MONTHLY RESEARCH SPOTLIGHT

A Novel Therapy, Using Writing, Shows Promise for PTSD

Aug. 23, 2023

The News

A comparatively quick treatment for post-traumatic stress disorder, in which a patient writes about traumatic experiences in five supervised 30-minute sessions, is as effective as the therapies most recommended by federal agencies, according to a study published on Wednesday.

The treatment, called written exposure therapy, involves asking clients to write down the thoughts and feelings that occurred during a traumatic event, and then speak with the therapist about the writing process. In later sessions, they are asked to write about how the event has affected their lives.

In the new study published in JAMA Psychiatry, 178 veterans with PTSD received either written exposure therapy or prolonged exposure therapy, which consists of eight to 15 therapy sessions that are 90 minutes long in which the patient vividly imagines the terrifying situation, and then, between sessions, confronts real-life reminders of it.

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The two therapies were found to be equally effective, and only 12.5 percent of subjects dropped out of the written exposure group before completing a course of treatment, compared with 35.6 percent in the prolonged exposure group. In 2018, a study by the same team found that written exposure therapy was as effective as cognitive processing therapy, another first-line, or most highly recommended, PTSD treatment.

Writing down traumatic memories may be easier for some people, if they feel shame or embarrassment about what happened to them, said Denise Sloan, a psychologist who helped develop the treatment and is an author of the study. She said patients were asked to write by hand, which takes longer and allows them to engage with the memory.

“It’s a slower process, that allows them to better think through ‘what happened next, and who was there, and what did they say,’ because they’re writing about it,” said Dr. Sloan, associate director of the Behavioral Science Division of the National Center for PTSD. “It slows everything down, versus just saying it out loud.”

The therapy was inspired by the work of James Pennebaker, a Texas psychologist who, in the 1980s, began experimenting with what he called “expressive writing,” and found that people who regularly wrote about negative life experiences had stronger immune systems and paid fewer visits to the doctor.

The first study of written exposure therapy as a treatment for PTSD appeared in 2012. It works, Dr. Sloan said, much the way other trauma-focused treatments do: by allowing the client to confront the traumatic memory, lessening their fear and avoidance, and allowing them to identify misconceptions like self-blame.

Why It Matters

Cognitive processing therapy and prolonged exposure therapy, the two treatments most highly recommended by the Departments of Veterans Affairs and Defense, have been in widespread use since the 1980s and are backed up by abundant research. A newer method, eye movement desensitization and reprocessing, is rapidly growing in popularity.

But all three are time-intensive, requiring sessions of 60 to 90 minutes for three months or more. A large number of patients — an average of 20 percent, and sometimes as high as 50 percent, studies have shown — drop out before completing a course of treatment.

Written exposure therapy, Dr. Sloan said, seems to achieve similar effects in fewer sessions.

“We have a lot of people that need mental health treatment, and we can’t accommodate the demand,” she said. “We need to revisit what we’re doing and how much is necessary for a good outcome. Because most people can’t go to treatment for 12 to 16 sessions.”

What’s Next

Data on the effectiveness of written exposure therapy is still emerging.

The studies comparing it to cognitive processing therapy and prolonged exposure therapy are non-inferiority trials — devised to demonstrate that a newer treatment is not worse than an established one — and “not as scientifically stringent” as trials devised to determine superiority, said Dr. Barbara Rothbaum, one of the developers of prolonged exposure therapy. She added that dropout rates at her clinic, at Emory University, were around 10 percent.

There is a reason, she said, that talk therapy has such a strong record of success in treating PTSD.

“There is something inherently healing about saying out loud the worse, most scary, most embarrassing, most shameful moment of your life to another human who is trying to be helpful,” she said. “Does it have to be that? No.”

Written exposure therapy was not endorsed as a first-line intervention by the Departments of Veterans Affairs and Defense in its most recent clinical practice guidelines, largely, Dr. Sloan said, because of the small number of published studies examining it.

That is likely to change over the next two years, she said, as a number of larger trials are completed. Clinicians, too, are going to have to get used to the idea of using writing, in addition to speech, to engage with patients on painful topics.

“Some people, they feel threatened by this, because it kind of challenges the crux of what they generally do,” she said. “It flies in the face of what they think is important in treatment.”

