Treatments for PTSD

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can develop in certain individuals after exposure to traumatic events, such as combat and sexual assault. PTSD is commonly treated with various types of psychotherapy and pharmacotherapy.

Treatments for PTSD
Specialtypsychiatry

Psychotherapy

Various practitioners have developed integrated programs of treatment that incorporate different psychotherapy techniques.

Techniques

Exposure therapy

Exposure therapy involves exposing the patient to PTSD-anxiety triggering stimuli, with the aim of weakening the neural connections between triggers and trauma memories (aka desensitisation).

Forms include:

  • Flooding – exposing the patient directly to a triggering stimulus, while simultaneously making them not feel afraid.
  • Systematic desensitisation (aka "graduated exposure") – gradually exposing the patient to increasingly vivid experiences that are related to the trauma, but don't trigger post-traumatic stress.

Exposure may involve a real life trigger ("in vivo"), an imagined trigger ("imaginal"), or a triggered feeling generated in a physical way ("interoceptive").[1]

Researchers began experimenting with virtual reality therapy in PTSD exposure therapy in 1997 with the advent of the "Virtual Vietnam" scenario. Virtual Vietnam was used as a graduated exposure therapy treatment for Vietnam veterans meeting the qualification criteria for PTSD. A 50-year-old Caucasian male was the first veteran studied. The preliminary results concluded improvement post-treatment across all measures of PTSD and maintenance of the gains at the six-month follow up. Subsequent open clinical trial of Virtual Vietnam using 16 veterans, showed a reduction in PTSD symptoms.[2]

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) focuses on the relationship between someone's thoughts, feelings, and behaviours. It helps people to understand the discrete nature of their thoughts and feelings, and to be better able to control and relate to them.

It is strongly recommended for treatment of PTSD by the American Psychological Association.[3]

Cognitive therapy

Cognitive therapy involves the therapist helping the patient develop and believe a new, less threatening understanding of their trauma experiences.

In one example of the specific practice of imagery rescripting, an adult patient who had a childhood trauma is encouraged to imagine the trauma experience from the point of view of an adult entering the room during the trauma and rescuing and protecting a vulnerable child.

Imagery rehearsal therapy helps people with nightmares. They document their nightmares, then work out how they would like them to change. They then regularly act out the improved dream scenarios.

Cognitive therapy is strongly recommended for treatment of PTSD by the American Psychological Association.[4]

Narrative exposure therapy

Narrative exposure therapy creates a written account of the traumatic experiences of a patient or group of patients, in a way that serves to recapture their self-respect and acknowledges their value. Under this name it is used mainly with refugees, in groups.[5] It also forms an important part of cognitive processing therapy.

It is conditionally recommended for treatment of PTSD by the American Psychological Association.[5]

Relaxation techniques

Relaxation techniques may be the earliest behavioural treatment for PTSD[6], and are often included as part of PTSD treatment.

Integrated programs

Prolonged exposure therapy

Prolonged exposure therapy (PE) was developed by Edna Foa and Micheal Kozak from 1986. It has been extensively tested in clinical trials. While, as the name suggests, it includes exposure therapy, it also includes other psychotherapy elements. Foa believes this therapy to incorporate all the efficacious elements of other known PTSD cognitive therapies. Foa was chair of the PTSD work group of the DSM-IV.

In prolonged exposure therapy, there will most likely be from 8 to 15 sessions. Patients will first be exposed to a past traumatic memory; following is an immediate discussion about the traumatic memory and, "in vivo exposure to safe, but trauma-related, situations that the client fears and avoids".[7]

Slowed breathing techniques and educational information is also touched on in these sessions.

PE is theoretically grounded in emotional processing theory, which states that PTSD symptoms are perpetuated by avoidance of trauma-related stimuli.[8] The goal of this therapy is "to reduce their emotional impact in terms of cognitive (thoughts), behavioral (behavior), or physiological effects (physical)".[9]

It is strongly recommended for treatment of PTSD by the American Psychological Association.[10]

Cognitive processing therapy

Cognitive processing therapy (CPT) was developed by Patricia Resick to treat PTSD in rape victims from 1988.[11][12] Clients write about their traumatic or scary memories in detail, and then read these memories to themselves daily and aloud in therapy sessions. This typically involves twelve sessions with a practitioner.[7] CPT draws on CBT, exposure therapy, narrative exposure therapy and information processing theory.

It is strongly recommended for treatment of PTSD by the American Psychological Association.[13]

Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) was developed by Francine Shapiro from 1988. It involves a patient thinking of upsetting images while they track a therapist moving their fingers back and forth in front of the patient. Patients are also asked to think of positive thoughts while they follow the fingers back and forth, then they write down what they are thinking.[7] This treatment is found to be similarly effective as exposure therapy.

