“Watkins et al. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions.” – Article summary

Trauma-focused interventions refer to interventions that directly address memories of the traumatic event or thoughts and feelings related to the traumatic event (e.g. EMDR). Non-trauma focused interventions refer to interventions that do not directly address memories of the traumatic event or thoughts and feelings related to the traumatic event (e.g. stress inoculation training).

A combination of medication and psychotherapy is not recommended for the treatment of PTSD. Treatment of PTSD needs to focus on the focus of reexperiencing symptoms. This is the index trauma. Treatment drop-out appears to be lower in present-centred treatments than in trauma-specific treatments.

There are several strongly recommended treatments for PTSD:

1. Prolonged exposure (PE)
   This treatment suggests that traumatic events are not processed emotionally at the time of the event. It attempts to alter the fear structures. Treatment typically consists of 8-15 sessions and includes psychoeducation about PTSD (1), breathing retraining (2), in vivo exposure (3) and imaginal exposure (4).
2. Cognitive processing theory (CPT)
   This treatment allows for cognitive activation of the memory while identifying maladaptive cognitions that are the result of the trauma. It aims to shift beliefs towards accommodation. Treatment typically consists of 12 weekly sessions. The patients attempt to identify assimilated and overaccommodated beliefs and learn new skills to challenge these beliefs. The skills are introduced through establishing the connection between thoughts, feelings and emotions related to individual’s maladaptive cognition to an event.
3. Cognitive behavioural therapy (CBT)
   This treatment aims to change negative appraisals (1), correct the autobiographical memory (2), and remove problematic behavioural and cognitive strategies (3). It includes exposure and cognitive techniques (e.g. cognitive restructuring).

The prolonged exposure treatment is based on the emotional processing theory. This theory states that fear is represented in memory as a cognitive structure that includes representations of the feared stimuli (1), the fear responses (2) and the meaning associated with the stimuli and responses to the stimuli (3). This fear structure can be dysfunctional when it does not represents a realistic threat anymore. This occurs when:

• The associations between the stimulus elements do not accurately reflect the real world.
• The avoidance responses are induced by harmless stimuli.
• The responses that are excessive and easily triggered interfere with adaptive behaviour.
• Safe stimuli and response elements are incorrectly associated with threat and danger.

The cognitive processing theory assumes that people attempt to make sense of what happened after a traumatic event. This can lead to distorted cognitions of themselves, the world and others (e.g. “I am worthless).

Assimilation refers to when incoming information is altered to confirm prior beliefs. This could result in self-blame (e.g. “I was assaulted because I did not fight back”). Accommodation refers to altering beliefs to accommodate new learning (e.g. “I couldn’t have prevented what happened”). Over-accommodation refers to changing beliefs to prevent trauma from occurring in the future (e.g. “the world is a dangerous place”).

Cognitive restructuring refers to teaching patients to identify dysfunctional thoughts and thinking errors (1), elicit rational alternative thoughts (2) and reappraise beliefs about themselves, the trauma and the world (3).