Treatments of PTSD 1 Running Head: Comparison of Two Treatments of Post Traumatic Stress Disorder

Comparing Two Treatments of Post Traumatic Stress Disorder: Eye Movement Desensitization and Exposure Therapy Amelia Farmer Queens University of Charlotte

Treatments of PTSD 2 Abstract Post traumatic stress disorder affects many different people for many different reasons. There are a number of events that are considered traumatic, and after traumatic events many people will need therapy or some other sort of treatment in order to get their lives back in order. Two treatments that are effective yet different are eye movement desensitization and reprocessing and prolonged exposure therapy. The purpose of this review is to examine the effectiveness of both treatments as well as criticisms of both, as well as to study the efficacy of each treatment and the populations with whom they work best.

Treatments of PTSD 3 Comparing Two Treatments of Post Traumatic Stress Disorder: Eye Movement Desensitization and Exposure Therapy Imagine you are a soldier at war. Every day, you see soldiers shot down and bombs exploding buildings, both at others and at yourself. Imagine you are driving to work or school one day and you suddenly hit an oncoming car, and the impact kills your friend in the passenger seat. Imagine you are at work, and suddenly an airplane crashes into your building and you must fight for your life. Imagine your home is now crumbled to the ground due to an unexpected earthquake, and youve lost everything you own. Thankfully, you survive these horrific incidents. However, you are now stuck with the memory of an incident that you will always wish you could forget. A common result from situations similar to these is Post Traumatic Stress Disorder (PTSD). PTSD affects 7.7 million or 3.5% of people age 18 and older, according to the Anxiety Disorders Association of America. If a person experiences a traumatic event and reacts with feelings of fear and helplessness lasting for longer than one month, then PTSD is diagnosed (Taylor et al, 2003). This topic is important because PTSD affects many different people in many different situations. The disorder can affect anyone from children, to teenagers, to adolescents. Traumatic events are typically unexpected, and the dramatic change in someones life causes a large amount of stress. There are some major indicators that a person is experiencing PTSD after a traumatic event. Taylor et al. (2003) characterized four basic dimensions of PTSD symptoms: Re-experiencing (e.g., flashbacks, nightmares); avoidance (e.g., efforts to avoid thinking about the trauma); numbing of general responsiveness (e.g., restricted range of affect); and hyper-arousal (e.g., exaggerated startle response). According to the

Treatments of PTSD 4 Harvard Mental Health Letter (2002), the people most likely to show stressful symptoms after a trauma are those who had stressful events occur directly after the trauma, sometimes because of the trauma. This information shows that just because an event may be considered traumatic, it does not necessarily mean PTSD will occur. Rape victims, war veterans, and battered women are among the many groups of people that are affected by PTSD. Everyday occurrences such as car accidents and the difficult death of a friend are also common causes of PTSD. Eye Movement Desensitization and Reprocessing There are many options for the treatment of PTSD. One of these is eye movement desensitization and reprocessing (EMDR). EMDR is defined by Cook, Biyanova, and Coyne (2009) as the following: During the reprocessing phases of treatment the patient is instructed to focus on aspects of the trauma or other memories and follow the psychotherapists fingers moving back and forth, approximately 18 inches in front of the patients eyes. After each set of eye movements, the psychotherapist stops and asks the patient to let go of the memory and to indicate what comes to mind. Depending upon the response, the client is guided to new areas of attention and the eye movements are engaged. This sequence is repeated until distress has been reduced, the belief in the positive thought has increased, and there are no disturbing physical sensations. (p. 519) The patient is encouraged to just notice (Lazrove, 1998, p. 603), or passively observe the thoughts and feelings that come about when the patient is thinking about the trauma. There are eight phases to the EMDR treatment technique. As described by

