How Do Thoughts and Symptoms Change During PTSD Treatment?

What you need to know

• Changes in negative thoughts about oneself and the world are linked to PTSD symptom improvement during treatment
• Taking medication (or even a placebo pill) along with therapy may alter how changes in thoughts and symptoms are related
• Starting therapy and medication at the same time may impact an important mechanism of symptom improvement in therapy alone

Background on PTSD and treatment

Posttraumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. Symptoms include intrusive memories, avoidance of trauma reminders, negative changes in thinking and mood, and heightened reactivity. PTSD can significantly impact a person’s daily functioning and quality of life.

Two evidence-based treatments for PTSD are:

1. Prolonged Exposure (PE) therapy: A type of cognitive-behavioral therapy that involves gradually confronting trauma memories and reminders in a safe, therapeutic context.

2. Selective serotonin reuptake inhibitors (SSRIs): A class of antidepressant medications, like sertraline, that can help reduce PTSD symptoms.

An important factor in PTSD is negative thoughts about oneself and the world that develop after trauma. For example, someone might think “I am incompetent” or “The world is completely dangerous.” These thoughts can maintain PTSD symptoms over time.

How do thoughts change during PTSD treatment?

Previous research has shown that as negative trauma-related thoughts improve during PE therapy, PTSD symptoms tend to decrease. Specifically, reductions in negative thoughts about oneself and the world have been linked to symptom improvement.

The order of these changes is important. Studies of PE therapy alone have consistently found that changes in thoughts occur before changes in PTSD symptoms. This suggests that improving how someone thinks about themselves and the world may be a key mechanism through which PE therapy works.

However, less is known about how thoughts and symptoms change when medication is involved in treatment. This study aimed to examine these patterns across different PTSD treatments, including therapy alone, medication alone, and combined therapy and medication.

The current study

This study was part of a larger clinical trial comparing three PTSD treatments for combat veterans:

1. Prolonged Exposure therapy + placebo pill (PE+PLB)
2. Sertraline medication + enhanced medication management (SERT+EMM)
3. Prolonged Exposure therapy + sertraline medication (PE+SERT)

176 veterans participated in 24 weeks of treatment. Their PTSD symptoms and trauma-related thoughts were assessed at the start of treatment and at 6, 12, and 24 weeks.

The researchers used statistical methods to examine how changes in thoughts and symptoms were related over time in each treatment condition.

Key findings

1. Sertraline + Enhanced Medication Management (SERT+EMM):

   • Changes in negative thoughts about self and the world were related to changes in PTSD symptoms in both directions.
   • This means improvements in thoughts led to symptom reduction, and symptom reduction also led to improved thoughts.

2. Prolonged Exposure + Sertraline (PE+SERT):

   • Changes in negative thoughts about the world were related to PTSD symptom changes in both directions.
   • However, for thoughts about oneself, only improvements in PTSD symptoms led to improved thoughts. Changes in thoughts did not predict later symptom change.

3. Prolonged Exposure + Placebo (PE+PLB):

   • Surprisingly, there was no significant relationship between changes in negative thoughts and PTSD symptoms in either direction.
   • The only exception was that PTSD symptom improvement led to later improvements in thoughts about the world.

These findings differ from previous studies of PE therapy alone, which have consistently shown that changes in thoughts (particularly about oneself) drive later symptom improvement.

What does this mean for patients and clinicians?

The results suggest that adding medication (or even a placebo pill) to therapy may alter how changes in thoughts and symptoms unfold during PTSD treatment.

In particular, the typical pattern seen in PE therapy - where improvements in how someone thinks about themselves drive later symptom reduction - may be disrupted when a pill is involved.

There are a few potential explanations for this:

1. Expectancy effects: When patients take a pill (even a placebo), they may expect it to drive their improvement. This could make them less likely to attribute positive changes to their own efforts or increased coping ability.

2. Attribution of change: Patients taking medication may be more likely to attribute their improvement to the medication rather than to changes in their own thoughts or behaviors.

3. Multiple change agents: When both therapy and medication are introduced simultaneously, it may be harder for patients to recognize the specific effects of each component.

Clinical implications

These findings have important implications for PTSD treatment:

1. Shared decision-making: Clinicians should discuss the pros and cons of different treatment options (therapy alone, medication alone, or combined treatment) with patients. This includes considering how each approach might impact the therapeutic process.

2. Staged approach: Rather than starting therapy and medication simultaneously, it may be beneficial to start with one treatment and add the other later if needed. This could allow patients to better recognize the effects of each component.

3. Addressing attribution: In combined treatments, clinicians may need to explicitly address how patients are attributing their improvement. Helping patients recognize their own role in recovery, even when taking medication, could be important.

4. Individualized treatment: The best approach may vary for each patient. Some may benefit more from combined treatment, while others may do better with a single treatment modality.

Conclusions

• Adding medication to therapy for PTSD may change how improvements in thoughts and symptoms are related during treatment.
• The typical pattern seen in exposure therapy alone - where changes in thoughts drive later symptom improvement - may not occur when medication is also involved.
• These findings highlight the importance of thoughtful treatment planning and shared decision-making between patients and providers when considering PTSD treatment options.

While this study provides important insights, more research is needed to fully understand the complex relationships between thoughts, symptoms, and different treatment approaches for PTSD. The goal is to continue refining treatments to provide the best possible outcomes for individuals struggling with PTSD.