A proposed neurophysiological basis behind EMDR is that it mimics REM sleep, which plays a vital role in memory consolidation. Imaging studies suggest that "eye movements in both REM sleep and wakefulness activate similar cortical areas."[14] Thus, the reorientation facilitated by EMDR "shifts the brain into a memory processing mode" without "integration of traumatic memories into associative cortical networks without interference from hippocampally mediated episodic recall."[14] The information can then be integrated completely, which consequently weakens the episodic memory of the event and the associations it produced. The restoration of the pathway can lead to recovery from PTSD.

EMDR for PTSD is supported by moderate quality evidence as of 2018.[15]

It is conditionally recommended for treatment of PTSD by the American Psychological Association.[16]

Brief eclectic psychotherapy

Brief eclectic psychotherapy for PTSD (BEPP) was developed by Berthold Gersons and Ingrid Carlier from 1994. It has an emphasis on the emotions of shame and guilt. It involves the patient creating a detailed account of the primary trauma experience (narrative exposure therapy) and writing a letter to person or organisation believed to be most responsible for the trauma. This occurs over sixteen sessions.[17]

It is conditionally recommended for treatment of PTSD by the American Psychological Association.[18]

Trauma-focused cognitive behavioral therapy

Trauma-focused cognitive behavioral therapy (TF-CBT) was developed by Anthony Mannarino, Judith Cohen and Esther Deblinger to help children and adolescents with PTSD. This was done from the mid 1990s.

It involves working through memories of the trauma in a safe and structured environment, trying to change unhelpful beliefs and thoughts, and gradual exposure to triggers which are being avoided. It is held over eight to 25 sessions with the child/adolescent and caregiver.

Trauma-focused cognitive behavioural therapy (CBT) has repeatedly been demonstrated to be effective and is currently recommended as a first-line treatment for PTSD by American Psychiatric Association; Australian Centre for Posttraumatic Mental Health, 2007 and National Institute of Clinical Excellence (NICE).

Stress inoculation training

Stress inoculation training was developed to reduce anxiety in doctors during times of intense stress by Donald Meichenbaum from 1985.[19] It is a package of techniques (relaxation, thought stopping and real-life exposure to feared situations) that has been used in PTSD treatment.[6]

Medication

There are many different therapies such as drug therapy, known as pharmacotherapy, is widely used as a treatment for PTSD. Drug therapy is considered less time consuming and easier to continue than psychotherapy (talk therapy). The only two medications for PTSD that are approved by the FDA are sertraline and paroxetine, both antidepressants of the selective serotonin reuptake inhibitors (SSRI) class.[20]

Medication is conditionally recommended for treatment of PTSD by the American Psychological Association.[21]

Antidepressants

Antidepressants are widely used in the treatment of PTSD and have consistently shown efficacy, though the magnitude of improvement is often modest. The most popular types of antidepressants are SSRIs, atypical antidepressants, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs).[20] SSRI are most often used as they are considered safer than TCAs and MAOIs.[22] To date, only sertraline and paroxetine carry FDA approval for PTSD, though in general, all SSRIs seem similarly effective. These medications appear to be helpful across all PTSD symptoms.[23] According to the APA Practice Guidelines, "SSRIs have proven efficacy for PTSD symptoms and related functional problems".[24]

Other medications

Prazosin, an alpha-adrenoceptor antagonist, is also widely prescribed, particularly for sleep-related symptoms. Early studies had shown evidence of efficacy,[20] though a recent relatively large trial failed to show a statistically significant difference between prazosin and placebo.[25] Antipsychotic medications have also been prescribed to treat PTSD, though clinical trials have not yielded consistent evidence for their efficacy.[20]

Autonomic Ganglion Blocks and PTSD

Stellate Ganglion Block (SGB) Treatment and Pterygopalatine Ganglion Block (Sphenopalatine, SPG, Sluder's, Nasal) SASPGB or Self-Administered SPG Blocks Stellate Ganglion Blocks used for CRPS (chronic regional pain syndrome) and other severe upper quadrant pains will sometimes relieve PTSD with a single shot. This had led to a multimillion dollar study by the Veterans Administration into this phenomena. [[Evidence Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic Stress Disorder (PTSD) Kim Peterson, MS, Donald Bourne, BS, Johanna Anderson, MPH, Katherine Mackey, MD, and Mark Helfand, MD, MS, MPH.]] This has led to the Stellate Ganglion Block being called "The God Block"

