23 Mar 2015
Anxiety is defined as being an unpleasant emotional state characterised by fearfulness and unwanted and distressing physical symptoms and thoughts Anxiety 1 Lecture, Slide 4 and disorders including phobias, Panic Disorder and Obsessive Compulsive Disorder (OCD), amongst others, all fall under the bracket of anxiety disorders. A survey conducted by the World Health Organisation (WHO) found that out of 25,000 people surveyed across 14 different countries, 8% had an anxiety disorder (Anxiety 2 Lecture). This essay will focus solely on Post Traumatic Stress Disorder (PTSD) and the varied treatments offered to help someone with the disorder.
PTSD is an anxiety disorder developed after a person has experienced a threatening event or situation where they have either witnessed or been the victim to serious injury, death or threatened death, leaving them in a position of feeling in constant danger or vulnerable in the world around them. These feelings can be brought on by either a one off event; for example a car accident or assault, or by continuous trauma including abuse or domestic violence (Anxiety 2 PowerPoint). Lifetime prevalence rates in the general population are around 5% for men and 10% for females, it is thought to affect 30% of those who experience a traumatic event and PTSD can be developed at any age, including childhood (NHS website). Gender differences may play a part in these statistics with women perhaps being better at reporting their symptoms, therefore meaning different treatments vary on effectiveness depending on the gender of the patient. Certain risk factors may also play a part in the likelihood of a person developing PTSD including pre morbid history, such as early separation in childhood leading to a possible disruption in attachment or a family history of anxiety in general or PTSD (Anxiety 2 PowerPoint).
PTSD is thought to be caused by Cognitive Behavioural factors with conditioning playing a large role in the development of the disorder; this is due to an unconditioned stimulus being associated with the negative feelings or anxiety felt in the traumatic situation (Anxiety 2 PowerPoint). For example, if a person was walking alone and was attacked they would associate walking alone with the fear felt when they were attacked; sparking the stress and anxiety felt when a person has PTSD. Cognitive factors are also thought to be involved due to the loss of control experienced; this can lead to changes in a person's outlook on life and is perhaps linked to the symptoms of depression often seen in people with PTSD (Anxiety 2 PowerPoint).
PTSD can be very disruptive to a person's life with symptoms including distressing memories, flashbacks and dreams; these can often be triggered by stimuli associated with the event. Withdrawal can also be a symptom of the disorder with the person avoiding people, places and objects that may remind them of the event; this can lead to a disconnection between the person and society. Physiological symptoms add to the feelings of anxiety with increased heart rate and muscle tension (Behavioural Health Evolution PDF). This makes treatment more complex with all these different aspects of the disorder needing to be addressed. Guilt and aggression are also common signs as to a person with PTSD; this can be due to a build up of stress over the traumatic event. For example, in a car accident when one person survives and the other does not, this may leave the survivor to experience guilt as to why they survived and not the other person and perhaps aggression due to the build up of stress leading to a 'fight or flight' evolutionary response, often resulting in violence. PTSD is diagnosed using the Diagnostic and Statistical Manual of Mental Health Disorders (DSM IV) where a person has to meet certain criteria stated to be diagnosed with the disorder.
There are a range of treatments available for PTSD, including drug therapy, group psychotherapy and social intervention. Cognitive Behavioural Therapy (CBT) is one of the main psychological treatments available to try to tackle PTSD. CBT is used as a basis to try and modify the way people behave and is used widely across many mental health problems to try and resolve them. Firstly people's initial thoughts are identified when confronted with certain situations, these beliefs then lead to the consequential behaviour which is quite often the issue (Royal College of Psychiatrists website). For example, for patients with PTSD, somebody frowning at them could be interpreted as a potential attacker if they have been assaulted. However, when the person is presented with other possible reasons for this behaviour, such as that person received some bad news, they may begin to realise that some of their beliefs need to be modified. CBT works by targeting these thoughts and helping the patient to overcome them. Patients are also taught relaxation techniques and therefore if relapse were to occur, often patients find it much easier to deal with it themselves. However, CBT requires motivation from the patient as it is time consuming and the person needs to be prepared to tackle their problems head on (Royal College of Psychiatrists website).
