Psychological treatments for posttraumatic stress disorder: recommendations for the clinician based on a review of the literature

This article reviews available research data supporting the use of psychotherapy in the treatment of posttraumatic stress disorder (PTSD). The authors highlight how this evidence might inform clinical choices in treating PTSD, as well as demonstrating how assumptions based on gaps in the available literature may be misleading. The authors first discuss findings concerning a number of interventions that are commonly used in the treatment of trauma victims or patients with PTSD: critical incident stress debriefing, psychoeducation, exposure therapy, eye movement desensitization reprocessing, stress inoculation therapy, trauma management therapy, cognitive therapy, psychodynamic psychotherapy, and hypnotherapy. They also discuss a number of treatment strategies that have recently been studied in PTSD, including imagery rehearsal, memory structure intervention, interpersonal psychotherapy, and dialectical behavior therapy. PTSD is associated with significant symptomatic morbidity, although desired outcomes in clinical practice are typically related more to reduction in social, interpersonal, and occupational impairment. The most methodologically robust studies, which have typically examined cognitive or behavioral treatments, indicate that psychotherapy helps to relieve symptom severity; however, there is no consistent information about whether these interventions are helpful in improving other domains of impairment and associated disability, even though these problems are often the greatest concern to patients. Nor does the available evidence indicate when, and for whom, various psychotherapeutic interventions should be provided, or whether different modalities of treatment can and should be combined, or sequentially offered, as is often done in specialized treatment programs. Clinicians should keep these issues in mind in reviewing the literature on current (and future) clinical research. Unfortunately, the current evidence base on psychotherapy for PTSD gives only limited guidance concerning clinical choices in managing PTSD. The authors therefore provide some clinical guidelines based on the literature for clinicians treating patients with PTSD.     

The Efficacy of Psychodynamic Psychotherapy in Specific Mental Disorders: A 2013 Update of Empirical Evidence

This article reviews the empirical evidence for psychodynamic therapy for specific mental disorders in adults. The focus is on randomized controlled trials (RCTs). However, this does not imply that RCTs are uncritically accepted as the gold standard for demonstrating that a treatment works. According to the results presented here, there is evidence from RCTs that psychodynamic therapy is efficacious in common mental disorders, that is, depressive disorders, anxiety disorders, somatic symptom disorders, personality disorders, eating disorders, complicated grief, posttraumatic stress disorder (PTSD), and substance-related disorder. These results clearly contradict assertions repeatedly made by representatives of other psychotherapeutic approaches claiming psychodynamic psychotherapy is not empirically supported. However, further research is needed, both on outcome and processes of psychodynamic psychotherapy. There is a need, for example, for RCTs of psychodynamic psychotherapy of PTSD. Furthermore, research on long-term psychotherapy for specific mental disorders is required.     

Contributions of psychodynamic approaches to treatment of PTSD and trauma: a review of the empirical treatment and psychopathology literature

Reviews of currently empirically supported treatments for post-traumatic stress disorder (PTSD) show that despite their efficacy for many patients, these treatments have high nonresponse and dropout rates. This article develops arguments for the value of psychodynamic approaches for PTSD, based on a review of the empirical psychopathology and treatment literature. Psychodynamic approaches may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by currently empirically supported treatments. They may be particularly helpful when treating complex PTSD. Empirical and clinical evidence suggests that psychodynamic approaches may result in improved self-esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defenses with concomitant decreased reliance on immature defenses, the internalization of more secure working models of relationships, and improved social functioning. Additionally, psychodynamic psychotherapy tends to result in continued improvement after treatment ends. Additional empirical studies of psychodynamic psychotherapy for PTSD are needed, including randomized controlled outcome studies.     

Unrecognized Antagonisms Complicating Business Enterprise

Abstract

Reviews of currently empirically supported treatments for post-traumatic stress disorder (PTSD) show that despite their efficacy for many patients, these treatments have high nonresponse and dropout rates. This article develops arguments for the value of psychodynamic approaches for PTSD, based on a review of the empirical psychopathology and treatment literature. Psychodynamic approaches may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by currently empirically supported treatments. They may be particularly helpful when treating complex PTSD. Empirical and clinical evidence suggests that psychodynamic approaches may result in improved self–esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defenses with concomitant decreased reliance on immature defenses, the internalization of more secure working models of relationships, and improved social functioning. Additionally, psychodynamic psychotherapy tends to result in continued improvement after treatment ends. Additional empirical studies of psychodynamic psychotherapy for PTSD are needed, including randomized controlled outcome studies.     