Treatments of PTSD 5 Silver, Rogers, and Russell (2008), the phases are: a) a brief gathering of the clients history; b) client preparation, designed to give information on EMDR to the patient; c) assessment, focusing on a particular experience; d) desensitization, utilizing eye movement or other stimulation (hand-tapping could be alternative); e) installation, helping patient identify with positive cognition; f) body scan, checking completeness of work; g) closure, determining the need for another evaluation before treatment ends; and h) reevaluation, assessing progress in treatment. Silver, Rogers, and Russell (2008) also describe EMDR treatment as an approach that treats both past thoughts, present feelings/triggers, and future functioning. Overall, EMDR is designed to treat all aspects of the PTSD and each trigger/cause. EMDR has treated PTSD patients suffering from a variety of problems, from people who have been in combat, to rape victims, to car crash victims. In a study by Lazrove and Triffleman (1998), eight subjects who fit the diagnosis of chronic PTSD as defined by the DSM-III-R were treated with the EMDR technique as described above. The subjects trauma experiences were either child death, sibling murder, car accident, assault, or patient death, with time since the trauma varying from 4 months to 9 years. Results showed that after EMDR treatment, PTSD symptoms decreased significantly among the subjects. Depressive symptoms also improved, since it is a part of PTSD and all PTSD symptoms decreased somewhat. This study shows how EMDR can be effective in treating PTSD and its symptoms. In another study by Carlson, Chemtob, Rusnak, Hedlund, and Muraoka (1998), EMDR was used as a treatment for PTSD among a group of combat veterans. The participants were 35 male veterans diagnosed with PTSD, ranging from ages 41-70. The

Treatments of PTSD 6 subjects were split into three groups, one receiving EMDR, one receiving relaxation therapy, and one receiving routine clinical care. Each subject underwent four phases of the EMDR: 1. Pretreatment, in which interviews and physiological measurements were taken; 2. Treatment, in which EMDR took place; and 3. Posttreatment/Follow up, in which the veterans were reassessed; and 4. Three month follow-up and nine month blind follow up (p. 8). Following the procedure, self evaluation of PTSD symptoms decreased among the subjects. Decreases were also found in depressive symptoms. Overall, the combat veterans receiving the EMDR treatments showed significantly decreased symptoms of PTSD over the other groups, even after a three month follow up. This study shows that EMDR is successful for treating even specific types of trauma such as combat. It is important to study combat-related stress victims because this affects a large portion of the population. Although EMDR seems to work in a variety of settings and has been proven to be effective in the treatment of PTSD, there are still criticisms about its consistency and quality. According to Boudeweyns and Hyer (1998) some criticisms are that EMDR studies have suffered from design flaws, especially poor sample definition, unreliable measures, non-blinded evaluations, and a lack of quality control of the treatments (p. 186). Also, research is still currently being down on EMDR to test its effectiveness over conventional treatments. The results have been mixed; some research suggests that exposure-based treatment is more effective than EMDR, whereas other studies suggest that EMDR is somewhat more effective (Taylor et al, 2003). In a study conducted by Taylor et al. (2003), when compared to exposure therapy, the EMDR treatments success rate among subjects was about 30% less than that of exposure therapy. This information

Treatments of PTSD 7 tells us that although EMDR has been shown to be effective in treating PTSD, it is still quite controversial and more research still needs to be conducted. Prolonged Exposure Therapy The second treatment to PTSD that will be discussed is prolonged exposure therapy. Prolonged exposure (PE) therapy consists of several weekly sessions. In a study by van Minnen, Wessel, Djikstra, and Roelofs (2002), the treatment was described as follows: Imaginal exposure was sustained for 60 minutes per session. Participants were instructed to close their eyes and to tell the story in the present tense while remembering the traumatic event as vividly as possible, including details, thoughts, and feelings. PE therapy has been used for years, and has been proven as an effective treatment for PTSD for which newer treatments are measured against. One aspect to the PE treatment which has been tested is the length of exposure sessions. A study was performed by Minnen and Foa (2006) which determined that of 92 subjects, with half the subjects going through treatment for 30 minutes and the other half for 60 minutes. The results showed that all subjects had decreased PTSD symptoms after the PE treatment, regardless of the amount of exposure time. This shows that PE is consistent and effective even if it is only done for a shorter period of time. In a study performed by Rauch et al. (2009), it was discovered that PE was not being used as a form of treatment in a Veterans Administration (VA) hospital system. Therefore, the authors chose to test PE treatment on a number of veterans returning from Iraq and Afghanistan, since they had never experienced this type of treatment before. The study consisted of ten veterans, both men and women, with varying severity of PTSD symptoms. After adding PE sessions to the treatment plans of these veterans, results

