Post-traumatic stress disorder (PTSD) is one of the most debilitating psychological conditions. The disorder may affect individuals from diverse backgrounds who were exposed to different traumatic and violent experiences at some point in their lives. PTSD is associated with multiple comorbidities, including anxiety, depression, chronic pain syndromes, substance abuse disorders, obesity, and heart diseases (van der Kolk et al., 2014). Besides that, PTSD substantially and negatively affects one’s performance of daily activities and significantly increases the risk of suicide (Pearce, Haynes, Rivera, & Koenig, 2018). Therefore, it is essential to implement effective treatment methods for those who suffer from this adverse condition in order to provide them with a chance to come back to normal life.
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Nowadays, many types of PTSD interventions are available to patients. The majority of them are either pharmacological or psychotherapeutic in nature. However, the effectiveness of such traditional remedies as antidepressants and cognitive-behavioral therapy (CBT) is currently under question. For instance, the results of a large control trial summarized by van der Kolk et al. (2014) revealed that 78% of participants still had PTSD symptoms six months after completing a behavioral therapy. Moreover, as reported by Hanling et al. (2016), the existing evidence-based PTSD treatments are effective only in 30-40% of cases. Therefore, besides exploring traditional treatments, a lot of contemporary studies investigate the effectiveness of alternative interventions as well.
Considering the ongoing debate on the effects of various PTSD interventions, the present paper will evaluate research findings on multiple types of treatment methods with the purpose of comparing their effectiveness. To attain the formulated goal, the paper will review high-quality peer-reviewed studies dedicated to the investigation of both conventional and unconventional treatment methods. The narrative will be arranged in three sections: psychotherapy, pharmacology, and alternative remedies. As part of each theme, the content and effects of the studied interventions will be described, and the comparison of researchers’ hypotheses, goals, and methods will be provided. In the final section, the effectiveness of all the explored interventions will be discussed to summarize the results of the present literature review.
A great variety of psychotherapies exist today, and many of them have a lot to offer for individuals with PTSD. A few possible treatments that were investigated in recent research studies include CBT, Psychodynamic Psychotherapy (PTD), Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive Processing Therapy (CPT). These psychological and cognitive-behavioral interventions are characterized by different approaches. To comprehend those differences, the content of the analyzed treatment measures will be briefly explained in the present section. When doing so, the descriptions of methods and procedures utilized by the authors of the selected studies will be primarily referred to.
Procedures and Study Methods
CBT and PTD were researched in a study by Levi, Bar-Haim, Kreiss, and Fruchter (2015), who had a goal of comparing the effectiveness of these two methods. Levi et al. (2015) used two samples of combat veterans with chronic PTSD: 148 individuals were recruited for 24 weekly CBT sessions and 95 persons for 50 weekly PTD sessions. Noteworthily, participants were assigned by professional therapists to a treatment method non-randomly, based on their mental characteristics. Those with more severe social and personality issues received PTD, which had a goal of helping patients to restore their personal integrity and regain control of life experiences. This treatment method comprised three stages: 1) development of a therapeutic alliance between therapists and their clients, 2) analysis of patients’ unconscious problems associated with an experienced trauma, and 3) termination that involves a free expression of negative emotions and an evaluation of therapy results.
As for CBT implemented by Levi et al. (2015), it included five phases. The therapy started with psycho-education aimed to comprehend the impacts of experienced trauma and proceeded to the reconstruction of the traumatic event and the identification of mental, emotional, and cognitive blocks. The final stages of CBT involved the exploration of the meaning of a chosen traumatic event through in vivo exposure, a summary of the therapy, and termination. In spite of differences in the two treatment methods and sample populations employed by Levi et al. (2015), they were evaluated by using the same analytical methods and instruments, including pre-and post-treatment analyses, as well as intention-to-treat analyses during the follow-up stage.
Another intervention type, EMDR, was examined in the study by Acarturk et al. (2015), who examined the therapy’s effectiveness in a sample of randomly selected Netherlands-based Syrian refugees with PTSD symptoms (n=15). The therapy consisted of four stages, including history discussion and treatment planning, education about EMDR, recollection of traumatic memories, and identification of negative cognitions. The seven-week EMDR course ended with desensitization by performing horizontal eye movements while recalling a target memory and the development of positive cognitions. When analyzing intervention results, the researchers compared the exposed group of participants to a control sample (n=14) comprised of individuals who were enrolled in a wait-list and did not receive any treatment. Similar to Levi et al. (2015), Acarturk et al. (2015) collected preliminary information about participants’ PTSD symptoms and consequently contrasted that data set with post-treatment and follow-up outcomes.
