Empirically Supported Psychological Treatments: EMDR

In this chapter we review the empirical foundation for Eye Movement Desensitization and Reproessing Therapy (EMDR) for posttraumatic stress disorder. We present a brief description of the therapy, critically review recent primary and meta-analytic investigations concerning its efficacy and effectiveness, offer a summary of recent primary investigations that addressed the mechanism of action for EMDR, and based on this overall review, we suggest limitations with recommendations for future research. Recent empirical investigations of the efficacy of EMDR have improved along a number of important dimensions, and these along with the few completed effectiveness trials, position this therapy among evidence-based frontline interventions for PTSD. What is less thoroughly researched, and thus less well understood, are putative models of its theoretical mechanism of action. In addition to continuing specific improvements in research concerning efficacy and effectiveness, we recommend more and higher quality empirical studies of its mechanism of action.

Individual Approaches to Prevention and Early Intervention

This chapter provides an overview of individual and small group-based approaches for prevention and early intervention of posttraumatic stress disorder (PTSD). Using the Institute of Medicine's (IOM) classification system for preventive interventions of mental disorders (universal, selective, and indicated), we describe individual and small group early interventions and review the effectiveness of these strategies. Specifically, psychological debriefing, psychological first aid, and psychoeducation have been used as selective interventions targeting individuals exposed to trauma with varying degrees of success. However, there is strong empirical support for using cognitive behavioral therapy as an indicated preventive intervention to help symptomatic individuals in the weeks or months following traumatic exposure. A review of the literature also suggests that future research should explore different modes of delivery and devote more attention to determining the best time to intervene after traumatic exposure.

Empirically Supported Psychological Treatments: Cognitive Processing Therapy

Cognitive Processing Therapy (CPT) has been recognized by the Institute of Medicine (2007) as one of the most effective treatments for PTSD. This chapter provides a brief overview of the CPT session content, the underlying mechanisms of the therapy, a review of the empirically based literature outlining the treatment effectiveness, limitations of the therapy, and areas of future research. In addition, the authors discuss the utility of the various versions of CPT, including cognitive only (CPT-C), group, individual, and combination. Further the research supporting the effectiveness of CPT for treating PTSD related to a variety of traumas, (e.g., combat, child abuse, and rape) and the significant impact CPT can have in areas of mental health related to PTSD (e.g., anger, guilt, social functioning) are described.

PTSD at Late Life: Context and Treatment

Our knowledge about the role of aging as a moderating or mediating influence on the expression of posttraumatic symptoms, and their remission and resolution, is nascent. This is reflected in the current state of empirically supported psychotherapies for older adults with PTSD. At this time, there are no empirically validated psychotherapeutic or psychopharmacologic treatments for this age group. This chapter highlights general issues and other factors unique to aging, such as changes in cognition, that must be taken into consideration when embarking on PTSD treatment with older adults. We review extant psychotherapy research that has applicability to this cohort: treatment studies on anxiety and depression for older adults, as well as treatment studies for younger adults with PTSD. Next, we describe promising PTSD interventions for older adults that have yet to be tested on large samples or in randomized controlled trials. The chapter culminates in the presentation of a multi-modal psychotherapy intervention designed to address factors unique to aging, and which involves a gentler version of trauma-related therapy that allows exposure to be optional.

Traumatic Stress in Older Adults

This chapter focuses on older adult trauma survivors. Information is presented on prevalence of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD); course, functional impairment, suicide risk, and health care utilization in older adults with PTSD; and the impact of demographic factors such as gender, ethnicity, and race on PTSD in older individuals. In general, rates of ASD and PTSD are lower in older adults compared to other age groups. PTSD in older adults has been linked to suicidal ideation and attempts, functional impairment, physical health, and increased healthcare utilization. Although delayed onset of PTSD has been empirically verified in some military samples with World War II veterans and younger adult civilians, it is rare in the absence of any prior symptoms and might more accurately be labeled “delayed recognition.” More information on trauma and PTSD in diverse populations of older adults is needed, such as racial and ethnic minorities, those with severe physical or mental impairment, noncommunity-residing groups, and those from nonindustrialized countries.

Epidemiology of Posttraumatic Stress Disorder in Adults

Posttraumatic stress disorder (PTSD) was established in 1980, when it was incorporated in the DSM-III. The PTSD definition brackets a distinct set of stressors—traumatic events—from other stressful experiences and links it causally with a specific response, the PTSD syndrome. Explicit diagnostic criteria in DSM-III made it feasible to conduct large-scale epidemiological surveys on PTSD and other psychiatric disorders, using structured diagnostic interviews administered by nonclinicians. Epidemiologic research has been expanded from Vietnam veterans, who were the center of DSM-III PTSD study, to civilian populations and postwar regions worldwide. This chapter summarizes information on the prevalence estimates of PTSD in U.S. veterans of the Vietnam War, soldiers returning from deployment in Iraq and Afghanistan, and civilian populations. It outlines research findings on the course of PTSD, risk factors, comorbidity with other psychiatric disorders, and the risk for other posttrauma disoders. It concludes with recommendations for future research.

Promising Psychological Treatments

Exposure to traumatic events is highly prevalent, which has led to the creation of multiple psychosocial and pharmacological treatment approaches for individuals who subsequently develop posttraumatic stress disorder (PTSD). Despite the availability of existing empirically supported treatments for PTSD, research indicates that a significant subset of patients fail to respond to treatment. As a result, there is a great need for the development of novel and innovative treatments that can address the diverse needs of individuals with trauma histories and that can alleviate symptoms of traumatic stress in a greater number of individuals. The following chapter outlines numerous promising treatments, including couple and family-based approaches, technological approaches, emotion-based therapies, pharmacological treatments, and treatments designed to address comorbidity. Although many of these approaches are in preliminary stages of development and require further study, they represent important progress in helping clinicians better serve the many needs of individuals with PTSD.

Prevention and Early Intervention Programs for Special Populations

Special populations have unique issues that need to be considered in the development and delivery of prevention and early intervention models. For these individuals, social context or stressors and support within their social environments may be particularly critical to consider in the wake of a traumatic exposure. In this chapter, we will discuss some of the environmental factors that are important to consider when planning and implementing prevention and early intervention programs for special populations and explore these factors in the case of refugee children.

Traumatic Stress in Special Populations

Special populations are individuals who by virtue of psychiatric, behavioral, cognitive, or physical disabilities are more likely to be exposed to psychological trauma. Individuals with severe psychiatric disorders, substance use disorders, developmental disabilities, and persons who are incarcerated are more likely to experience trauma throughout their lives, especially interpersonal victimization, and are more likely to develop posttraumatic stress disorder (PTSD). Trauma and PTSD have a negative impact on special populations, often exacerbating psychiatric symptoms and substance abuse, and interfering with community functioning. Despite the high rates of trauma and PTSD in special populations, these problems are often not identified, and when they are, they are rarely treated. Recent progress has been made in adapting treatments developed for PTSD in the general population to special populations, including persons with severe mental illness and individuals with substance use disorders.

Future of Classification in Posttraumatic Stress Disorder

This chapter reviews the status of modifications to the definition of PTSD and proposed changes for DSM-5. We include a brief history of the diagnosis and trace its evolution in the Diagnostic and Statistical Manual of Mental Disorders (DSM). We discuss some of the current controversies related to the definition of PTSD including its location among the anxiety disorders, the utility of Criterion A and its subcomponents, and the factor structure of the symptoms. We review the rationale for the addition of new symptoms and modifications to existing criteria now and conclude with comments on future directions for research on PTSD.