Ellen Barry covers mental health. She has served as The Times’s Boston bureau chief, London-based chief international correspondent and bureau chief in Moscow and New Delhi. She was part of a team that won the 2011 Pulitzer Prize for International Reporting.

J Am Acad Child Adolesc Psychiatry. 2022 Aug; 61(8): 957–959.

Published online 2022 Feb 24. doi: 10.1016/j.jaac.2022.02.007

PMCID: PMC8865911

PMID: 35219806

Posttraumatic Stress Disorder in Children in the Context of the COVID-19 Pandemic

Betty Pfefferbaum, MD, JD∗

Author information Article notes Copyright and License information Disclaimer

With its global spread and protracted threat, mounting morbidity and mortality, pervasive social and economic ramifications, vital public health measures, and often compromised risk communication, the COVID-19 pandemic has increased the risk to children’s emotional health relative to more common biological, natural, and man-made events. Posttraumatic stress disorder (PTSD) and PTSD symptoms have been the primary focus of child disaster mental health research. The adult literature has questioned the appropriateness of focusing on PTSD in the context of the COVID-19 pandemic, because most of the extensive adult research on PTSD has not appropriately assessed all diagnostic criteria for the disorder.1 The pandemic experiences of participants in most studies examined in a recent review did not meet the PTSD exposure criterion,1 which requires that exposure be “directly” experienced, witnessed in person, secondary to the involvement of a close family member or friend, or “repeated or extreme” contact with “aversive details” of the event.2 Instead, participants’ experiences were primarily indirect (eg, media contact) and constituted fear related to contracting the disease.1 This concern extends to the relatively few empirical COVID-19 studies of PTSD in children and exemplifies a problem in many child disaster mental health studies, especially those assessing general population samples that primarily comprise children who do not meet the PTSD exposure criterion.

A review of exposure characteristics, PTSD rates, and the assessment of diagnostic criteria in 6 COVID-19 studies that assessed PTSD in general child populations3, 4, 5, 6, 7, 8 evidenced the concerns raised in the adult literature.1 Only 2 papers provided much detail on participants’ COVID-19 experiences or exposure,5 , 6 and none clearly limited the diagnosis of PTSD to participants who met the exposure criterion. In a sample with a sizeable number of children who knew someone who tested positive for, or died of, COVID-19, 45% scored above the study’s threshold for PTSD.5 In another study, relatively few Saudi Arabian children personally suffered COVID-19 or had close relatives or friends with the disease, although the authors reported “potential PTSD” in 13.0% of the participants.6 Two other studies used scales to assess children’s pandemic experiences but provided minimal information on the items queried8 or the results.3 , 8 Reported rates of “probable PTSD” were 35.4% in a sample of adolescents in a “severely affected” area of China8 and 16.9% in a sample of students in a Chinese community after strict lockdown measures had been lifted.3 Two studies, which noted widespread public health restrictions but failed to describe participants’ COVID-19 exposures, found that 20.7% of children from regions across China scored above the study’s cutoff for PTSD4 and “high risk” for PTSD in 3.16% of a sample of Chinese school children in an area that was not severely affected by the disease.7

The 6 child studies varied in assessing other criteria needed to diagnose PTSD, including a specific constellation of symptoms anchored in the traumatic experience, clinically significant distress or impaired functioning, and symptoms for more than 1 month.2 All but 1 of the studies3 used well-established tools to assess PTSD. Unfortunately, for the most part, the papers failed to indicate whether and/or how these tools were modified. Only 2 of the scales used included all DSM-5 symptoms,7 , 8 and only 1 paper considered the requisite constellation of PTSD symptoms.7 One study clearly anchored symptoms in the pandemic experience,8 and 1 study queried children’s pandemic experiences and administered a scale that linked children’s symptoms to the coronavirus illness.6 The scales used in the other studies linked symptoms to a traumatic or stressful event, but the papers did not indicate whether the assessment referenced COVID-19.3, 4, 5 , 7 Most studies identified a cut-off score to indicate probable PTSD with scales that assessed the presence,3 , 5 frequency,6 , 8 or severity4 of endorsed symptoms. To indicate risk for PTSD, 1 study measured the frequency of symptoms and specified a score for the requisite number of symptoms in each of the 4 PTSD symptom clusters.7 The scales used in some studies assessed functioning3 or how distressed4 or bothered7 , 8 participants were by symptoms, but none of the papers explicitly mentioned measuring or scoring distress or functioning.3, 4, 5, 6, 7, 8 One study assessed symptoms “in the past month,”6 2 studies used scales that specified a 1-month duration,3 , 5 and others referenced8 or used scales4 with a shorter timeframe. The timeframe in 1 study was unclear.7