The last therapy type that will be discussed in this section is CPT, which was explored by Pearce et al. (2018). In their case study, Pearce et al. (2018) examined whether the integration of patients’ spiritual values and beliefs into a CPT course can help them cope well with moral injury and distress whose role in PTSD progression and treatment are currently understudied. The intervention consisted of twelve sessions, including psycho-education; discussion of spirituality, compassion, and traumatic events; exploration of negative cognitions linked to one’s moral injury; and implementation of spiritual resources to restore trust and self-esteem. To evaluate the results, Pearce et al. (2018) compared patients’ PTSD diagnosis scores before and after the treatment.
Importance and Implications
As the conducted review reveals, different study methods and designs were employed by researchers and described in the selected articles. These distinctions are important to note since they are associated with disparate levels of research credibility. For instance, non-random sampling utilized by Levi et al. (2015) may indicate that the results of their study are not generalizable to the general population. At the same time, the findings by Pearce et al. (2018) seem to be less trustworthy than those received by Acarturk et al. (2015) and Levi et al. (2015) because the former obtained evidence by using the case study design with only one individual in the sample. These limitations will be considered in the further comparison of treatment effectiveness in the final section of the present literature review.
Nowadays, many classes of drugs can be taken as part of pharmacologic therapy aimed to combat PTSD. As stated by Stein (2019), patients can frequently be resistant to psychotherapy. Thus, the use of various medications can help to increase the efficacy of interventions and may be particularly effective in alleviating acute PTSD symptoms (Stein, 2019). The therapies that will be reviewed in this section involve the use of such drugs as ketamine and stellate ganglion block (SGB).
Procedures and Study Methods
Intravenous ketamine injections are a novel pharmacological intervention method for PTSD. According to Feder et al. (2014), ketamine is an antagonist of the glutamate N-methyl-d-aspartate receptor, which means that it works as an anesthetic and painkiller. Due to the features of the medication, it is frequently used for the treatment of patients with resistant depression symptoms, which makes ketamine a potentially effective remedy against PTSD (Feder et al., 2014). The efficacy and safety of this drug are explored in the study by Feder et al. (2014).
The authors of the selected study utilized a double-blind, randomized control trial design. They contrasted the results obtained from forty-one patients with chronic PTSD who were randomly exposed to either a 0.5 mg/kg dose of ketamine hydrochloride or a 0.045 mg/kg dose of placebo (midazolam) for more than 40 minutes. The assessment of drug safety and efficacy was conducted 40, 120, and 240 minutes after the injection, as well as on the second, third, and seventh days after the procedure. Noteworthily, all participants were asked to avoid using any psychotropic drugs, alcohol, and other substances during the trial period in order to measure the duration of ketamine effects. Those patients whose PTSD diagnosis score remained significantly low as per the Clinician-Administered PTSD Scale (CAPS) for two weeks after the drug infusion was freed from repeating the procedure.
Like ketamine infusions, SGB is a non-traditional pharmacologic treatment method for PTSD. The administration of SGB helps to both inhibit efferent sympathetic effects and relieve pain in the upper extremities and the head (Hanling et al., 2016). Hanling et al. (2016) explored the drug’s effectiveness in terms of PTSD treatment in their double-blind, randomized control trial since a few of the previous studies reported the beneficial effects of the medication in cases of depression. The researchers recruited a total number of forty-two individuals with both combat-related and combat-unrelated PTSD who had the CAPS score of 40 or higher. The participants were randomly assigned to either an SGB injection or a sham injection (placebo). Those in the sample exposed to the treatment of interest received an injection of 5 mL of 0.5% ropivacaine in the area above the right C5 or C6 vertebra. The same techniques and procedure steps, including ultrasound guidance and injection of moderate sedation medication, were utilized for the control group. Consequently, Hanling et al. (2016) conducted assessments one week and one month after the treatment and compared the primary and post-treatment outcomes in both study populations.
Importance and Implications
Both the selected studies employed similar study designs and almost the same sample sizes. Their main advantage is the double-blinded randomization, which means that both researchers and participants were not aware of what type of intervention was received by each patient in the trial. Such an approach allows minimizing the occurrence of behavioral changes that can impact the outcomes of the investigation (“Placebo and drug kits,” 2017). Based on this, it is valid to say that the findings obtained by Hanling et al. (2016) and Feder et al. (2014) are characterized by a significant level of validity and credibility, which will speak in favor of these studies in the further comparative discussion of interventions’ effectiveness.