Pterygopalatine Ganglion Block: The Stellate Ganglion is at the bottom of the Superior Cervical Sympathetic Chain. Sympathetic fibers from the SG run to the Superior cervial ganglion and continue to the Sphenopalatine Ganglion, which is the largest Parasympathetic Ganglion of the Head which also contains Sympathetic and Somatosensory nerves. Blocking of the Sphenopalatine Ganglion can alleviate symptoms of severe anxiety, PTSD as well as numerous pain syndromes including headaches, migraines, TMD as well as a host of nasal, sinus and eye pains. This has led to SPG Blocks being called t"The Miracle Blocks". Sphenopalatine Ganglion Blocks have been safely utilized for over 110 years with any significant negative side effects. Blocks of the Shenopalatine ganglion can be done by injections, either intra-oral or extra-oral or by trans-nasal approach. Extra-oral injections can be done via Suprazygomatic approach or infrazygomatic approach. The most effective method of delivery for chronic conditions is Self-Administered SPG Blocks or SASPGB. [[Cranio. 2019 May;37(3):201-206. doi: 10.1080/08869634.2019.1592807. Neuromuscular Dentistry and the Role of the Autonomic Nervous System: Sphenopalatine Ganglion Blocks and Neuromodulation. An International College of Cranio Mandibular Orthopedics (ICCMO) Position Paper Ira L Shapira]]

Created: February 2017.

Alternative, complementary, and non-traditional treatment

Alternative medicine is any practice that is put forward as having the healing effects of medicine.[26][27] Its characteristics are that it does not originate from evidence gathered using the scientific method, is not part of biomedicine, and is contradicted by scientific evidence or established science.[26][27] Over the last decade, alternative treatment has become increasingly common in treating veterans with post-traumatic stress disorder. It is often used selectively in clinical trials. While it is not yet accepted medical treatment, there are often studies being done to test its effectiveness. Usually, it is used as a last resort due to the failure of conventional treatment.

Yoga therapy treatment

Yoga may be useful as a treatment for PTSD, but the evidence for this is weak.[28]

Trauma group therapy

In trauma group therapy, the groups range from 12 to 18 members and are completed over a 10- to 12-week period. Group therapy is cost-effective, and allows the participant to know they are not alone which can help in building another support system beside their family, and help in the development of people skills (communication, adversity, and confidence).[29] Group cognitive behavioral therapy is based on participants connecting and sharing past experiences while developing trust. Since World War II, the method of having soldiers come together and converse amongst each other has been in practice.[30] Patients remember and examine their war experiences and are encouraged to provide a clear picture without hiding or omitting details.[31] In “A Meta-Analytic Review of Exposure in Group Cognitive Behavioral Therapy for Posttraumatic Stress Disorder,” written by Barrera, she mentions that there are some three concerns with group therapy. Barrera mentions that members in the group can develop secondary post-traumatic stress disorder from hearing others traumatic events and that one participant may think their traumatic event is not comparable to another member’s event. These concerns can cause a delay in recovery, and there may not be enough time in a session for participants to talk about their experiences.[29]

Animal-assisted therapy

Clinicians can recommend animal-assisted therapy (AAT) to PTSD-affected patients when there are issues of isolation, anger management, and difficulty with social interactions.[32] AAT consists of a treatment plan of human-animal therapy interaction. Animals, like dogs, typically interact with individuals or groups who have anxiety, schizophrenia, addiction, and depression. Hospitalized patients are often the most likely candidates for animal-assisted therapy, but AAT can also help people in personal homes, schools, community centers, nursing homes, or rehabilitation centers. “Interaction with the  animals... decrease[s] blood pressure and to have a calming effect on individuals with dissociative disorder.”[32] AAT can also reduce anger and stress. AAT is often overlooked or not considered within PTSD patients treatment options.

Present centered therapy

Present centered therapy (PCT) is a non-trauma-focused, evidence-based psychotherapy (EBP) for PTSD. According to VA/DOD PTSD treatment guidelines (2015), it is currently a second-line recommended treatment (i.e., “weak-for”) for PTSD. [33][34]

Other interpersonal psychotherapy approaches

Other approaches, in particular involving social supports,[35][36] may also be important. An open trial of interpersonal psychotherapy[37] reported high rates of remission from PTSD symptoms without using exposure.[38] A current, NIMH-funded trial in New York City is now (and into 2013) comparing interpersonal psychotherapy, prolonged exposure therapy, and relaxation therapy.[39][40][41]

