Research roundup: Post-traumatic stress disorder

This month's roundup presents recent research related to PTSD and practical considerations for treatment

by Practice Research and Policy staff

September 30, 2010 Post-traumatic stress disorder (PTSD) is an anxiety disorder that can develop as a result of exposure to a terrifying or traumatic event or ordeal. Traumatic events that may trigger PTSD include personal assaults, accidents, natural disasters and combat.

According to the National Institute of Mental Health, approximately 7.7 million American adults — about 3.5 percent of all people ages 18 or older — meet the criteria for PTSD. An independent Rand Corporation study indicated that as of 2008, approximately 17 percent of servicemen and women returning from Iraq and Afghanistan showed symptoms of PTSD, and those symptoms increased over time if untreated.

With so many people in society affected by PTSD, and especially the overrepresentation of PTSD in those returning from combat, psychologists are more likely than ever to work with individuals with a history of trauma. The articles below examine recent areas of research into PTSD and practical considerations for treatment.


Lanius, R.A., Vermetten, E., Loewenstein, R., Brand, B., Schmahl, C., Bremner, J., & Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167, 640-647.

Summary

The authors provide an extensive review of the literature and suggest that individuals with post-traumatic stress disorder (PTSD) can experience two different types of emotion dysregulation. Clinical and neurobiological evidence suggests that one type of emotion dysregulation is characterized as “dissociative” or an overmodulation of affect, while the other, more common, type is characterized as undermodulation of affect with a predominance of re-experiencing and hyperarousal symptoms. These two different types of affect dysregulation appear to have different neural manifestations. Re-experiencing/hyperarousal reactivity is viewed as a form of emotion dysregulation that involves emotional undermodulation, mediated by failure of prefrontal inhibition of limbic regions. In contrast, the dissociative emotion dysregulation involves emotional overmodulation mediated by midline prefrontal inhibition of the same limbic regions. Alternating symptom profiles of PTSD can be understood as an active interplay between these two types of emotional dysregulation.  Interestingly, individuals who experienced severe, prolonged exposure to trauma, such as combat or childhood abuse, tend to show more chronic symptoms of dissociation in comparison to those who experienced a single traumatic event.

Practical considerations

Individuals who demonstrate more emotion dysregulation in the form of dissociative symptoms may require a different treatment approach than those who demonstrate re-experiencing and hyperarousal reactivity. Carefully assessing individuals with PTSD to determine the type of dysregulation may lead to better decisions regarding treatment strategies. Assessment tools involving brain imaging may someday help in this process.  Developing strategies for better emotion regulation may be an important first step in treatment, particularly if treatment will involve a trauma processing or exposure-based element. 


Cloitre, M., Stovall-McClough, K.C., Nooner, K., Zoorbas, P., Cherry, S., Jackson, C.L., Gan, W., & Petkova, E. (2010). Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry, 167, 915-924.

Summary

Individuals who experienced abuse during childhood and then developed PTSD typically demonstrate difficulty with affect regulation and interpersonal relationships, which contributes to problems in overall functioning. Affect dysregulation and interpersonal difficulties require treatment attention not only to improve personal functioning but also to facilitate greater engagement in treatment.  Evidence-based PTSD treatments generally recommend processing of trauma memories or trauma-distorted cognitions in order to resolve PTSD but individuals who lack affect regulation and interpersonal skills may face difficulties with such therapeutic exploration. The authors evaluated the benefits and risks of a treatment combining an initial preparatory phase of skills training in affect and interpersonal regulation (STAIR) followed by exposure by comparing it against two control conditions: supportive counseling followed by exposure (Support/Exposure) and skills training followed by supportive counseling (STAIR/Support). A group of 104 women with childhood abuse-related PTSD were assigned to one of the treatment conditions. STAIR/Exposure produced greater improvements in emotion regulation than Support/Exposure and greater improvements in interpersonal problems than either of the other treatment conditions. Those individuals in the STAIR/Exposure condition had a lower dropout rate and fewer PTSD symptoms during the exposure phase of treatment. Finally, the STAIR/Exposure condition was associated with fewer cases of PTSD worsening relative to both of the other two conditions.

Practical considerations

Individuals with PTSD who experienced chronic and early-life trauma may achieve greater benefit from a treatment that provides skills training in affect and interpersonal regulation as well as therapeutic exposure to trauma memories. 


Adler, A.B., Bliese, P.D., McGurk, D., Hoge, C.W., & Castro, C.A. (2009).
Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: Randomization by platoon. Journal of Consulting and Clinical Psychology, 77, 928-940
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Summary

Armed services personnel who have experienced military-related traumatic events show an increase in mental heath problems, and such problems increase in the months following return from combat. Effective early interventions with this at-risk population are critical. Platoons returning from a year-long deployment to Iraq were randomly assigned to standard post-deployment stress education, Battlemind debriefing, and small and large group Battlemind training. The term Battlemind is defined as the soldier’s inner strength to face fear and adversity in combat with courage. Battlemind comprises self-confidence, or taking calculated risks and handling future challenges, and mental toughness, or overcoming setbacks and maintaining positive thoughts during times of adversity. Results from a four-month follow-up with 1,060 participants showed those with high levels of combat exposure who received Battlemind debriefing reported fewer posttraumatic stress symptoms, depression symptoms and sleep problems than those in stress education. Small group Battlemind training participants with high combat exposure reported fewer posttraumatic stress symptoms and sleep problems than stress education participants. Compared to stress education participants, large group Battlemind training participants with high combat exposure reported fewer post-traumatic stress symptoms and lower levels of stigma and, regardless of combat exposure, reported fewer depression symptoms.

Practical considerations

Debriefing strategies have been controversial but this study suggests that brief, focused “debriefing” in the occupational context may have benefits. This training did not occur immediately after trauma but rather after soldiers returned from deployment. The Battlemind model itself focuses on positive changes and does not emphasize detailed retelling of traumatic events. Since all members of the platoon participated in the intervention, no individual experienced any stigma and all experienced the benefit of potential support from other members of the platoon. These features may be particularly important for soldiers and other similar occupations. 


Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., Kluse, M., & Marmar, C. (2010). Posttraumatic stress disorder and risk of dementia among US veterans. Archives of General Psychiatry, 67, 608-613.

Summary

Researchers identified the patient records of older veterans who had received care at Department of Veterans Affairs medical centers and who did not have dementia at the beginning of the record review. They tracked the records of these veterans over a period of seven years and examined the relationship between having a diagnosis of PTSD and developing dementia. A total of 181,093 records were reviewed and approximately 30 percent of the identified veterans had PTSD. About 17 percent of the veterans were newly diagnosed with dementia during the follow-up period. Veterans with PTSD had a higher incident rate of newly diagnosed dementia than those veterans without PTSD.  Researchers controlled for a variety of factors, including age, head injury, substance abuse and depression and found that those with PTSD still had almost twice the risk of developing dementia as those without PTSD. Several mechanisms linking the increased risk of dementia to PTSD diagnosis are discussed in the article.

Practical considerations

While this study does not indicate whether successful treatment of PTSD reduces the risk of later development of dementia, the risk of future dementia may be further motivation for individuals to seek treatment for PTSD. Additionally, clinicians may wish to consider whether any strategies to strengthen cognitive skills or otherwise potentially inoculate or stave off early symptoms of dementia may be particularly beneficial to persons with PTSD. Last, given the increased possibility of dementia in older adults with PTSD, clinicians may need to consider whether modifications to treatment are necessary if early signs of dementia are beginning to manifest themselves.

Special thanks to Joan Cook, PhD, of APA Division 56 (Trauma Psychology) who assisted on this article.