Who's Treating PTSD?

When I hear or read stories about posttraumatic stress disorder, two key questions come to mind: Who is doing the treatment, and do they know how to treat this disorder?

As to the first question, it seems that "counseling" is the operative word for sufferers of PTSD. We hear and read over and over that a person suffering from PTSD is referred to a counselor, sometimes a therapist, for care.

Second, do the people doing the counseling or psychotherapy know the specific treatments for PTSD that have demonstrated the most success? I’ve spoken with numerous therapists from different disciplines, and it is clear that traditional, open-ended psychotherapy (plus medication management in the case of psychiatrists) continues to dominate treatment approaches for PTSD. This is the case even though a variety of exposure, relaxation, and behavioral techniques has shown better results, according to an overview of PTSD treatment research by the Department of Veterans Affairs’ National Center for PTSD. In fact, the VA is way ahead of more traditional clinical settings in using specialized treatments for PTSD with proven track records. For example, researchers at the agency are in the process of developing initiatives to train mental health staff in the delivery of cognitive-processing therapy and prolonged exposure therapy, two treatments for PTSD that produce positive results (J. Trauma Stress 2010;23:663-73).

First Sounds of PTSD

I remember as a teenager, while in my father’s surgical office, picking up the phone and hearing on the other end what would turn out to be my first exposure to a person with PTSD, as I look back. The patient on the line, Jim, was calling in a panic and telling me – before he knew who I was – about seeing things in his head that reminded him of things that had happened on the battlefield during World War II.

My father, an eye surgeon, was in the middle of a procedure and could not come to the phone. So I continued to listen to Jim and told him that it would be alright, not knowing what else to do. Jim had been my father’s patient for several years before my dad had become an ophthalmologist, and had continued in his care after an eye injury subsequent to a traumatic event years earlier while he was in the military during the war.

After Jim recounted his story to me, my father took the phone and appeared to calm him. Later, my father explained the entire story, and how Jim had an "anxiety neurosis" and "soldier’s heart" with vivid memories (flashbacks) of a combat experience in the war where he was injured. He once saw a psychiatrist, according to my father, and was given a sedative. But it didn’t help, and Jim did not follow up with the three- or four-times-a-week explorative talk therapy, which was the main type of outpatient care at the time.

My father was clear, as he understood psychotherapy at the time, that getting Jim to lie on a couch and relive his childhood would not stop the memories (flashbacks). Rather, Jim needed some type of "here and now" reassurance that things would be okay. My dad did tell me that "one day we’ll have a medication to treat these anxiety-ridden neurotic people." To a large extent, we do have medications that work for many depressions and anxiety disorders – but not always for PTSD.

A Long History

The history of war-related trauma in this country began to be documented around the time of Civil War. Jacob Mendes Da Costa, an internist who served as an assistant surgeon in the U.S. Army during that war, first recognized a set of anxieties centering around heart symptoms. But no cardiac illness was discovered. Over the years and well into the 20th century, many names – including Da Costa’s syndrome as well as combat neurosis, shell shock, soldier’s heart, neurocirculatory asthenia, and/or simply anxiety neurosis, as my father called it – have been applied to this syndrome.

PTSD can result from severe war-related traumas as well as from traumatic experiences caused by natural and manmade disasters, assaults, and a variety of life-threatening experiences that appear to adversely affect emotional functioning. By 1980, when the DSM-III was first published, PTSD finally had been recognized as a mental disorder and was so named. Today, we know that it is important to recognize the existence of subclinical and subthreshold PTSD, which I discussed over the years as author of "The Psychiatrist’s Toolbox" column (Clinical Psychiatry News, May 2009, p. 23). These more ambiguous cases also need to be treated in an organized and codified behavior and cognitive manner (Clinical Psychiatry News, December 2004, p. 20).

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.

When I hear or read stories about posttraumatic stress disorder, two key questions come to mind: Who is doing the treatment, and do they know how to treat this disorder?

As to the first question, it seems that "counseling" is the operative word for sufferers of PTSD. We hear and read over and over that a person suffering from PTSD is referred to a counselor, sometimes a therapist, for care.

Second, do the people doing the counseling or psychotherapy know the specific treatments for PTSD that have demonstrated the most success? I’ve spoken with numerous therapists from different disciplines, and it is clear that traditional, open-ended psychotherapy (plus medication management in the case of psychiatrists) continues to dominate treatment approaches for PTSD. This is the case even though a variety of exposure, relaxation, and behavioral techniques has shown better results, according to an overview of PTSD treatment research by the Department of Veterans Affairs’ National Center for PTSD. In fact, the VA is way ahead of more traditional clinical settings in using specialized treatments for PTSD with proven track records. For example, researchers at the agency are in the process of developing initiatives to train mental health staff in the delivery of cognitive-processing therapy and prolonged exposure therapy, two treatments for PTSD that produce positive results (J. Trauma Stress 2010;23:663-73).

First Sounds of PTSD

I remember as a teenager, while in my father’s surgical office, picking up the phone and hearing on the other end what would turn out to be my first exposure to a person with PTSD, as I look back. The patient on the line, Jim, was calling in a panic and telling me – before he knew who I was – about seeing things in his head that reminded him of things that had happened on the battlefield during World War II.

My father, an eye surgeon, was in the middle of a procedure and could not come to the phone. So I continued to listen to Jim and told him that it would be alright, not knowing what else to do. Jim had been my father’s patient for several years before my dad had become an ophthalmologist, and had continued in his care after an eye injury subsequent to a traumatic event years earlier while he was in the military during the war.

