In the management of stress-induced disorders one has to consider symptoms, severity, duration and social ramification of the trauma. It is particularly important for treatment planning to include co-occurring disorders. Psychological interventions are always required. Pharmacological treatments may be administered as adjuvants to psychological therapy or with the primary aim of suppressing stress-induced symptoms.
Acute stress disorder
No systematic studies have been conducted on the treatment of the newly described acute stress disorder. The therapeutic approach is symptomatic. Benzodiazepines are helpful to calm a person and induce sleep. Beta-blockers and clonidine have been used on the assumption that they reduce stress-induced noradrenergic hyperactivity. Clonidine also has anxiolytic and sedating effects that may be useful for reducing the intensity of anxiety ().
Posttraumatic stress disorder
In acute posttraumatic stress disorder (PTSD), benzodiazepines and possibly clonidine may be useful for reducing anxiety and hypervigilance. Sargent & Slater (1940) used medications such as ether to induce abreaction in soldiers with PTSD. Under the influence of the drug, and with guidance by the therapist, patients vividly relived their traumatic experience. This treatment was based on the assumption that uncovering of repressed or dissociated material through emotional abreaction might promote healing. In addition, reexperiencing the trauma in a controlled environment might lead to a perception of mastery over the experience. Abreaction studies in neurotic patients suggest that the healing effect lies primarily in an unfreezing of fixed response patterns that make patients temporarily more suggestible. The resulting altered state of mind permits the implantation of healthier attitudes. Abreaction alone is rarely helpful because newly gained attitudes must be reinforced through systematic therapy; however, it can act as catalyst that permits the initiation of change ().
In chronic posttraumatic stress disorder, pharmacotherapy is only modestly effective. Most controlled studies have been conducted on combat veterans. While benzodiazepines are helpful for brief, time-limited administration, antidepress-ants have gained a prominent role in chronic treatment. The tricyclic antidepressants, imipramine and amitriptyline, the monoamine oxidase inhibitor, phenelzine, and the selective serotonin reuptake inhibitor, fluoxetine, have proven superior to placebo in reducing PTSD symptoms (). The placebo response in controlled studies has been approximately 20%, which is lower than that for other anxiety disorders and depression. Antidepressants reduce intrusive, avoidance, and hyperarousal symptoms. In the treatment of chronic posttraumatic stress disorder, it is important that sufficiently high doses be given and that the trials be of sufficient length. A minimum should be 5-8 weeks and preferably longer, because some patients improve only after several months of treatment. The antidepressants are generally only partially effective. Most patients continue to experience symptoms but to a lesser degree. Some may need lifelong pharmacotherapy, and for them, attempts to reduce the dose may lead to relapse even 20 or more years after combat exposure. Patients with severe symptoms often require a combination of pharmacotherapeutic agents combined with psychological interventions.
Acute stress disorder
There are no controlled treatment studies of acute stress disorder (). Experience suggests that this disorder requires immediate attention. The value of debriefing alone – i.e., talking through the traumatic experience – has been questioned (). It is important to obtain detailed information about the trauma and its realistic consequences. Treatment should be given early, and it should be brief, problem-focused and simple. Patients should be placed in a safe area but preferably near the place where the trauma occurred. They should be told that they will recover quickly (), and if possible, returned in a short time to the environment in which the trauma occurred ().
Armstrong et al., (1991) developed a treatment program that consists of: (1) an introductory phase in which the therapist establishes contact and explains treatment procedures, (2) a fact-finding phase during which the patient retells personal experiences in relation to the traumatic event, (3) a cognitive phase during which reactions to the most stressful aspects of the event are explored, (4) an affective phase in which the patient is encouraged to discuss emotional reactions to the event, with emphasis on those that do not constitute weakness, and (5) a phase in which enquiries are made about physical and emotional symptoms since the event. At that point common features of the stress response syndromes and their normalization are brought up, and (6) a final phase that focuses on reentry and consolidation is completed. Obviously, individual psychological and social needs have to be considered, and treatment may have to be modified accordingly.
Posttraumatic stress disorder
Controlled studies concerning the efficacy of various therapeutic interventions have been conducted in combat veterans and rape victims but not other PTSD populations. There is considerable controversy about how effective psychological interventions may be. Andrews (1991) suggested that cognitive-behavioral techniques are more effective than psychoanalytically-oriented psychotherapy. A carefully conducted study in Israeli veterans, whose treatment was based on cognitive, behavioral and social theories, led to subjective improvement but objective worsening of symptoms (); however, other outcome studies have yielded more favorable results. Foa et al. (1995) compared three treatment modalities, namely stress inoculation, prolonged imaginal exposure and supportive counseling with a wait-list control in rape victims. Initially, stress inoculation was superior; however, by the fourth month, imaginal exposure appeared more beneficial. Imaginal exposure appeared to induce major changes in memory representations, and therefore, produced more a profound change than stress inoculation. The technique was helpful when first applied but lost some of its impact when patients stopped practicing it. Other outcome studies have been less clear. In some studies, one technique was superior to others, but in others no differences were found. Desensitization appeared to have only a modest impact. Flooding was effective in some patients but led to worsening and complications in others. The effect of flooding depends upon whether the emotion that is elicited can be processed and brought to a satisfactory resolution, or whether it opens emotional wounds without providing relief.
