Why PTSD Treatment Education Is An Important Part Of PTSD Treatment
Psychologists Meike Müller-Engelmann and Laura Schwartzkopff discuss their new research evaluating different forms of PTSD treatment.
By Mark Travers, Ph.D. | September 9, 2021
A new research article appearing in Frontiers in Psychology examines five different forms of treatment for PTSD and offers a glimpse into the types of patients that prefer each one. For instance, results suggest that cognitive behavioral therapy (CBT) and prolonged exposure therapy are the two most preferred treatment forms overall, but that older patients tend to prefer psychodynamic treatments over CBT.
I recently spoke with the lead authors of the project, Laura Schwartzkopff (M.Sc.-Psych.) and Dr. Meike Müller-Engelmann, to discuss their findings in more detail. Here is a summary of our conversation.
What inspired you to investigate the topic of PTSD treatments and what did you find?
The inspiration to investigate the treatment preferences of treatment-seeking traumatized adults in Germany was on the one hand influenced by our clinical observation — that patients are often rather uninformed regarding their treatment options and that many clinicians do not use evidence-based trauma-focused treatments. Another inspiration was research suggesting that although many evidence-based therapy options for traumatized patients exist, the dropout and nonresponse rates for the recommended treatments remain high (Schottenbauer et al., 2008).
We approached this discrepancy between research recommendation and clinical practice by asking PTSD patients about their treatment preferences. In our study, we investigated the individual preferences of 104 traumatized adults regarding five psychotherapeutic treatments for PTSD (for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy, and stabilization). We furthermore examined how demographic and psychopathological factors affect patients' treatment preferences and the reasons for choosing a specific treatment. We found that EMDR and psychodynamic psychotherapy were both preferred by nearly 20% of the sample while prolonged exposure and CBT were both preferred by almost 30%.
Only 4% of respondents preferred stabilization, which was significantly less popular than the other options. Neither demographic nor clinical variables were associated with treatment preferences, except that patients who preferred psychodynamic psychotherapy were older than those who preferred cognitive behavioral therapy. According to our findings, the perceived treatment mechanism (e.g., "Confronting and dealing with the trauma seems important to me"; "To find out the unconscious effect of the trauma on me") played the largest role in patients' choices of treatment (41%), as well as the perceived treatment efficacy (26%).
To conclude, we found different treatment options to be preferable in the analysis of patients' treatment preferences. Thus, our findings may suggest that patients seeking treatment are often rather uninformed about treatment options and may change their treatment preferences after being provided with comprehensive information. Therefore, thoroughly educating patients about general treatment options could help to better match their needs with evidence-based treatments.
Can you talk a little bit about why PTSD is such an important disorder to treat?
Armed conflict in Afghanistan, earthquakes in Haiti, current flood disasters in Germany, a mass pile-up on a Texas highway, terrorist attacks, war, sexual violence — the topic of "traumatic events" is omnipresent and even words from trauma therapy, such as "trigger," have found their way into everyday language.
According to epidemiological surveys with different samples, 20-90% of people experience at least one potentially traumatic event during their lifetime (Benjet et al., 2016; Breslau et al., 1998; Hepp et al., 2006).
Post-traumatic stress disorder (PTSD) is a mental disorder that can develop following such traumatic life events, such as being exposed to actual or threatened death, serious injury, or sexual violence (Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), American Psychiatric Association, 2013). With a lifetime prevalence in the general population between 1% and 11% (about 1.9% in Europe), PTSD is a common mental health condition (Alonso et al., 2004; Kilpatrick et al., 2013).
People suffering from PTSD experience four sets of symptom clusters: intrusive memories of the traumatic event, avoidance of reminders of the traumatic event, hyperarousal (e.g., being easily startled or having troubles with sleep or concentration), and negative alterations in mood or cognitions (e.g., ongoing feelings of anger, shame, or guilt and the conviction that it will happen again) (American Psychiatric Association, 2013).
The disorder burden and the social costs associated with PTSD are considered high, with studies demonstrating three times higher overall health care costs for PTSD sufferers than for non-PTSD controls (Bothe et al., 2020; Marciniak et al., 2005). If PTSD is left untreated, it can become chronic and massively impair the quality of life of those affected (Kessler, 2000; Steinert et al., 2015).
