Psychiatry - July 2008 - (Page 47)

the story of a particular incident, recorded it, and reviewed the tape repeatedly between sessions. In each session, he would review the incident with his therapist and examined the different aspects of his thought processes and emotions as they emerged. Over the course of 14 sessions, his PTSD Checklist (PCL, a 17-item self-report measure of PTSD severity with scores ranging from 17 to 85)29 scores were reduced from a high of 70 to a final score of 20, where it remained two years after initial treatment. SSgt B related in a subsequent interview, “My body was back home, but my mind was still in Iraq. I was looking forward to another deployment just because I felt more comfortable there, less out of place. Now I can look forward to deployment to continue working on our overall mission, and not my personal demons.” Eye movement desensitization and reprocessing (EMDR) therapy. EMDR was developed by Shapiro,30 and involves reviewing the worst aspect of the trauma with the therapist leading the patient in repetitive horizontal eye movements, and the patient repeating particular coping statements. EMDR takes place over 1 to 4 sessions, and thus is more efficient timewise than other forms of therapy. The precise movement was initially postulated by Shapiro to specifically interrupt the neural pathways involved in memory retrieval and allow the patient to more appropriately reintegrate the memories, although other repetitive movements have been found to be useful as well.20 Case 6. Airman D is a 24-year-old female active duty service member who developed PTSD after a motor vehicle accident. She was unable to drive for several months after the initial trauma because of a paralyzing fear of having another accident. She was also plagued with ruminations over the incident and nightmares. She was referred to a community provider who specialized in EMDR and after a four-session course in which she repeatedly reflected on aspects of her accident while guided in horizontal eye movements by her therapist. She was able to drive again, although she still felt twinges of anxiety when getting behind the wheel. She no longer had nightmares and did not ruminate over the incident. Stress inoculation training (SIT). SIT is another form of CBT, which was developed for the management of anxiety symptoms. It includes an education component and a variety of coping skills, including muscle relaxation, assertiveness training, thought stopping, and other techniques. It has been successfully used to treat rape survivors,31 motor vehicle accident survivors,32 and to help prevent PTSD.33 Meichenbaum provides a comprehensive review of the technique and evidence.34 Psychodynamic psychotherapy. Psychodynamic psychotherapy is a collective term for several types of therapies, including brief and longterm orientations. Psychodynamic therapies are not manualized but rather allow the patient to guide therapy to some extent. The approach can best be conceptualized by Freud’s seminal paper, “Remembering, Repeating and Working Through.”35 It stresses the importance of unconscious material, repression, defense mechanisms, and the impact of a person’s life experiences on their present world view and symptom formation. In psychodynamic psychotherapy, unconscious conflicts are brought to conscious awareness, and the patientpsychiatrist relationship serves as a model for understanding the patient’s relationships outside therapy. Brief psychodynamic psychotherapy generally takes place over 12 to 16 sessions, and revolves around a single focus. Long-term psychodynamic psychotherapy ideally occurs over a minimum of 40 sessions, generally once or twice weekly, and examines the various patterns in the patient’s life and seeks to make the unconscious tendencies conscious so that destructive cycles can be broken. Psychoanalysis generally occurs 3 to 5 times weekly over years, examining multiple facets of a patient’s development and psyche in order to achieve lasting change and character development. Brom and colleagues36 conducted a randomized, controlled trial of 112 patients with PTSD randomly assigned to brief psychodynamic psychotherapy, trauma desensitization, or hypnotherapy, and found clinically meaningful improvements with all three forms. Eiser37 describes several psychodynamic explorations of the meaning of nightmares in the larger context of PTSD and an individual’s character structure.13 Psychodynamic psychotherapy may produce change that continues after therapy ends.37 Psychodynamic psychotherapy may also be useful for those patients who cannot tolerate CBT, PE, or EMDR, or who wish to gain a deeper understanding into their motivations and character.37 Brief and group interpersonal approaches have been reported to be useful in treating PTSD, and it may be particularly useful for those with complex PTSD.37 Schottenbauer notes that psychodynamic psychotherapy may work more slowly than other treatments but studies imply that change continues after therapy ends.37 Schottenbauer37 also provides a helpful review of various developmental issues and their implications for psychotherapy. Case 1, continued. After her adjustment to using her CPAP on a regular basis, Mrs. C was able to engage in brief psychodynamic psychotherapy over 20 sessions with a marked reduction in the quality and quantity of nightmares and an improvement in her relationship with her husband. She is currently contemplating re-engaging in longerterm therapy to address her residual symptoms of PTSD and remains medication-free by her choice. POWER STRUGGLES WITHIN THE THERAPEUTIC RELATIONSHIP Patients with PTSD have a strong need to feel in control of something because their illness makes them feel so out of control. Often, this need permeates the therapeutic relationship and results in a conscious or unconscious [JULY] Psychiatry 2008 47

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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