Discrepant results are not surprising when one considers differences not only between but also within apparently homogeneous groups of posttraumatic stress disorder patients. Thus, individualization of treatment is essential. Recommended methods, while good for learning, should not be followed rigidly but modified according to the needs of individual patients. Psychosocial treatment strategies are discussed extensively by Meichenbaum (1994) and by Lehrer & Woolfolk (1993).
The best results have been obtained with anxiety management training, a treatment program that includes biofeedback, relaxation, and cognitive restructuring with stress inoculation training. This approach includes an educational phase and some coping skills training with homework. Coping skills include muscle relaxation, breathing control, covert modeling, exposure, thought stopping and guided self-dialogue. Studies show that, while all treatments are of some use, a combination tends to be more effective than a single method. Psychological interventions are less effective in veterans than in rape victims, probably because of the greater chronicity and comorbidity in the former group.
In practice, the treatment plan must include the formation of positive rapport. Some patients avoid formal mental health services because they cue for distressing memories (). Patients need to develop a realistic appraisal of the trauma and be educated regarding their symptoms. At the same time, the meaning of the trauma for the individual needs to be explored. Important also is the examination of perceived responsibility for having been traumatized. This includes reassurance about one’s behavior and actions taken during the traumatic experience. The goal is the acceptance of one’s behavior and the gradual mastery over one’s feelings. Among holocaust survivors, intrusive thoughts about deceased relatives may become less distressing when they are viewed as cherished memories of loved ones rather than recollections of horror (). The feeling of gaining control over one’s life and over potential new traumas has a strengthening effect.
Relaxation techniques alone or combined with exposure to trauma-related stressors may lead to desensitization. Flooding, i.e., direct, often maximal, exposure to traumatic cues, leads at first to abreaction that is followed, under the proper guidance of a therapist, to a calmer view of the traumatic event. During exposure, it is important for victims to give not only a detailed description of the stimuli but also their reactions, appraisal, and threat-related thoughts. During exposure, trust in the therapist is of crucial importance because it is his or her influence that modifies the emotional tone of the distressing memories. Memories of the insult may never become neutral but become less painful. When exposure to a stressor is not possible, guided recollection of memories can be used. Its aim is to reduce the hyperarousal and excessive reactivity to traumatic memories. In addition, avoidance, when it is present, needs to be reduced and social interaction improved ().
As stated above, treatment must begin with the establishment of rapport. A full exploration of the circumstances of the trauma and its psychological and social impact precedes actual treatment. Then, a treatment program is developed in collaboration with the patient who needs to realize that progress can only be made if he or she takes an active role. First, the increased arousal is treated with relaxation techniques. Then attempts are made to reduce intrusive thoughts and images for which several approaches are available. The choice of technique depends on the patient’s psychopathology and ability to participate in treatment. With systematic desensitization, the therapist induces fearful images while the patient is in a relaxed state. It obviously is not effective if the patient cannot relax. Imaginary or in vivo exposure involves repeated reliving of the trauma with the aim of processing the experience and deriving a satisfactory closure. Cognitive working through of the traumatic experience under the guidance of a therapist is essential for bringing about change. Avoidance is treated with gradual exposure to the feared situations. The sequencing of exposures and demands for behavioral change need to be tailored individually. Realistic expectations for outcome should be set from the beginning. Patients need to realize that treatment will most likely reduce but not alleviate their symptoms. The goal of therapy should be better functioning in spite of the persistent symptoms.
The treatment plan needs to take into account the special needs of a patient. Disaster victims need to be resettled and helped to rebuild their lives. Victims of crime need help in dealing with stressful legal matters such as cross examination during the trial of a perpetrator. As noncompliance is frequent, the therapist needs to be patient and flexible in dealing with patent’s anxieties and often changing feelings. Cultural aspects also have to be considered in the treatment of PTSD. For instance, Asians from far east regions are culturally prohibited from expressing strong or negative emotions, and, therefore, tend to somatize. Belief in the physical nature of their distress and ‘karma’, the idea that the disaster is a consequence of evil deeds done in previous lives, is a stumbling block to psychotherapy (). Such patients accept pharmacotherapy combined with reassurance and direct advice better than they do Western-style cognitive-emotional psychotherapies.
Selections from the book: “The anxiety disorders” (1998)