Can you briefly describe each of the five PTSD treatments you evaluated in your study? What are they and why do they work?
Psychotherapies for the treatment of PTSD can be broadly divided into two categories: trauma-focused interventions and non-trauma-focused interventions (Cusack et al., 2016; Watkins et al., 2018). The first group includes those treatment approaches that directly address the traumatic event (e.g., eye movement desensitization and reprocessing (EMDR; Shapiro, 2001), exposure therapy (Foa & Rothbaum, 1998), and cognitive behavioral therapy (CBT; Ehlers & Clark, 2000)), whereas non-trauma-focused treatment approaches seek to treat PTSD symptoms without directly focusing on the traumatic event (e.g., stabilization) (Watkins et al., 2018).
Among several different psychotherapy options for PTSD, prolonged exposure (Foa and Rothbaum, 1998), CBT (Ehlers & Clark, 2000), and EMDR (Shapiro, 2001) are proved to be especially efficacious in improving symptoms of PTSD (Lewis et al., 2020). In some European countries like Germany and France, trauma-adapted psychodynamic therapies as well as stabilization are also part of the psychotherapeutic care of traumatized patients, but studies on their efficacy are currently scarce (Paintain & Cassidy, 2018).
Thus, in our study we investigated the following five psychotherapeutic treatments for PTSD:
This treatment is based on the assumption that posttraumatic stress disorder is essentially maintained by avoiding trauma-related thoughts, feelings, and memories. The so-called exposure is the key mechanism of this treatment, which means that the symptoms are reduced by directly addressing (confronting) the memories of the traumatic experience. This includes a detailed report about the traumatic event as well as exercises in which the patient imagines the traumatic experience. The exposure can take place mentally, i.e. in sensu, or if necessary in vivo, i.e. through confrontation with trauma-relevant places, things, or people.
Eye movement desensitization and reprocessing (EMDR)
This treatment was named after right-left eye movements, which, like any back-and-forth movement, can have a calming and integrating effect. In EMDR therapy, the patient, under the guidance of the therapist, performs horizontal eye movements while imagining the traumatic experience. This effect can also be achieved by (right-left) alternating touches, e.g., of the hands, or listening to bilateral music (with sounds alternating between the right and left ear). The former experience can thus be experienced and placed in a new context.
Cognitive behavioral therapy (CBT)
In this treatment, stressful thoughts related to the trauma are analyzed. People who have been traumatized often suffer from distorted distressing views, e.g., "I am to blame for the rape/attack", "I am not safe", and "My life is destroyed forever." These thoughts lead to feelings of guilt, shame, fear, etc. In the treatment, patients learn to recognize and challenge these beliefs and to find more balanced, appropriate beliefs again. This procedure usually leads to a reduction in stressful feelings and thus of the symptoms of posttraumatic stress disorder.
The focus of trauma-adapted psychodynamic therapy is to identify and treat the unconscious effects of trauma on the patient. It is assumed that the trauma is such an overwhelming experience that it could not be processed in the moment. In therapy, the conditions for processing are regained. The therapy focuses less on the symptoms, but is primarily concerned with gaining insight, i.e., recognizing a connection between the stresses today and the traumatic experiences. Here, the therapeutic relationship is of utmost importance, which means that feelings and behaviors that emerge within this relationship reflect problems in the patient's daily life and can be addressed within the therapeutic relationship.
Often, this treatment does not directly deal with the traumatic experience but rather aims to stabilize the patient's psychological state and to make the burden bearable. This is achieved, for example, by techniques to deal with tension, stress, and strong emotions. This may involve learning calming actions that help to distract oneself. It is also important to learn to recognize tension at an early stage and to deal with it actively. In addition, imaginative techniques like imaging a safe place or relaxation exercises can be used. For stabilization work, the traumatic experience is not dealt with directly. According to studies, treatments that exclusively consist of stabilization have a low effectiveness and do not allow for long-term healing.
Is it fair to say that patients respond better to treatments they prefer, or is the efficacy of the therapy unrelated to patient preferences?
