Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral Perspectives

Canadian Psychology, Aug 2005 by Wetmore, Ann

STEVEN TAYLOR (Ed.) Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral Perspectives New York: Springer, 2004, 336 pages (ISBN 0-8261-2047-4, US$48.95 Hardcover)

To paraphrase Steven Taylor, the editor, in his Preface, this collection of articles on PTSD intends to present reader-practitioners with a stand-alone source of descriptions of the state of the art in PTSD research and treatment. The text was expanded from a special issue produced for the Journal of Cognitive Psychotherapy, entitled "Current Directions in the Treatment of Posttraumatic Stress Disorder" - which might have been a more apt title to retain, as this volume gives a very laudable overview of PTSD treatment from a cognitive-behavioural perspective, but, leaves many unanswered research questions regarding "advances" in treatment. In this regard, the text could be considered "necessary but not sufficient," perhaps reflecting the state of affairs in PTSD research investigations as a whole. The list of noteworthy contributors (33 in total) includes many names well recognized in PTSD circles, with a definite American slant (e.g., the majority of the authors, approximately 82%, are American, along with two Canadians, two Australians and two from the United Kingdom to provide "International" representation).

While this edited volume covers many state of the art CBT approaches in Part I and Part II, ranging from Exposure Therapy and EMDR to Cognitive Restructuring and Social Support, its unique and outstanding contribution is in Part III, which is dedicated to "Special Populations" with PTSD, specifically, Military Populations, those with predominant Anger, Chronic Pain, Dissociation, and Children and Adolescents. This may, in fact, be the first book to single out such "special needs" groups and begin to address their particular problems in PTSD treatment. New treatment approaches, such as "Imagery Rehearsal Therapy" (IRT) for posttraumatic nightmares, and "Kubany's Cognitive Therapy for Trauma Related Guilt" present intriguing possibilities. Again, the research literature is, as yet, limited.

Treatment for anger amongst PTSD groups is a complex task, and the contributing authors in this section have rigorously compared Prolonged Exposure, Stress Inoculation Training, and combination interventions to determine the efficacy of CBT in anger reduction. Much of the data (in many of the chapters) are drawn from populations experiencing PTSD as a result of rape, domestic violence, abuse, and motor vehicle accidents. The generalizability of these positive CBT results and treatment applications to other "special needs groups," such as survivors of large-scale natural catastrophes, is questionable and requires further investigation, beyond the scope of this volume.

The chapter discussing PTSD and dissociation evolves as a theoretical and conceptual review of dissociation, with both encouragement and cautions for the use of Exposure Therapy with this particular population. For example, as the effectiveness of exposure therapy is thought to depend on the degree of emotional engagement with the previously avoided traumatic memories, the tendency for the client to dissociate in order to reduce anxiety when exposed to overwhelming stimuli may impede progress. The importance of a thorough clinical assessment of both capacity for dissociation and risk of self-harm prior to beginning exposure treatment is emphasized. Specific strategies are detailed, to help dissociative clients deal with flashbacks ("grounding" techniques; emphasis on safety and breathing), emotional numbing, and extreme anxiety or panic reactions during exposure treatment vital considerations for the scientist-practitioner.

Perhaps the most-detailed treatment protocols are contained in the chapter on "Treating PTSD in the Context of Chronic Pain." The authors suggest that chronic pain may be comorbid with PTSD in 20% to as many as 75% of patients. Some very specific underlying factors and perpetuating mechanisms are discussed, such as intrusive memories triggering pain as a form of "somatosensory flashback." Despite the scarcity of research on the treatment of co-morbid PTSD and chronic pain, this chapter details several "multicomponent" CBT interventions, ranging from 9 to as many as 17 weekly sessions, with two case studies compared for illustration. The tendency is for pain treatment to take place prior to PTSD interventions (subject to modification on an individual basis, if necessary), with most effective results arising, not surprisingly, from multidisciplinary teams, and not excluding the possibility of pharmacological therapies in addition to CBT. An extremely helpful table details the components of CBT interventions for PTSD, alongside suggested modifications when pain is comorbid.

In Part II, the chapter on "Multiple Channel Exposure Therapy of PTSD" presents the tantalizing prospect of a therapy program adapted from "cognitive processing therapy" (CPT) and CBT for panic disorder, which would incorporate cognitive restructuring and serve to maximize the effectiveness of exposure-based PTSD treatments through "physiological, cognitive, and behavioral channels." Although intriguing, the outline of the actual treatment program is sketchy, and the interested reader is forced to seek other resources for detailed descriptions. Cautions regarding the use of procedures such as interoceptive exposure on an individual office basis, without the back-up of a clinical facility, are not mentioned.