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Post-Traumatic Stress Disorder (PTSD) Treatment Implications from a Post
Traumatic Growth (PTG) Perspective incorporating Positive Psychology
Interventions within Cognitive Behavioural Approaches: Review Article
Principal Author: Caroline Ward-Goldsmith MAPP Researcher Department of Psychology
University of East London Docklands Campus
email: U1327120@uel.ac.uk
Abstract
Post Traumatic Stress Disorder (PTSD) is a condition for which epidemiology studies cite
prevalence rates of 7.8% in the general population (Kessler, et. al., 2005), with a high cumulative
incidence (at risk) rate seen among war veterans of 60% or more (Kilpatrick, et. al., 2003).
This review article sets out the case for consideration of Post-Traumatic Stress Disorder (PTSD)
as a Biological, Psychological and Social construct. The efficacy of therapeutic approaches
which promote Post Traumatic Growth (PTG) are discussed in relation to the possibility of
recovery for affected neural structures considering neuroplasticity, which has been shown to
promote neurogenesis as a response to effective therapeutic intervention regarding long term
positive prognosis for the individual.
Overview of PTSD
PTSD is a long term painful and frightening bio-psychosocial condition which results from
exposure to trauma experienced as a threat to mortality (APA, 2013) the memories of the event
linger and victims often have vivid flashbacks. Frightened and traumatized, they are constantly
on edge and the slightest of cues triggers a protective fear response in order to avoid further
exposure (Viatcheslav & Wlassoff, 2016, brainblogger.com). Epidemiology studies cite
prevalence rates for PTSD at 7.8% in the general population (Kessler, et. al., 2005), with a high
cumulative incidence (at risk) rates seen among war veterans of 60% or more (Kilpatrick, et. al.,
2003)
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Typically sufferers try to avoid people, objects, and situations which remind them of the
experience; this behaviour is debilitating and interferes greatly with life function, satisfaction and
enjoyment (Friedman, 2013)
Background to PTSD
The Oxford Dictionary defines Trauma from the 17th century Greek meaning for wound. The
revised meaning is listed as; Emotional shock following a stressful event or a physical injury,
which may lead to long-term injury or neurosis (Allen, Fowler & Fowler, 1990)
Once Neurosis has set in a positive reconstruct is required to promote posttraumatic growth
(PTG) Therefore taking into account a positive construct perspective we can appreciate that
in traumatic experiences, as catastrophic as they often appear, we can find opportunities for
meaning and personal growth (Tedeschi & Calhoun, 2004)
Post Traumatic Growth (PTG)
Posttraumatic growth is not about returning to or recreating the life you had before trauma;
rather, it draws to attention an appreciation of adjustment of perspective and opportunities for
positive change that often come in the aftermath of significant trauma. Janoff-Bulman, 2006).
Exploring the research and new thinking around resilience we find that (PTG) shares many dual
concepts and strategies which help the person cope with upsets and challenges while developing
strengths to aid thriving in other areas which compensate (Calhoun, Cann & Tedeschi, 2010).
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Bio-psychosocial Considerations in PTSD
From a psychological point of view Trauma can be defined as an experience which overwhelms
the individual beyond their capacity to rationalise the experience at a given point in time or in a
given situation. When children are exposed to psychological trauma it is the overwhelming
aspect of the experience which causes them to cognitively blank out while remaining conscious
(Van der Kolk, 2005) They learn to exist in a constant state of denial where the conscious mind
just refuses to acknowledge what is taking place in order to preserve function. Survivors often
describe experiences of feeling ‘like I wasn’t there’ and ‘it was as if I was watching it happens to
someone else’ (Herman, 1997)
Initiating a treatment plan often has a high focus on making sure there are supports in place
before therapy begins which can act as protective factors during emergence of realisation of the
trauma which occurred. Otherwise there is a risk of further trauma becoming entrenched
considering noradrenergic signalling in the amygdala contributing to the reconsolidation of fear
memory (Debiec & LeDoux, 2006)
Memory consolidation is a category of processes which stabilize a memory trace after its initial
acquisition (Dudai, 2004) Consolidation is distinguished into two specific processes, synaptic
consolidation, which is synonymous with late-phase LTP (Bramham, 2005) and occurs within
the first few hours after learning, and systems consolidation, where hippocampus-dependent
memories become independent of the hippocampus over a period of weeks to years. Recently, a
third process has become the focus of research, reconsolidation, in which previously
consolidated memories can be made labile (changeable) again through reactivation of
the memory trace.(Nutt & Malizia, 2004)
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Neuroanatomy of PTSD
Two structures of neuroanatomy are significantly affected in PTSD. Firstly the Hippocampus