The extent to which children are likely to meet full criteria for a diagnosis of PTSD related to their COVID-19 experiences remains unclear. It is difficult to reconcile the PTSD rates in the 6 studies with the relatively low levels of DSM-5 qualifying exposure reported and with the fact that most of the studies did not assess all DSM-5 PTSD symptoms; most did not specify whether symptoms were linked to the children’s COVID-19 experiences; none explicitly reported including an assessment of distress or functioning in determining diagnostic status; and some did not document the required minimum 1-month duration of symptoms. Indirect experiences and concerns about the pandemic, even in severely affected communities, do not constitute the requisite exposure for PTSD. Moreover, clinical cutoff scores that simply sum endorsed symptoms, and even those that consider the specific number and distribution of symptoms across symptom clusters, do not establish clinically significant outcomes, especially if these symptoms do not cause distress or affect functioning. These concerns do not mean that the assessment of PTSD in general population samples is inappropriate; instead, they caution against overdiagnosis, which has implications for both clinical care and research. Notwithstanding the potential theoretical and clinical importance of individual posttraumatic symptoms and subthreshold outcomes, clinicians should avoid attributing clinical significance to symptoms that may represent normative distress rather than pathology, and researchers should be rigorous in investigating PTSD to avoid contaminating intervention science with misapplied approaches that produce misleading results and inaccurate conclusions.

Children’s experiences (eg, direct exposure vs community effects) and outcomes (eg, psychiatric conditions vs distress) are key considerations in the choice of services used to address their needs. Clinicians must identify and treat those children with psychiatric conditions, whereas trained school personnel and paraprofessionals commonly deliver resilience-enhancing interventions in nonclinical community settings. Thus, diagnostic considerations are important in planning and delivering services, in selecting interventions, and in personnel decisions. With respect to the COVID-19 pandemic, children who themselves, or whose family members, contract the disease are more likely to require clinical services than those whose only contact with the pandemic reflects generalized concern. Children with pre-existing conditions and past trauma exposure are at heightened risk. It remains unclear whether the rate of PTSD is increasing in the context of this pandemic, but the stress occasioned by it is likely to have lasting implications for many children.

Epidemics, pandemics, and global and novel catastrophes suggest the importance of continued attention to what constitutes trauma exposure. The PTSD exposure criterion has been modified across successive editions of the DSM. To underscore the importance of diagnosis in the context of this and future pandemics, it would seem appropriate and prudent to re-examine and consider modifying the PTSD exposure criterion to clarify specifically which, if any, experiences with pandemics should qualify as trauma exposure. Because of the importance of diagnosis in guiding clinical care, researchers should opt for rigor when choosing outcome measures and should be circumspect in interpreting their results. Research is needed to examine whether and how increased stress may contribute to the incidence of PTSD in children in the future.

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Footnotes

The author has reported no funding for this work.

This article is part of a special Clinical Perspectives series shedding a new and focused light on clinical topics within child and adolescent psychiatry. The series covers problems, controversies, or tenets of the care of children and adolescents with psychiatric disorders from a new vantage point, including populations, practices or clinical topics that may be otherwise overlooked. The series was edited by Deputy Editor Schuyler W. Henderson, MD, MPH, and Editor-in-Chief Douglas K. Novins, MD.

Disclosure: Dr. Pfefferbaum has reported no biomedical financial interests or potential conflicts of interest.

All statements expressed in this column are those of the authors and do not reflect the opinions of the Journal of the American Academy of Child and Adolescent Psychiatry. See the Guide for Authors for information about the preparation and submission of Commentaries.