The use of imagery in the treatment of posttraumatic stress disorder

The role of visual imagery in the symptomatology of posttraumatic stress disorder (PTSD) has not been fully appreciated. The occurrence of intrusive recollections of a traumatic event in the form of flashbacks is very common and may suggest a possible approach to treatment for many individuals with PTSD. A case is presented in which a combat veteran in psychodynamic psychotherapy for PTSD was successfully treated by capitalizing on his tendency to have flashbacks. In this instance, abreaction and subsequent working through of affective reactions to the abreaction resolved his disorder. Technical considerations and patient selection are discussed, and it is suggested that further study of the efficacy of this approach is warranted.     

The place of psychodynamic psychotherapy in the integrated treatment of posttraumatic stress disorder and trauma recovery

Psychodynamic psychotherapists treating posttraumatic stress disorder (PTSD) sufferers can draw on an accumulated body of trauma studies from their own field to guide their work. However, these reports, often based on case studies or conceptual reviews, do not have the same empirical conclusiveness as more recent evidence-based research demonstrating the efficacy of cognitive-behavioral and body-oriented therapies. In this article, a psychodynamic psychotherapist reflects on his treatment of an Israeli man who developed PTSD after enduring 4 terrorist attacks. The author shows how assimilative integration offered him a theory- and research-based model that helped him comfortably combine separate treatment interventions. He also shows how this model helped him locate with some precision the specific contribution of psychodynamic psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Cognitive therapy for posttraumatic stress disorder

The authors describe the clinical presentation of Posttraumatic Stress Disorder (PTSD) according to the cognitive-behavioral model. The vulnerability factors for the development of PTSD are discussed. The foundations of the cognitive approach to PTSD are presented and guidelines on the contends and duration of the psychotherapy is proposed.     

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.     

Development of a scale for measuring techniques in the psychotherapy of borderline patients

Studies of psychodynamic psychotherapy require an instrument to measure the application of the prescribed therapeutic techniques during ongoing treatment. The authors describe the development of such an instrument, the Therapist Verbal Intervention Inventory (TVII), designed specifically for use in the study of the treatment of patients with borderline personality disorders. The TVII was designed, in addition, to test the hypothesis that psychodynamic techniques defined at a middle level of inference could be reliably rated by trained clinicians. The authors present data on the inter-rater reliabilities and inter-rater agreements obtainable with the TVII in the hands of highly experienced clinicians and in the hands of an independent group of junior clinicians trained in its use. The TVII appears to be a potentially useful tool for monitoring psychotherapy techniques in ongoing studies of the treatment of patients with severe personality disorders. Psychiatrists at the advanced resident level or immediate postresidency level have been trained to use the TVII to rate videotaped therapy sessions reliably.     

Compulsive buying and binge eating disorder--a case vignettes

Compulsive buying behaviour has recently received long overdue attention as a clinical issue. Aim of this report is to describe treatment of two female patients diagnosed with compulsive buying disorder in comorbidity with binge eating disorder. In both cases, criteria for diagnosing of other axis I or axis II disorder were not present. Fluvoxamine was used in pharmacotherapy, and psychodynamic psychotherapy as a psychotherapeutical approach. We conclude that fluvoxamine and psychodynamic psychotherapy may be effective in treatment of compulsive buyers in comorbidity with binge eating disorder.     

Efficacy of psychodynamic short-term psychotherapy for children and adolescents with depression

Depression is highly prevalent in children and adolescents. Psychodynamic therapies are only insufficiently evaluated in this field although many children and adolescents suffering from depression are treated using this approach. Therefore, the aim of our study was to evaluate the efficacy of psychodynamic short-term psychotherapy (PSTP) for the treatment of depression in children and adolescents. In a waiting-list controlled study, 20 children and adolescents fulfilling diagnosis of major depression or dysthymia were included. The treatment group received 25 sessions of psychodynamic psychotherapy. Main outcome criterion was the Impairment-Score for Children and Adolescents (IS-CA) as well as the Psychic and Social-Communicative Findings Sheet for Children and Adolescents (PSCFS-CA) and the Child Behavior Checklist (CBCL), which were assessed at the beginning and the end of treatment. The statistical and clinical significance of changes in these measures were evaluated. There was a significant advantage of the treatment group compared to the waiting group for the IS-CA. The effect size of the IS-CA total score was 1,3. In contrast to the treatment group, where 20% of the children showed clinically significant and reliable improvement, no subject in the waiting-list control group met this criterion. Comparable results were found for the PSCFS-CA and for the internalising score assessed with the CBCL. The results show that psychodynamic short-term psychotherapy (PSTP) is an effective treatment for depressed children and adolescents. Still, some of the children surely require more intensive treatment.     