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Today many patients and medical practitioners show an increasing interest in the use of alternative intervention methods, which include different types of physical exercising, homeopathy, naturopathy, and some more non-traditional treatment types. Many of these interventions are considered to be safer than conventional pharmacotherapies since they normally do not induce any severe adverse side effects (Engel et al., 2014). Besides that, some studies demonstrated that alternative treatments, such as yoga and acupuncture, can significantly alleviate the symptoms of such physical and psychological conditions as anxiety, depression, stress, asthma, hypertension, and diabetes (Engel et al., 2014; van der Kolk et al., 2014). The mechanisms of some alternative therapies’ function also imply that they can have beneficial effects in the case of PTSD. Therefore, such remedies as yoga, acupuncture, and aerobic exercise will be reviewed in the present section of the literature review.
Procedures and Study Methods
Aerobic exercise as a therapy for PTSD was investigated in a randomized control trial by Fetzner and Asmundson (2014). Based on the findings of a few previous studies, the researchers hypothesized that attentional focus inherent with physical exercising has a therapeutic effect, allowing patients to become distracted from negative thoughts and feelings. To verify this assumption and assess the effectiveness of aerobic exercise as a treatment method for PTSD, Fetzner, and Asmundson (2014) recruited thirty-three patients who were expected to complete a two-week course of stationary biking exercise.
The participants were randomly assigned to different groups with the purpose to either draw their attention to somatic sensations associated with the exercise (Group 1) or distract from those somatic sensations by making them watch a documentary during the intervention (Group 2). At the same time, Group 3 was allowed to complete the exercising sessions without any distractions or introspective prompts. To compare the outcomes in the three samples, Fetzner and Asmundson (2014) used data collected before the exercise course, as well as the results of immediate post-treatment assessment, one-week follow-up, and one-month follow-up. The differences in participants’ PTSD characteristics and previous fitness levels were considered during the analysis to eliminate the potential impacts of these variables on final study findings.
As a form of physical exercise, yoga is associated with a similar attentional focus as aerobic exercise. However, yoga also involves an element of mindfulness, which is linked to some promising favorable effects in terms of emotional regulation (van der Kolk et al., 2014). Considering the abovementioned assumptions, van der Kolk et al. (2014) investigated the effects of yoga therapy in the sample of sixty-four adult women with PTSD (CAPS score > 45). The participants were randomly assigned to either a ten-week yoga program designed by certified yoga instructors or to a supportive female health education course. While the first treatment option drew women’s attention to bodily sensations during physical activity sessions and incorporated meditational practices, the second one only instructed the involved women on self-care practices. To compare the effects in two population groups, van der Kolk et al. (2014) used both self-reported and objective assessment instruments before, during, and after the treatment. The researchers employed rigorous statistical analysis tools to reveal changes in symptom trends during both interventions.
The last alternative remedy that will be reviewed in the present section is acupuncture, which was explored in the study by Engel et al. (2014). According to the results of previous research projects, acupuncture affects the limbic system, prefrontal cortex, and autonomic nervous system, which are involved in the development of some PTSD symptoms (Engel et al., 2014). However, the mechanisms through which acupuncture works are not entirely understood, which makes the study of the intervention’s effects particularly important. Thus, Engel et al. (2014) compared whether the combination of a four-week acupuncture course with usual PTSD treatment (UPC) (n=28) would induce better patient outcomes compared to UPC alone (n=27). The exposed sample group received eight acupuncture sessions during which thin needles were inserted at certain bodily points in their subcutaneous tissues by professional acupuncturists for 15-30 minutes. As for UPCs, they comprised such traditional interventions as pharmacology and psychotherapy and differed in the case of every participant. Pre- and post-treatment outcomes were compared for both population groups, and differences in UPCs were registered to minimize the chance of outcome bias.
Importance and Implications
The three studies discussed above employed the same research design, which is associated with a substantial degree of validity. Nevertheless, the researchers used different sample sizes, and their study populations significantly differed in terms of demographic characteristics. For example, van der Kolk et al. (2014) focused on the analysis of female participants and, therefore, it is not clear whether their findings can be generalized to males as well. At the same time, Engel et al. (2014) reported a small sample size as the main limitation of their study, whereas the differences in participants’ UPCs could affect their study outcomes as well. Sample groups investigated by Fetzner and Asmundson (2014) were also relatively small and, moreover, comprised an unequal number of patients (thirty-three, twenty-five, and eight). In addition, their study lacked a non-exposed control group, which makes it difficult to tell whether the changes in participants’ conditions were due to the intervention of some other factors. Overall, it means that the findings of each of the three studies may need some further verification through further research with enhanced methods.
