and games may be a more

or coping techniques have been used to help the child regain a sense of calmness.

**8.3.3 Exploring and correcting inaccuate attributions** 

effective approach to explore their inaccurate attributions.

**2. Strategies for gradual exposure** 

experiences.

reassuring thoughts (e.g., I am strong, I can handle this situation, I am not really in danger now).