An augmented model of brief psychodynamic interpersonal therapy for patients with nonepileptic seizures

Nonepileptic seizures (NES) are one of the most common functional (medically unexplained) symptoms seen by neurologists. Although most experts consider psychotherapy the treatment of choice, few therapeutic approaches have been described in detail. Given that NES occur in the context of many different psychopathologies, it remains uncertain whether there is 1 intervention that can benefit all comers or whether it is necessary to offer individualized psychotherapy. This article describes an approach grounded in psychodynamic interpersonal therapy but augmented with elements of cognitive-behavioral therapy, somatic trauma therapy, and the involvement of caregivers and family members. The approach was developed in the setting of a specialist psychotherapy service for patients with functional neurological disorders presenting to British hospital-based neurologists. The authors have previously shown that it is associated with significant improvements in psychological functioning, health-related functioning, and a symptom count. Three case reports illustrate how the treatment can be adapted to meet different patients' needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Cultural influences in psychotherapy with refugee survivors of torture and trauma.

A selective review of the literature describing treatment of refugee survivors of torture and trauma revealed that approaches to psychotherapy used in treating South American patients differed from those used in treating Indochinese patients. South American patients were receptive to psychodynamic psychotherapeutic approaches that focused on detailed recollection of past trauma. Indochinese patients responded to a broader-based rehabilitation approach that could include psychotropic medication, supportive psychotherapy, and assistance in meeting practical needs. The authors suggest that many of the differences in treatment of the two groups may be attributed to cultural factors, with South American patients reflecting an affinity for the Western philosophical assumptions in which psychodynamic therapy is rooted and Indochinese patients reflecting a cultural background that values responsibility to the group, deference to authority, and restrained modes of emotional expression.     

Treatment of traumatized refugee children with Eye Movement Desensitization and Reprocessing in a psychodynamic context

This study examines the effects of a psychodynamic approach of Eye Movement Desensitization and Reprocessing (EMDR) in treatment of traumatized refugee children. Among a child psychiatric outpatient refugee team, 13 children with post-traumatic stress disorder (PTSD), were treated by EMDR incorporated in a traditional psychodynamic therapeutic approach. The Posttraumatic Stress Symptom Scale for Children (PTSS-C) and the Global Assessment of Functioning (GAF) were administered before and after the treatment, to measure the effects. After treatment, a significant improvement was noticed in the functioning level and all PTSS-C scales, mostly in re-experiencing and least in the avoidance symptoms. The improvement in the functioning level was significantly correlated with the reduction of the PTSD-non-related and the depression, but not with that of the PTSD-related symptoms. Used in a psychodynamic context, EMDR is suggested to be effective treatment for traumatized refugee children. Our findings support the hypothesis of child-specific criteria for PTSD.     

Testing psychodynamic psychotherapy skills among psychiatric residents: the psychodynamic psychotherapy competency test

OBJECTIVE: Training in psychodynamic psychotherapy remains a core requirement of psychiatric residency training programs, yet no standard measures of competency exist to document residents' knowledge and skills in this area. To address this issue, the authors developed a written test of applied knowledge of psychodynamic psychotherapy technique and theory, the Psychodynamic Psychotherapy Competency Test. Their goal in this article was to evaluate the validity of this test. METHOD: The test was given to a group of 36 psychoanalytic experts and 206 residents in their second, third, and fourth psychiatric postgraduate years from 10 programs located in different parts of the United States. Program directors provided information on the number of hours of psychodynamic didactic teaching, supervision, and resident-conducted psychodynamic psychotherapy and rated the psychodynamic psychotherapy skills of residents in their fourth postgraduate year on the basis of cumulative supervisor reports. RESULTS: There were significant differences in test performance between residents and faculty experts and between residents in their second and fourth postgraduate years: more advanced residents and experts had progressively better scores. The mean scores of fourth-year residents in different programs differed significantly, but the scores of second-year residents did not. Higher test scores were positively associated with both number of hours of resident-conducted psychotherapy and number of hours of supervision. Among fourth-year residents, test scores correlated significantly with program director evaluations. CONCLUSIONS: This initial study supports the validity of the Psychodynamic Psychotherapy Competency Test as well as the feasibility of testing psychotherapy skills in a standardized fashion.     