Research into the effectiveness of CBT when treating PTSD has been conducted by Taylor et al. (2001). Here 50 participants completed a 12 week course of CBT having been involved in a road traffic collision. 45 of these participants also completed a 3 month follow up. They received 6 stages of CBT including an education in how CBT works, cognitive restructuring, relaxation and exposure. Results found that the participants had "significant reductions in PTSD symptoms" (Taylor et al, 2001) following the treatment. This shows how CBT is effective not only to reduce symptoms in the short term, but also that the person can maintain the results. Hinton, Hoffman, Rivera, Otto and Pollack (2011) also found CBT to be effective in managing a treatment resistant type of PTSD in Latino women. 12 participants received muscle relaxation therapy and 12 received a form of CBT that was culturally adapted. The participants were assessed before and after treatment and then again at a 12 week follow up. Results showed that the women receiving the culturally adapted CBT improved significantly more in symptoms than those who were being treated using the muscle relaxation (Hinton et al., 2011). This research demonstrates how CBT can be used cross-culturally to treat the disorder and therefore could be argued that due to its potential to be widely used, it is a more effective way to treat PTSD. However, only women were used in this study so it is not known how men would react to being treated in the same way, therefore limiting the study to only being generalised to females. Gender has been found to be a factor in the effectiveness of CBT (Felmingham & Bryant, 2012). This study comprised of over 100 males and females who received either exposure therapy or exposure and cognitive restructuring therapy. There were no gender differences in the reduction of symptoms immediately after but, in a 6 month follow up, men displayed more severe symptoms of PTSD than women (Felmingham & Bryant, 2012). This study demonstrates how gender differences can affect the outcome of certain therapies in the longer term and therefore would need to be taken into account when treating a patient with PTSD.
Group therapy is also argued to be an effective way of treating PTSD as within a group people are able to help one another through the trauma and as they are all going through the same thing. This is thought to be because all of the group members will have had a similar experience and therefore are able to relate to each other, helping them to see that their symptoms are normal for what they have been through (Schwartz, 1990). Khoo, Dent and Oei (2011) conducted a study into group CBT in PTSD patients who had been in the military. Participants were Australian combat veterans who undertook a 6 week programme of group CBT and were assessed again after 3, 6 and 12 months. It was found that there were statistically significant and sustained improvements in the first year after the therapy (Khoo, Dent and Oei, 2011). This demonstrates how people may benefit from being around those who are similar to themselves and that seeing their improvements can help aid their own recovery.
Eye Movement Desensitisation and Reprocessing Therapy (EMDR) is another psychological therapy used in the treatment of PTSD. It is based upon the theory that the memory of the traumatic event has got 'stuck' in the brain meaning that the person constantly has the feelings of anxiety and stress related to that memory (Edward Sim - PTSD Treatments website). EMDR works by getting the patient to imagine the distressing event and the thoughts and feelings associated with it, then the patient will be asked to start the eye movements, often from side to side (EMDR UK and Ireland website). This process is thought to shift the memory into a file where it is no longer an ongoing threat to the person and therefore reduces the symptoms of PTSD (Edward Sim - PTSD Treatments website).
Research has supported the use of EMDR therapy including a study conducted by Nijdam, Gersons, Reitsma, de Jongh and Olff (2012). In this study there were 140 participants with 70 assigned to be treated by CBT and the remaining 70 by EMDR. Nijdam et al. (2012) found that despite both treatments being equally effective in reducing the symptoms of PTSD, the EMDR therapy led to a much quicker reduction in symptoms. This could show how EMDR is a faster relief from the disorder and therefore perhaps more effective. This is because the symptoms of PTSD are very disruptive to a person's life so the quicker the person can be put at ease, the better.
Research into the effectiveness of the different methods of treating PTSD is heavily weighted towards the use of psychological treatments such as CBT and EMDR as these therapies have been supported by many studies. Van Etten and Taylor (1998) conducted a Meta analysis from 61 studies looking into the outcome of treatments for PTSD; this contained those researching into drug therapy and psychological therapies including behaviour therapy, EMDR, relaxation training and hypnotherapy. The results for these were compared with that of control therapies such as placebo pills. It was found that psychological therapies were more effective than drug therapies in reducing the symptoms of PTSD and, that after a 15 week follow up, the results for EMDR and behaviour therapy were maintained (Van Etten & Taylor, 1998). This adds support to the argument that psychological therapies are not only extremely effective in the treatment of PTSD, but that these results can be upheld in the long term.
PTSD is a disorder causing a huge impact on a person's life and so needs to be treated in an appropriate manner. Psychological therapies aim to help a person overcome the disorder whilst, in the case of CBT, allowing the person gain control of their symptoms and giving them the power to prevent relapse. In this respect, psychological therapies are very successful and, as the research described in this essay demonstrates, there is strong support for the use of psychological therapies. However, this essay has solely focused on the treatment of PTSD which is only one of many anxiety disorders; therefore the research is limited to representing the effectiveness of psychological treatments for PTSD and not necessarily of other anxiety disorders. Nevertheless, there is still strong support for the use of psychological therapies such as that put forward by Van Etten and Taylor (1998) showing that therapies such as CBT and EMDR are more effective than the use of drugs. For that reason, it can be concluded that the use of psychological therapies when treating PTSD are an appropriate and effective method due to the amount of evidence supporting their use.
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