Treatments of PTSD 8 showed that fifty percent of treated veterans had scores below 15 suggesting they no longer met criteria for PTSD (p. 61). The scores were an assessment of all symptoms. This study shows that PE is effective in reducing PTSD symptoms in veterans in the VA hospitals, suggesting that it would possible benefit the patients if this treatment remained available to all veterans suffering from PTSD. Therefore, like EMDR, PE shows effectiveness among combat-related stress victims. Like EMDR, however, PE is still not a perfect form of treatment, according to Eftekhari, Stines, and Zoellner (2006). These authors discusses several different studies on PE for the treatment of PTSD symptoms, and they discovered that more research needs to be done on several aspects: cross-cultural effects of the treatment, how it treats less obvious trauma-related symptoms such as guilt and anger, the impact of comorbid disorders such as substance-abuse or depression, and specific traumas such as sexual abuse victims. Also, according to Eftekhari, Stines, and Zoellner (2006), experts in the field have explored common myths that prevent the use of PE in the treatment of PTSD. (p. 75). These myths include the patients fears of intensifying the symptoms when talking about them and patient dropout rates. This information shows that many therapists may not see PE as an effective form of treatment for PTSD symptoms, meaning there may be reasons why psychologists do not use PE that needs to be researched more. Some possible reasons could be that there are now more recent treatments that can be tried instead of PE, or possible the length of time it takes for PE to achieve results. Conclusion Post traumatic stress disorder is a serious condition that affects children, adolescents, adults, and elderly who have experienced a variety of different traumatic

Treatments of PTSD 9 events, from combat, to witnessing sudden deaths, to natural disasters. Several studies have been done to test the effectiveness of both of the treatments discussed, eye movement desensitization and reprocessing as well as prolonged exposure therapy. Both treatments have proven to be effective in some way among different population groups. EMDR is a newer therapy, only about twenty years old, and is still being researched for each symptom among different subject groups. It has so far proven to be extremely effective in many cases, although there are still some hesitations and questions about it, such as to its design and reliability. The same can be said for the prolonged exposure therapy, which has also shown to be effective but still has some questions and limitations, such as the fact that some patient drop-out rate and fear of bringing the traumatic thoughts to mind. Both of these treatments have been shown to be effective in combatrelated trauma victims. It is safe to say that although both have proven to be effective, there is not one therapy that can be said is more effective or better than the other. Both treatments are somewhat difficult to perform on the patients, because it is extremely hard for patients to surface their feelings and thoughts about an even they have been trying to suppress. Further research still needs to be done on both treatments in order to figure out what works best for which PTSD patients and why.

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Treatments of PTSD 13 Taylor, S., Thordarson, D., Maxfield, L., Fedoroff, I., Lovell, K., & Ogrodniczuk, J. (2003, April). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330-338. Retrieved September 28, 2009, doi:10.1037/0022-006X.71.2.330 van Minnen, A., Wessel, I., Dijkstra, T., & Roelofs, K. (2002). Changes in PTSD Patients' Narratives During Prolonged Exposure Therapy: A Replication and Extension. Journal of Traumatic Stress, 15(3), 255. Retrieved from Academic Search Premier database. (2002). What causes post-traumatic stress disorder:two views. Harvard Mental Health Letter, 19(4), 8. http://ezproxy.queens.edu:2159