Benzodiazepines

Benzodiazepines are not recommended for the treatment of PTSD due to a lack of evidence of benefit and risk of worsening PTSD symptoms.[42] Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs can cause dissociation.[43] Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia.[44][45][46] While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2–5 times.[47] Additionally, benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there is some evidence that benzodiazepines may actually contribute to the development and chronification of PTSD. For those who already have PTSD, benzodiazepines may worsen and prolong the course of illness, by worsening psychotherapy outcomes, and causing or exacerbating aggression, depression (including suicidality), and substance use.[47] Drawbacks include the risk of developing a benzodiazepine dependence, tolerance (i.e., short-term benefits wearing off with time), and withdrawal syndrome; additionally, individuals with PTSD (even those without a history of alcohol or drug misuse) are at an increased risk of abusing benzodiazepines.[48][49] Due to a number of other treatments with greater efficacy for PTSD and less risks (e.g., prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, cognitive restructuring therapy, trauma-focused cognitive behavioral therapy, brief eclectic psychotherapy, narrative therapy, stress inoculation training, serotonergic antidepressants, adrenergic inhibitors, antipsychotics, and even anticonvulsants), benzodiazepines should be considered relatively contraindicated until all other treatment options are exhausted.[50][51] For those who argue that benzodiazepines should be used sooner in the most severe cases, the adverse risk of disinhibition (associated with suicidality, aggression and crimes) and clinical risks of delaying or inhibiting definitive efficacious treatments, make other alternative treatments preferable (e.g., inpatient, residential, partial hospitalization, intensive outpatient, dialectic behavior therapy; and other fast-acting sedating medications such as trazodone, mirtazapine, amitripytline, doxepin, prazosin, propranolol, guanfacine, clonidine, quetiapine, olanzapine, valproate, gabapentin).[48][51][52]

Glucocorticoids

Glucocorticoids may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes PTSD, but long-term use may actually promote neurodegeneration.[53]

Cannabinoids

As of 2019 cannabis is specifically not recommended as a treatment.[54][55] However, use of cannabis or derived products is widespread among U.S. veterans with PTSD.[56]

The cannabinoid nabilone is sometimes used for nightmares in PTSD. Although some short-term benefit was shown, adverse effects are common and it has not been adequately studied to determine efficacy.[57] Currently, a handful of states permit the use of medical cannabis for the treatment of PTSD.[58]

MDMA

Researchers are exploring the use of MDMA as an adjunctive treatment with evidence-based psychotherapy, but there is not any evidence for improved efficacy for this combination treatment as of 2020.[59]

Multicultural perspectives

Trauma is ingrained in culture, and different cultures receive and treat trauma in different ways.[60] Some cultures treat trauma with ancient practices such as praying or ritual.[60]

Historical trauma is defined as traumatic stressors resulting from historical events that affect indigenous and First Nation communities. Many therapists use cultural intervention, the practice of culture, a sense of belonging and having a purpose and "a return to indigenous traditional practices" as a form of treatment for HT.[61] This works by not making First Nation individuals adapt to the problems that result from historical trauma, or by First Nation individuals trying to change the way they think, “but rather spiritual transformations and accompanying shifts in collective identity, purpose, and meaning making.”[61] Many Indigenous and First Nations communities developed HT as a result of forced European colonization beginning in the 15th century. HT came about during the colonial era and is ongoing. HT is often overlooked due to mental health professionals working under the impression that PTSD symptoms are as equivalent to those that undergo historical trauma. HT is often misunderstood by some mental health professionals because these only focus on the individual, not historical causes and events.

Researchers at the Stress-response Syndromes Lab at the University of Zurich, Switzerland, use the historical contributions of the Swiss psychologist Carl Gustav Jung to develop culturally sensitive treatments like symbolism and different myth stories to treat PTSD. Jung’s psychology asserts that “the fundamental ‘language’ of the psyche is not words, but images...studying the trinity of myths, metaphors, and archetypes enhances clinical interventions and psychotherapy.”[62]

A combination of Western psychotherapy and Japanese culture is helpful when using psychotherapy as an effective treatment in Japan.[63] "After the Kobe-Awaji earthquake in 1995...Japanese psychologists became acutely aware of the need to receive specialized training in the treatment of posttraumatic stress disorder (PTSD) as well as crisis intervention."[63] Psychotherapy is a recent practice used in Japan in which some practices of western psychotherapy are “modified to suit the Japanese client population” and forms to create a sense of cultural integration.[63] The  two main methods of treatment practices Japanese psychotherapists work with are nonverbal tasks and parallel therapy.

Recommendations

A number of major health bodies have developed lists of treatment recommendations. These include:

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