Psychodynamic psychotherapy of ADHD: A review of the literature

Contributions of psychodynamic psychotherapy to the treatment of children with attention deficit hyperactivity disorder (ADHD) have been sparse. However, mixed results of other interventions, including behavior therapy and medication, call for a systematic examination of psychodynamic contributions to treatment of ADHD children. A systematic review of the literature on psychodynamic psychotherapy with ADHD children yielded a combination of 23 case studies, research reports, and theoretical writings. Questions relevant to the practice of psychodynamic psychotherapy were the focus and included a review of psychodynamic diagnosis of ADHD, theoretical orientations of psychodynamic psychotherapy, identification of core treatment issues, clinical examples, and theoretical perspectives on therapeutic change as well as practice techniques. A review of 231 abstracts resulted from key word searches including ADHD, Psychotherapy, Psychodynamic, and Psychoanalytic. Once inclusion criteria were met, the information from the literature was organized according to categories reflecting the review's focus. Findings of the review are provided to guide psychodynamic psychotherapists in their treatment of ADHD children. Recommendations for future individual and group studies are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Current mental health in women with childhood sexual abuse who had outpatient psychotherapy.

PURPOSE: This study from Norway examines mental health status of women with child sexual abuse (CSA) who formerly had outpatient psychotherapy for anxiety disorders and/or depression. The relative contributions of CSA and other family background risk factors (FBRF) to aspects of mental health status are also explored. SUBJECTS: At a mean of 5.1 years after outpatient psychotherapy, 56 female outpatients with CSA and 56 without CSA were personally examined by an independent female psychiatrist. Systematic information about current mental health and functioning was collected by structured interview and questionnaires. RESULTS: Among women with CSA 95% had a mental disorder, 50% had PTSD, and mean global assessment of functioning (GAF) score was 61.8+/-10.6. In contrast, 70% of women without CSA had a mental disorder, 14% had PTSD, and mean GAF 71.2 + 8.5. GAF and trauma scale scores were mainly determined by CSA, while FBRF mainly influenced the global psychopathology and dissociation scores. DISCUSSION: We have little knowledge on the mental health status at long-term in women with CSA who had psychotherapy. This study found their mental status to be rather poor, and worse than that of women without CSA who had psychotherapy for the same disorders. From the broad spectrum of mental disorders associated with CSA, this study concerns only women treated as outpatients for anxiety disorders and/or non-psychotic depressions. CONCLUSION: Women with CSA showed poor mental health at long-term follow-up after treatment. The fitness of the psychodynamic individual psychotherapy given, or to what extent treatment can remedy the consequences of such childhood adversities, is discussed.     

Treatment manuals for long-term psychodynamic psychotherapy and psychoanalysis

An essential component of any clinical trial is the need to deliver treatment in a fashion that is uniform and that can be replicated. The advent of treatment manuals in psychotherapy research has been an important step towards meeting the standard of uniform treatment. Defining long-term psychodynamic treatments as those lasting a year or longer, there are only three published manuals for long-term psychodynamic psychotherapy: supportive-expressive psychotherapy (SE), transference focused psychotherapy (TFP), and mentalization-based treatment (MBT). This article reviews and compares these treatment manuals across six dimensions: 1) frame of reference and conceptualization of disorder(s) treated, 2) mechanisms of change, 3) treatment frame and format, 4) therapist stance and therapeutic relationship, 5) specifics of clinical technique and 6) ratings of adherence and competence. Despite the disparate nature of the three manualized treatments, a number of core features are shared by SE, TFP and MBT. The successful manualization of the three long-term psychodynamic psychotherapies reviewed suggests that psychoanalytic treatments could also be manualized.     

Post-traumatic stress disorder: Hypotheses from clinical neuropsychology and psychopharmacology research

Characteristic features of post-traumatic stress disorder (PTSD) include intrusive memories, avoidance, memory and concentration difficulties, and hyperalertness. Neuropsychological investigations of individuals with PTSD have suggested global and specific impairments of performance on standardized tests of memory. The use of the Emotional Stroop test has shown that trauma-related words are a sensitive measure of clinical state in PTSD patients. The Stroop paradigm has also shown that patients with PTSD appear to be characterized by implicit, explicit and autobiographical memory impairment. Available treatments for chronic post-traumatic stress disorder include cognitive-behaviour therapy, psychodynamic therapy and pharmacotherapy. Whereas drug treatment alone can rarely alleviate the suffering in PTSD, it appears to be most useful as an adjunct to psychotherapy. Tricyclic antidepressants are generally thought to be effective in alleviating symptoms, including nightmares, depression, sleep disorders and startle reactions, but are less able to relieve numbing. On the other hand, selective re-uptake blockers may be effective in decreasing numbing. However, rigorous clinical trials with double-blind placebo-controlled designs need to be performed to confirm these results. With new scientific discoveries in the understanding of PTSD, a new generation of pharmacological treatment is likely to emerge. (Int J Psych Clin Pract 2000; 4:3-18)