within the limbic system which plays important roles in the consolidation of information from
short-term memory to long-term memory and spatial navigation (Wise, 1999) It helps an
individual to record new memories and retrieve them later in response to specific and relevant
environmental stimuli. The hippocampus also helps to distinguish between past and present
memories. Secondly, the Amygdalae which are dual neural structures like pea shaped glands
located on both sides of the brain just under the Hippocampus and concerned with memory
perception, feeling emotions in other people and the ability to experience fear and the many
changes this causes in the body. (Bremne, Elzinga, et. al., 2008)
Reduced Hippocampal volume accounts for the memory loss and impairment often found in
sufferers of PTSD when viewed in neuroimaging studies. (Hull, 2002) Additionally, changes
occur in the medial prefrontal cortex. (Shin, Rauch & Pitman 2006). This area is specifically
concerned with relaying information for processing regarding the regulation of negative
emotions including a fear response which occurs when confronted with specific stimuli. PTSD
patients show a marked decrease in the volume of ventromedial prefrontal cortex and the
functional ability of this region. (Koenigs & Grafman, 2009)
The amygdalae and Hippocampus have been shown to change their physical characteristics and
function in PTSD. (Debiec & LeDoux, 2006)
Auto-associative memory, also known as auto-association memory which is actually a generic
term that refers to all memories that enable retrieval of data from a tiny sample or cue (Asaad,
Rainer & Miller, 1998)
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Traditional memory stores data at a unique address and can recall the data upon presentation of
the complete unique address. Auto-associative memory function however is capable of retrieving
a piece of data upon presentation of only partial information from that piece of data. (Wise &
Murray 1999)
PTSD patients with reduced hippocampal volume lose the ability to discriminate between past
and present experiences or interpret environmental contexts correctly. They may often have
irrational fears which trigger memories of the trauma for example if a person was assaulted in a
car park they may fear all car parks and avoid them. (Murray & Wise, 1996). The Hippocampus
which is concerned with memory and spatial awareness can have a traumatic memory attached to
the wrong space, whereby the feared place is only similar in characteristics to where a trauma
occurred. This results in the closely connected Amygdala which processes emotions becoming
hyperactive and the sufferer exhibits feelings of anxiety, panic, and extreme stress reactions.
(Bremner, 2006)
Positive Psychology intervention (PPI) through empirical and theoretical approaches with PTSD
presents a paradigm within which to effectively build resilience to cope with the stress produced
by dysfunctional activity in neuro-structures in order to promote neurogenesis (Joseph & Linley,
2005)
Effective therapy can assist and aid recovery and create positive experiences that, while not
changing the traumatic situation, give a sense of meaning and purpose to life as it continues on.
(Cahill & Foa, 2004)
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Five aspects of posttraumatic growth (PTG) which enable resilience.
Summarised by Lisa Danylchuk Positive Psychotherapist
1. Personal Strength
What helps one feel strong and to access resources within? How do people cope with pain, both
emotional and physical? There are many ways of dealing with sensations and emotions that feel
uncomfortable, and many of us seek out behaviours that have drawbacks—using
substances, overworking, or distracting from the pain rather than moving through it. What can
we do to help connections to our psyche in a healthy way and process uncomfortable emotions?
Many find strength in sports, exercise, creative endeavours (music, art, theatre), or in connecting
with and helping others. Take some time to reflect in therapy, upon what could serve the
individual best in this way.
2. New Possibilities
With trauma often comes an organic shift in perspective. Perhaps things that used to be
meaningful no longer carry your interest, while other topics feel suddenly more compelling.
Take time in therapy to reflect on what the person may want to leave behind and what is pulling
attention moving forward. Often with trauma, people experience a shift and reprioritization of
values; if this has happened, explore with the client what new possibilities exist? How can they
shift how they spend time and energy to reflect these changes?
3. Relating to Others
Social supports are a huge way that we move through difficulty. Trauma may be what leads us
to reach out for professional help, or to confide in a friend. We may also have a deeper sense
of compassion for others who are suffering, leading us to relate to the world in an entirely new
way.
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Take time in therapy to look at relationships—with family, friends, community, and society at
large. Where do you they connected, seen, and supported? These are places that can be helpful
and healing. If they do not feel they have people who support now is a wonderful time to reach
out and set up some protective relationship factors.
