AND DESENSITIZATION TECHNIQUES

In an attempt to change and extinguish many of the intrusive symptoms of PTSD, more confrontational and invasive techniques of

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therapy have evolved. The technique with the best documentation is cognitive-behavioral therapy, a method designed to change the im-plications or meaning of intrusive symptoms. The various techniques under this category share, to some extent, the process of extinction of a conditioned response by eliciting the response (memory, emotion) in an environment that does not contain a trigger (cues, threat) for that response. The meaning of the response in relation to the basic sur-vival instinct is changed and diminished as exposure to the response occurs repeatedly in a benign environment. As a result, habituation through repeated exposure progressively diminishes the fear/arousal response in PTSD. Such techniques as imaginal exposure and sys-tematic desensitization involve guided reexperiencing of traumatic memories and images in a controlled therapeutic setting.

Numerous studies suggest that these techniques have a substantial therapeutic effect on reducing intrusive and cue-related arousal symp-toms in PTSD.^6-9Flooding, however, may carry significant risk. In-tense arousal and reexperiencing may duplicate the original traumatic experience, and without a concomitant internal and external environ-ment that incorporates a sense of safety and empowerenviron-ment, the vic-tim may move immediately into the freeze response. Severe dissocia-tive reactions and enduring aversive psychological symptoms may complicate therapeutic techniques incorporating flooding.¹⁰In addi-tion, most studies document that the primary PTSD symptoms that benefit from exposure techniques are those involving arousal, fear, and traumatic reexperiencing. Late symptoms of avoidance, dissoci-ation, somatizdissoci-ation, and depression may be less responsive to cogni-tive-behavioral techniques.

Many of the clinical studies in these techniques also suffer from methodological problems, often related to standard outcome mea-sures. Also, the spectrum of expression of symptoms in PTSD varies greatly, with wide variation in manifestation of symptoms of arousal and avoidance. Gender differences in response to trauma play a sig-nificant role in efficacy of various techniques, as might be expected.

The nature of the traumatic stress and the context of the environment in which it occurred predictably produce variations in the clinical manifestations of the resulting traumatic symptoms. Studies compar-ing the effectiveness of therapy for PTSD in female assault victims are, therefore, likely to show significantly different outcomes than similar therapy in Vietnam War veterans, both because of gender

dif-ferences and the nature of the traumatic experience. By themselves, these studies do not necessarily reflect the efficacy of a technique useful in one population but not useful in another. Indeed, studies of Vietnam veterans in general show resistance to many therapeutic techniques, including pharmacotherapy, a finding that has been at-tributed at least in part to the association of guilt with the traumatic experience.¹¹

Adverse responses to exposure techniques by Vietnam veterans have raised concerns that reinforcement of guilt in exposure tech-niques might substantiate rather than desensitize arousal and anxiety.

Based on these concerns, Rothbaum and Foa advocate developing techniques for guilt reduction because of its prevalence in PTSD in general.¹² Meanwhile they recommend the use of exposure-based therapy for arousal-related symptoms, and cognitive techniques for issues related to guilt.

Several mechanisms have been proposed to account for the appar-ent efficacy of exposure-based therapies for PTSD.¹³ Habituation through repetitive exposure to the precipitating internal or external cue for the traumatic response might lessen the arousal response and correct the notion that anxiety is inevitable unless avoidance or disso-ciation is activated. Second, deliberate confrontation with the trau-matic memories blocks or inhibits negative reinforcement associated with the repetitive arousal/avoidance cycle. Third, repeatedly reexper-iencing the traumatic experience through confrontation or memory in a safe and supportive setting incorporates the message of safety into the traumatic memory, helping the patient to realize that the memory itself is not dangerous. Fourth, focusing intently on the traumatic memory or cue for a prolonged period of time separates it from the nontraumatic portion of the patient’s existence, thereby reducing the patient’s tendency to generalize the trauma to any arousal cue. Fifth, imaginal reexperiencing assists the patient in restructuring the mean-ing of traumatic memories from representmean-ing states of helplessness and incompetence to states of mastery and control. Finally, repeated exposure to traumatic memories allows patients to focus on those portions of the experience that reflect negatively on themselves, and to modify those perceptions into a positive model.¹³

Techniques directed toward anxiety management have also been employed extensively in PTSD treatment. These techniques are de-signed to develop coping skills in lessening arousal and anxiety, and

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generally involve body-training exercises, often supplemented with biofeedback. Examples include deep muscle relaxation, breathing exercises, thought stopping, cognitive restructuring, covert model-ing, and stress inoculation. All of these techniques employ active in-tervention by the patient in diminishing painful somatic or emotional symptoms through learned techniques of self-regulation designed to control or diminish that part of the trauma cycle involving arousal.

They do not address symptoms of avoidance and dissociation. In-deed, it is theoretically possible that a number of these techniques might enhance dissociative tendencies as a means of achieving relief from arousal symptoms, since the only objective measures for suc-cess are based on reduction of measures or symptoms of physiologi-cal arousal. It is no surprise that these techniques in general do show improvement in arousal symptoms after treatment, lasting as long as six months in cases, but studies testing them contain methodological flaws, including lack of confirmation of PTSD diagnostic criteria.

Nevertheless, studies combining anxiety management and exposure techniques seem to show that a combination of these approaches might present the best clinically tested treatment for chronic PTSD.¹²