This is Part 2 of a 3-part series on posttraumatic stress disorder (PTSD) and eating disorders by Dr. Mary Hill. To access the first post describing the co-occurrence of eating disorders and PTSD click here.
Evidence-based trauma therapies reduce symptoms of posttraumatic stress disorder (PTSD) and common co-occurring problems like depression, and improve functioning and well-being.1 Prolonged exposure (PE), cognitive processing therapy (CPT), and trauma-focused cognitive behavioral therapy (CF-CBT) are well-established evidence-based treatments for individuals with PTSD.2,3,4,5 Descriptions of each treatment and how they work are presented below.
PE has the strongest recommendation as a treatment for individuals with PTSD in clinical practice guidelines.2,3,4,5 It addresses problematic avoidance that develops as a result of the trauma. People with PTSD often try to avoid things that remind them of the trauma because encountering people, places, objects, and memories that remind them of the trauma is highly distressing. Avoidance reduces distress in the moment, but ultimately makes PTSD worse. Over time, people avoid more and more trauma reminders, even those that most people would consider safe. Not only does this avoidance keep PTSD symptoms going, it negatively impacts individuals’ ability to engage in meaningful activities and live the kind of lives they want.
PE works by helping individuals limit problematic avoidance through gradual, systematic exposure to feared but safe stimuli (e.g., places, situations, memories). Essentially, PE helps individuals face their fears safely. PE involves two types of exposure: imaginal exposure and in vivo exposure. During imaginal exposure, individuals retell the trauma memory. The major goal of imaginal exposure is to help individuals emotionally process the trauma memory in order to reduce PTSD symptoms. By repeatedly telling the trauma narrative, individuals better organize and process the memory and their cognitive and emotional reactions to it.
During in vivo exposure, individuals approach objectively safe trauma-related situations (e.g., going to crowded places) that they have avoided because of trauma-related distress. Through direct experience during exposure, individuals learn that the trauma memory, reminders, and physiological responses are not dangerous, and the distress experienced when encountering them is temporary. In addition, new information learned through direct experience that is incompatible with trauma-related beliefs (e.g., “people can’t be trusted,” “I can’t handle being out by myself”) promotes improved quality of life as individuals reengage in meaningful activities previously avoided because of trauma-related distress.6
CPT is another evidence-based treatment that focuses on one’s beliefs about self, others, and the world that changed as a result of the trauma and how these beliefs affect emotions and behaviors. Specifically, unhelpful beliefs related to power and control, esteem, safety, trust, and intimacy are addressed. It is thought that these beliefs that developed after the trauma make PTSD worse.
The primary focus of CPT is to modify dysfunctional cognitions that impair functioning, known as “stuck points.” For example, the “just world belief” states that, “good things happen to good people, and bad things happen to bad people.” If that is believed to be true, it can be hard for trauma survivors to make sense of why something bad happened to them and may impact their ability to engage in their lives as they did before the trauma. CPT challenges stuck points by teaching individuals how to assess whether facts support their stuck points. If not, they can work with their therapist to create a new perspective. CPT is believed to work by developing more balanced and helpful beliefs which decrease difficult emotions and other PTSD symptoms.7
Finally, TF-CBT is an evidence-based treatment for children with PTSD or traumatic grief and their parents. Treatment includes components of PE and CPT. TF-CBT is comprised of psychoeducation about trauma and PTSD, teaching relaxation skills and other coping skills, in vivo exposure to reminders of the trauma, creation of a trauma narrative (which is similar to imaginal exposure), processing trauma-related thoughts and emotions, and developing safety skills.8
Despite research support for these treatments, many trauma survivors and therapists express concern that trauma-focused therapies will make people with PTSD feel worse.9 However, the literature shows that most who participate in evidence-based PTSD treatment improve and do not experience worsening of PTSD symptoms or depression.10,11 These treatments are safe and effective, although it is important to find a therapist who is trained in the treatment modality, and it can be beneficial to ensure that individuals have good coping skills prior to beginning treatment as addressing trauma in treatment can be emotionally intensive. Although there are currently no established guidelines for when to address trauma in treatment for individuals with eating disorders or which treatment may be most beneficial, evidence-based PTSD treatments can be used in combination with eating disorders treatments. It is important for future research to assess the best way to integrate treatment for both PTSD and eating disorders.
- van Minnen, A., Zoellner, L. A., Harned, M. S., & Mills, K. (2015). Changes in comorbid conditions after prolonged exposure for PTSD: A literature review. Current Psychiatry Report, 17, 1-16, doi: 10.1007/s11920-015-0549-1
- Bisson, J. & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 3, 1-122. doi: 10.1002/14651858.CD003388.pub3
- Institute of Medicine (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, D.C. The National Academic Press.
- Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Cook Middleton, J., …Gaynes, B. N. (2016). Psychological treatments for adult with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. doi: https://doi.org/10.1016/j.cpr.2015.10.003
- Difede, J., Olden, M. & Cukor, J. (2014). Evidence-based treatment of post-traumatic stress disorder. Annual Review of Medicine, 65, 319-332. doi: 10.1146/annurev-med-051812-145438
- Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.
- Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Washington, DC: Department of Veterans Affairs.
- Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press.
- Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., Hembree, E. A., and Karlin, B. E. (2014). Factors related to clinician attitudes toward prolonged exposure therapy for PTSD. Journal of Traumatic Stress, 27, 423-429. doi: 10.1002/jts.21945
- Jayawickreme, N. J., Cahill, S. P., Riggs, D. S., Rauch, S. A. M., Resick, P. A., Rothbaum, B. O., and Foa, E. B. (2014). Primum non nocere (first do no harm): Symptom worsening and improvement in female assault victims after prolonged exposure for PTSD. Depression and Anxiety, 31, 412-419. doi: 10.1002/da.22225
- Foa, E. B., Zoellner, L. A., Feeny, N. C., Hembree, E. A., & Alvarez-Conrad, J. (2002). Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology, 70, 1022-1028. http://dx.doi.org/10.1037/0022-006X.70.4.1022