Trauma brings us face to face with our mortality and, as such, can lead us to appreciate and even
treasure moments of peace or connection we may have taken for granted.
4. Appreciation of Life
Hamilton Jordan describes this best in his book No Such Thing as a Bad Day (2000): “After my
first cancer, even the smallest joys in life took on new meaning—watching a beautiful sunset, a
hug from my child, a laugh with Dorothy. That feeling has not diminished with time. After my
second and third cancers, the simple joys of life are everywhere and are boundless, as I cherish
my family and friends and contemplate the rest of my life, a life I certainly do not take for
granted.” (Jordan, 2000)
Trauma brings us face to face with our mortality and, as such, can lead us to appreciate and even
treasure moments of peace or connection we may have taken for granted.
5. Spiritual Change
Many trauma survivors report a shift in relating to the spiritual world.
The diagnostic (DSM)
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definition of trauma explains that many traumatic experiences involve
exposure to death or threatened death. This may bring to the forefront questions of mortality,
afterlife, and spiritual meaning. We may find ourselves asking, “Why did this happen to me?” or
“What has become of the person who passed?” These questions and the answers we seek are
deeply personal and have significant implications for how we understand ourselves and the
world. Allow time for these reflections in the aftermath of trauma (Goodtherapy.org, 2016)
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Diagnostic and Statistical Manual of the American Psychiatric Association now in its 5th Edition- DSM-5
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Treatment and Prognosis for Recovery from PTSD
A PTSD recovery paradigm would include consideration for including a multi-systems
therapeutic approach over an ongoing period of time. Possibly 6 – 36 months depending on the
individual severity, considerations and circumstances. Therapy frequency would likewise vary
over time depending on engagement with approach and trust built up with the therapist (Hetrick,
et. al., 2013)
Although it is beyond the scope of this review to go into all therapuetuc approaches those which
have shown the highest efficacy in PTSD include;
Cognitive behavioural therapy (CBT), and Prolonged-exposure therapy (PET) - developed for
use in PTSD at the University of Pennsylvania (Foe,,et. al., 1999). In this type of treatment, a therapist
guides the client to recall traumatic memories in a controlled fashion so that clients eventually regain
mastery of their thoughts and feelings around the incident. (APA.org, 2016)
Cognitive-processing therapy (CPT), a form of cognitive behavioral therapy (CBT) was, developed at
Boston University (Resick, et. al., 2002). This treatment includes an exposure component but places
greater emphasis on cognitive strategies to help people alter erroneous thinking that has emerged because
of the event. Practitioners may work with clients on false beliefs that the world is no longer safe, for
example, or that they are incompetent because they have "let" a terrible event happen to the
Stress-inoculation training (SIT), another form of CBT (Foe,,et. al., 1999) where practitioners teach
clients techniques to manage and reduce anxiety, such as breathing, muscle relaxation and positive
self-talk.
Eye-movement desensitization and reprocessing (EMDR) - where the therapist guides clients
to make eye movements or follow hand taps, for instance, at the same time they are recounting
traumatic events. It's not clear how EMDR works, and, for that reason, it's somewhat
controversial (Taylor, et. al., 2003).
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Pharmacotherapy - The empirical and theoretical basis for effective drug treatments for PTSD are
discussed at length in a very informative chapter in the Handbook of PTSD science and practice
The above therapeutic interventions are discussed at length (Friedman, et. al., 2007). The
publication reviews psychobiological abnormalities associated with PTSD, mechanisms of action of
medications used to treat PTSD and a review of the growing literature on clinical trials. The additional
therapeutic interventions are discussed at length in an excellent article from the Journal of the
PTSD National Centre USA (Friedman & Schnurr, 2008) from which the above are summarised.
Regarding the pathophysiology of PTSD, there have been recent research findings to suggest the
disorder is reversible. The human brain can be re-wired with behavioural therapies which have
been shown to increase the volume of the hippocampus in PTSD patients (Bremner, Elzinga, &
Schmahl et. al., 2008). The brain is a finely-tuned instrument, which although fragile also has an
outstanding neuroplasticity and ability to adjust and regenerate promoting neurogenesis (Kays,
et. al., 2012)
Considering evidence suggesting changes in neuroanatomy associated with PTSD, psychological
deficits and social restrictions, PTSD is best viewed within a biopsychosocial construct
(Crawford & Dawn, 2013). The prognosis for recovery is hopeful and dependant on said
biopsychosocial variables, including protective factors such as home environment, significant
others, employment situation and multi modal therapeutic approaches (Kays, et. al., 2012).
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2,365 Words.
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