As we did not examine the relationship between treatment preference and treatment outcome in our study, we can only respond here based on previous treatment studies. There is preliminary evidence that taking patients' treatment preferences into account can improve treatment outcomes, including fewer treatment dropouts and enhancing therapeutic alliance (i.e. Delevry & Le, 2019; Swift et al., 2018; Windle et al., 2020; Zoellner et al., 2019). Based on these findings, it can be assumed that patients will particularly benefit from a therapy if the treatment approach fits their preferences. Nevertheless, due to considerable heterogeneity between studies in recent meta-analyses, further studies are needed before firm conclusions can be drawn (Windle et al., 2020).
What insights does your research hold for individuals who are researching different courses of treatment for PTSD?
Based on our study, which indicates that PTSD patients differ in their treatment preferences, comprehensive patient education and preference assessments may improve care of PTSD patients. Certainly, it must be kept in mind that clinical institutions cannot cover and offer all PTSD treatment options. However, considering patient preferences may increase treatment compliance and thus outcome and treatment completion.
Are there any gender differences in the presentation and treatment of PTSD?
Epidemiological findings indicate that although men are more likely to experience traumatic events than women, women are twice as likely as men to develop PTSD (Ditlevsen, & Elklit, 2010; Kessler et al. 1995). Many factors have been proposed to explain the gender difference in the prevalence of PTSD (Olff, 2017) — one is the type of trauma experienced, which influences the probability of developing PTSD (i.e., women show higher rates of sexual trauma, a trauma with the highest probability of developing PTSD) (Guina et al., 2019; Kessler et al., 1995).
Regarding gender differences in the treatment outcomes for PTSD, the literature suggests that women are more likely to seek treatment after traumatization than men (Gavrilovic et al., 2005). Furthermore, there is preliminary evidence that women appear to respond better to PTSD treatments than men (Blain et al., 2010; Wade et al., 2016). Regarding treatment preference, findings appear to be inconclusive. In our study, we did not find any influence of gender on treatment preference. However, it is certainly relevant for further studies to take gender-specific characteristics into account and to continue to investigate them in order to be able to provide optimal care for traumatized patients.
What is the relationship between PTSD and depression?
Epidemiological studies show that about 80% of patients with PTSD have a lifetime diagnosis of at least one more mental disorder (AWMF, 2019). In terms of depression, studies show that approximately half of people with PTSD also suffer from depression (Kessler, Sonnega, Bromet, Hughes, & Nelson,1995). Depression and PTSD share some symptoms, for example, impaired concentration, anhedonia, or sleeping difficulties, but can also be distinguished from each other based on, for example, PTSD-specific symptoms such as trauma-related intrusive memories (Gros, Price, Magruder, & Frueh, 2012). It is debated whether depressive symptoms in PTSD patients should be seen as part of a general "post-traumatic syndrome" rather than a separate disorder (Flory & Yehuda, 2015). However, for clinicians, as well as researchers, considering both as comorbid disorders seems of particular importance for treatment planning and prognosis.
Are you planning any follow-up research on this topic?
Yes, we have planned further studies that aim to investigate and improve the care of traumatized patients.
Alonso, J., Angermeyer, M. C., Bernert, S., Bruffaerts, R., Brugha, T. S. H., Bryson, et al. (2004). Prevalence of mental disorders in Europe: results from the European study of the epidemiology of mental disorders (ESEMeD) project. Acta Psychiatr. Scand. 109, 21–27.
AWMF-S3-Leitlinie Posttraumatische Belastungsstörung. AWMF-Register-Nr. 155/001 (2019).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Benjet, C., Bromet, E., Karam, E. G., Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., ... & Koenen, K. C. (2016). The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. Psychological medicine, 46(2), 327-343.
Blain, L. M., Galovski, T. E., & Robinson, T. (2010). Gender differences in recovery from posttraumatic stress disorder: A critical review. Aggression and violent behavior, 15(6), 463-474.
Bothe, T., Jacob, J., Kröger, C., & Walker, J. (2020). How expensive are post-traumatic stress disorders? Estimating incremental health care and economic costs on anonymised claims data. The European Journal of Health Economics, 21, 917-930.
Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998) Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 55(7):626–632
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., ... Weil, A. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141.
Delevry, D., and Le, Q. A. (2019). Effect of Treatment Preference in Randomized Controlled Trials: Systematic Review of the Literature and Meta-Analysis. The Patient- Patient-Centered Outcomes Research, 12, 1-17.