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References

1. Asmundson G.J.G., Taylor S. Garbage in, garbage out: the tenuous state of research on PTSD in the context of COVID-19 pandemic and infodemic. J Anxiety Disord. 2021;78 doi: 10.1016/j.janxdis.2021.102368. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

2. American Psychiatric Association . 5th ed. American Psychiatric Association; Washington, DC: 2013. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. [Google Scholar]

3. Cao C., Wang L., Fang R., et al. Anxiety, depression, and PTSD symptoms among high school students in China in response to the COVID-19 pandemic and lockdown. J Affect Disord. 2022;296:126–129. doi: 10.1016/j.jad.2021.09.052. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

4. Ma Z., Idris S., Zhang Y., et al. The impact of COVID-19 pandemic outbreak on education and mental health of Chinese children aged 7-15 years: an online survey. BMC Pediatr. 2021;21:95. doi: 10.1186/s12887-021-02550-1. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

5. Murata S., Rezappa T., Thoma B., et al. The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depress Anxiety. 2021;38:233–246. doi: 10.1002/da.23120. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

6. Sayed M.H., Hegazi M.A., El-Baz M.S., et al. COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia. PLoS One. 2021;16(8) doi: 10.1371/journal.pone.0255440. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

7. Yue J, Zang X, Le Y, An Y. Anxiety, depression and PTSD among children and their parent during 2019 novel coronavirus disease (COVID-19) outbreak in China. Curr Psychol. Published online November 14, 2020. 10.1007/s12144-020-01191-4 [PMC free article] [PubMed] [CrossRef]

8. Zhen R, Zhou X. Latent patterns of posttraumatic stress symptoms, depression, and posttraumatic growth among adolescents during the COVID-19 pandemic. J Trauma Stress. Published online August 2, 2021. 10.1002/jts.22720 [PMC free article] [PubMed] [CrossRef]

November 2020

Did Media Coverage of 9/11 Increase Risk for PTSD in Children?

By: Matthew Tull, PhD

The effects of the tragic events of September 11, 2001, were inescapable and may have increased risk for PTSD in children and adults. Even people far away from the terrorist attacks on the World Trade Center and Pentagon were exposed to upsetting and traumatic images. This was largely due to the extensive television coverage of the terrorist attacks. A study in the Journal of Anxiety Disorders, conducted by Dr. Michael Otto and colleagues at Massachusetts General Hospital and Harvard Medical School, examined whether this extensive media coverage may have put children at risk for the development of PTSD.

Kids and Media Coverage of 9/11: The Study

This study looked at 84 mothers and their 166 children (ages 7 to 15) from the Boston area who did not have a loved one killed in the 9/11 attacks. The majority of the children heard about the attacks either in the morning (53%) or afternoon (42%) of 9/11. In addition, many children were exposed to some television coverage of the events.

13.8% did not watch any television coverage of the attacks.
25.9% watched under an hour of television coverage of the attacks.
22.3% watch one hour of television coverage of the attacks.
30.7% watched 2 to 4 hours of television coverage of the attacks.
4.8% watched 4 to 6 hours of television coverage of the attacks.
2.4% watched over 6 hours of television coverage of the attacks.

PTSD Rates and Risk Factors for PTSD

They found that 5.4% of children and 1.2% of parents in the study had symptoms consistent with a diagnosis of PTSD stemming from indirect exposure to 9/11 events. An additional 18.7% of children and 10.7% of parents showed some symptoms of PTSD, but not enough for an official PTSD diagnosis).

Among all children, the amount of television watched on 9/11 was not linked with PTSD rates. However, when considering only children 10 and younger, the development of PTSD was related to the amount of television watched on the day of 9/11. Children who showed more distress during the week of 9/11 and identified more with the victims of 9/11 were more likely to develop symptoms of PTSD.

Looking Out For Our Children

When people think of PTSD, they often think that a person has to directly experience a traumatic event. However, this study shows that even indirect exposure to traumatic events can increase the likelihood of developing PTSD in populations that may be considered vulnerable, such as children.

The live television coverage of 9/11 meant that many children were exposed to distressing images that may have been hard for them to comprehend or cope with. In situations like this, it is important for parents to monitor what their children are watching and, at the same time, help them understand and cope with the situation.

The Sidran Institute, a nonprofit organization that provides resources on trauma and PTSD, provides some helpful tips for how parents can help their children cope with and understand a traumatic event.

Otto, M.W., Henin, A., Hirshfeld-Becker, D.R., Pollack, M.H., Biederman, J., & Rosenbaum, J.F. (2007). Posttraumatic Stress Disorder Symptoms Following Media Exposure to Tragic Events: Impact of 9/11 on Children at Risk for Anxiety Disorders. Journal of Anxiety Disorders, 21, 888-902. doi:10.1016/j.janxdis.2006.10.008

https://www.sidran.org/resources