After Jim recounted his story to me, my father took the phone and appeared to calm him. Later, my father explained the entire story, and how Jim had an "anxiety neurosis" and "soldier’s heart" with vivid memories (flashbacks) of a combat experience in the war where he was injured. He once saw a psychiatrist, according to my father, and was given a sedative. But it didn’t help, and Jim did not follow up with the three- or four-times-a-week explorative talk therapy, which was the main type of outpatient care at the time.

My father was clear, as he understood psychotherapy at the time, that getting Jim to lie on a couch and relive his childhood would not stop the memories (flashbacks). Rather, Jim needed some type of "here and now" reassurance that things would be okay. My dad did tell me that "one day we’ll have a medication to treat these anxiety-ridden neurotic people." To a large extent, we do have medications that work for many depressions and anxiety disorders – but not always for PTSD.

A Long History

The history of war-related trauma in this country began to be documented around the time of Civil War. Jacob Mendes Da Costa, an internist who served as an assistant surgeon in the U.S. Army during that war, first recognized a set of anxieties centering around heart symptoms. But no cardiac illness was discovered. Over the years and well into the 20th century, many names – including Da Costa’s syndrome as well as combat neurosis, shell shock, soldier’s heart, neurocirculatory asthenia, and/or simply anxiety neurosis, as my father called it – have been applied to this syndrome.

PTSD can result from severe war-related traumas as well as from traumatic experiences caused by natural and manmade disasters, assaults, and a variety of life-threatening experiences that appear to adversely affect emotional functioning. By 1980, when the DSM-III was first published, PTSD finally had been recognized as a mental disorder and was so named. Today, we know that it is important to recognize the existence of subclinical and subthreshold PTSD, which I discussed over the years as author of "The Psychiatrist’s Toolbox" column (Clinical Psychiatry News, May 2009, p. 23). These more ambiguous cases also need to be treated in an organized and codified behavior and cognitive manner (Clinical Psychiatry News, December 2004, p. 20).

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.

When I hear or read stories about posttraumatic stress disorder, two key questions come to mind: Who is doing the treatment, and do they know how to treat this disorder?

As to the first question, it seems that "counseling" is the operative word for sufferers of PTSD. We hear and read over and over that a person suffering from PTSD is referred to a counselor, sometimes a therapist, for care.

Second, do the people doing the counseling or psychotherapy know the specific treatments for PTSD that have demonstrated the most success? I’ve spoken with numerous therapists from different disciplines, and it is clear that traditional, open-ended psychotherapy (plus medication management in the case of psychiatrists) continues to dominate treatment approaches for PTSD. This is the case even though a variety of exposure, relaxation, and behavioral techniques has shown better results, according to an overview of PTSD treatment research by the Department of Veterans Affairs’ National Center for PTSD. In fact, the VA is way ahead of more traditional clinical settings in using specialized treatments for PTSD with proven track records. For example, researchers at the agency are in the process of developing initiatives to train mental health staff in the delivery of cognitive-processing therapy and prolonged exposure therapy, two treatments for PTSD that produce positive results (J. Trauma Stress 2010;23:663-73).

First Sounds of PTSD

I remember as a teenager, while in my father’s surgical office, picking up the phone and hearing on the other end what would turn out to be my first exposure to a person with PTSD, as I look back. The patient on the line, Jim, was calling in a panic and telling me – before he knew who I was – about seeing things in his head that reminded him of things that had happened on the battlefield during World War II.

My father, an eye surgeon, was in the middle of a procedure and could not come to the phone. So I continued to listen to Jim and told him that it would be alright, not knowing what else to do. Jim had been my father’s patient for several years before my dad had become an ophthalmologist, and had continued in his care after an eye injury subsequent to a traumatic event years earlier while he was in the military during the war.

After Jim recounted his story to me, my father took the phone and appeared to calm him. Later, my father explained the entire story, and how Jim had an "anxiety neurosis" and "soldier’s heart" with vivid memories (flashbacks) of a combat experience in the war where he was injured. He once saw a psychiatrist, according to my father, and was given a sedative. But it didn’t help, and Jim did not follow up with the three- or four-times-a-week explorative talk therapy, which was the main type of outpatient care at the time.

My father was clear, as he understood psychotherapy at the time, that getting Jim to lie on a couch and relive his childhood would not stop the memories (flashbacks). Rather, Jim needed some type of "here and now" reassurance that things would be okay. My dad did tell me that "one day we’ll have a medication to treat these anxiety-ridden neurotic people." To a large extent, we do have medications that work for many depressions and anxiety disorders – but not always for PTSD.

A Long History

The history of war-related trauma in this country began to be documented around the time of Civil War. Jacob Mendes Da Costa, an internist who served as an assistant surgeon in the U.S. Army during that war, first recognized a set of anxieties centering around heart symptoms. But no cardiac illness was discovered. Over the years and well into the 20th century, many names – including Da Costa’s syndrome as well as combat neurosis, shell shock, soldier’s heart, neurocirculatory asthenia, and/or simply anxiety neurosis, as my father called it – have been applied to this syndrome.

PTSD can result from severe war-related traumas as well as from traumatic experiences caused by natural and manmade disasters, assaults, and a variety of life-threatening experiences that appear to adversely affect emotional functioning. By 1980, when the DSM-III was first published, PTSD finally had been recognized as a mental disorder and was so named. Today, we know that it is important to recognize the existence of subclinical and subthreshold PTSD, which I discussed over the years as author of "The Psychiatrist’s Toolbox" column (Clinical Psychiatry News, May 2009, p. 23). These more ambiguous cases also need to be treated in an organized and codified behavior and cognitive manner (Clinical Psychiatry News, December 2004, p. 20).

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.