Ditlevsen, D. N., & Elklit, A. (2010). The combined effect of gender and age on post traumatic stress disorder: do men and women show differences in the lifespan distribution of the disorder?. Annals of general psychiatry, 9(1), 1-12.
Ehlers, A. and Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.
Flory, J. D., & Yehuda, R. (2015). Comorbidity between post-traumatic stress disorder and major depressive disorder: alternative explanations and treatment considerations. Dialogues in clinical neuroscience, 17(2), 141-150.
Foa, E. B. and Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York: Guilford Press.
Gavrilovic, J. J., Schützwohl, M., Fazel, M., & Priebe, S. (2005). Who seeks treatment after a traumatic event and who does not? A review of findings on mental health service utilization. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 18(6), 595-605.
Gros, D. F., Price, M., Magruder, K. M., & Frueh, B. C. (2012). Symptom overlap in posttraumatic stress disorder and major depression. Psychiatry research, 196(2-3), 267-270.
Guina, J., Nahhas, R. W., Kawalec, K., & Farnsworth, S. (2019). Are gender differences in DSM-5 PTSD symptomatology explained by sexual trauma?. Journal of interpersonal violence, 34(21-22), 4713-4740.
Hepp, U., Gamma, A., Milos, G., Eich, D., Ajdacic–Gross, V., Rössler, W., ... & Schnyder, U. (2006). Prevalence of exposure to potentially traumatic events and PTSD. European archives of psychiatry and clinical neuroscience, 256(3), 151-158.
Kessler, R. C. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry. Special Issue: Focus on posttraumatic stress disorder, 61, 4−14.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of general psychiatry, 52(12), 1048-1060.
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., and Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J. Trauma. Stress 26, 537–547.
Lewis, C., Roberts, N. P., Andrew, M., Starling, E., and Bisson, J. I. (2020). Psychological therapies for post-traumatic stress disorder in adults: Systematic review and meta- analysis. European Journal of Psychotraumatology, 11(1), 1729633.
Liddon, L., Kingerlee, R., and Barry, J. A. (2018). Gender differences in preferences for 752 psychological treatment, coping strategies, and triggers to help‐seeking. British 753 Journal of Clinical Psychology, 57(1), 42-58.
Marciniak, M. D., Lage, M. J., Dunayevich, E., Russell, J. M., Bowman, L., Landbloom, R. P., et al. (2005). The cost of treating anxiety: the medical and demographic correlates that impact total medical costs. Depress. Anxiety 21, 178–184.
Olff, M., Langeland, W., Draijer, N., & Gersons, B. P. (2007). Gender differences in posttraumatic stress disorder. Psychological bulletin, 133(2), 183- 204.
Paintain, E., and Cassidy, S. (2018). First-line therapy for post-traumatic stress disorder: a systematic review of cognitive behavioural therapy and psychodynamic approaches. Counselling and psychotherapy research 18, 237–250. doi: 10.1002/capr.12174
Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., and Gray,
S. H. (2008). Non-response and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry 71, 134–168.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York: Guilford Press.
Steinert, C., Hofmann, M., Leichsenring, F., & Kruse, J. (2015). The course of PTSD in naturalistic long-term studies: high variability of outcomes. A systematic review. Nordic journal of psychiatry, 69(7), 483-496.
Swift, J. K., Callahan, J. L., Cooper, M., and Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.
Wade, D., Varker, T., Kartal, D., Hetrick, S., O'Donnell, M., & Forbes, D. (2016). Gender difference in outcomes following trauma-focused interventions for posttraumatic stress disorder: Systematic review and meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 356–364.
Watkins, L. E., Sprang, K. R., and Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258.
Windle, E., Tee, H., Sabitova, A., Jovanovic, N., Priebe, S., and Carr, C. (2020). Association of patient treatment preference with dropout and clinical outcomes in adult psychosocial mental health interventions: a systematic review and meta-analysis. JAMA Psychiatry 77, 294–302.
Zoellner, L. A., Roy-Byrne, P. P., Mavissakalian, M., & Feeny, N. C. (2019). Doubly randomized preference trial of prolonged exposure versus sertraline for treatment of PTSD. American Journal of Psychiatry, 176(4), 287-296.