Comparison of Treatment Effectiveness
The majority of the reviewed studies revealed that the studied interventions were associated with statistically significant improvements in patients’ health conditions. For instance, the research of CBT and PTD conducted by Levi et al. (2015) revealed that both interventions led to better functioning levels and a considerable decline in PTSD and depression symptoms. Levi et al. (2015) observed that right after the treatment, 35% of individuals exposed to CBT were in remission compared to 45% of persons exposed to PTD. Moreover, 33% of CBT patients were still in remission during the eight-to-twelve-months follow-up compared to 36% of PTD recipients (Levi et al., 2015). It means that the differences in the positive effects of these psychotherapies are insignificant and can be considered long-term.
EMDR demonstrated some lasting positive results in reducing both PTSD and depression symptoms as well. For example, the severity of PTSD symptoms as per the Impact of Event Scale-Revised in the exposed sample group had dropped from the score of 64.80 during pre-treatment to 22.87 during posttreatment (seven weeks), and 18.93 during a four-week follow-up evaluation (Acarturk et al., 2015). At the same time, the outcomes in the non-exposed control group remained almost unchanged: 56.93 during pre-treatment and 54.21 during post-treatment (Acarturk et al., 2015). Acupuncture was associated with similar effects based on the results of the PTSD Checklist assessment. Those exposed to acupuncture and UPC together showed a decline from the score of 58.1 (pre-treatment) to 38.8 (four weeks) that they managed to maintain even during the twelve-week follow-up (Engel et al., 2014). In contrast, patients who received only UPC in the research by Engel et al. (2014) did not show any significant short-term or long-term positive changes.
Persistent favorable effects in terms of PTSD-related trauma regulation were also observed in patients who participated in a yoga course. While the control group that merely received education exhibited positive changes in symptom management during the intervention, only yoga class participants were able to maintain those changes (van der Kolk et al., 2014). At the same time, two other promising intervention methods, Ketamine infusions and a two-week aerobic exercise program were linked to short-term reductions in PTSD symptoms. The research by Fetzner and Asmudson (2014) revealed that 89% of participants in the total study population showed a significant decline in PTSD severity after exercising regardless of whether they received cognitive distractions or not. Ketamine intake also led to a drastic decline in the severity of PTSD symptoms, and the positive effect remained strong within 24 hours after injection (Feder et al., 2014). However, the findings suggest that in the latter two interventions, the gains can quickly be lost if patients stop the treatment.
It seems that the evidence obtained by Levi et al. (2015) is the most reliable since the researchers utilized the biggest sample sizes compared to other authors whose studies were discussed. Nevertheless, it is valid to say that the use of control groups by Acarturk et al. (2015), van der Kolk et al. (2014), and Feder et al. (2014) contributed to the reliability of their findings as well regardless of the small samples. At the same time, evidence received by Engel et al. (2014) and Fetzner and Asmudson (2014) has lower quality. The former failed to register the differences in participants’ UPCs, whereas the latter did not compare aerobic exercise intervention with a non-exposed group or a population receiving a different/regular treatment. Thus, it is essential to explore acupuncture and aerobic exercise further in the studies with better research designs.
Finally, the literature review results suggest that interventions associated with less positive outcomes are SGB and spiritually integrated CPT. Although Hangling et al. (2016) utilized rigorous study methods, they did not reveal any significant differences in the effects of SGB and sham injections on patients with PTSD. As for the CPT, a case study design employed by Pearce et al. (2018) was not enough to establish the effectiveness of the treatment. Pearce et al. (2018) indicated that the method of their interest might be beneficial in the treatment of PTSD since it targets patients’ moral and spiritual resources. Still, further empirical comparative studies and control trials are required to verify their hypothesis.
The literature review indicated that patients with PTSD now have access to many effective interventions. Psychotherapies (CBT, PTD, and EMDR) and such alternative treatments as yoga are particularly promising since their long-term effectiveness is verified by empirical evidence obtained in high-quality studies. Ketamine injections are also advantageous in terms of reducing acute PTSD symptoms. However, as a pharmacologic treatment, Ketamine may be associated with adverse side effects that are yet to be explored longitudinally. Overall, it is valid to conclude that in order to increase the chance of positive treatment outcomes, individuals with PTSD and their healthcare practitioners must consider combining a few of the discussed interventions. Even those methods whose effectiveness remains under question due to the identified research design limitations can potentially relieve some PTSD symptoms and improve one’s quality of life.
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