Treatment

The first line of treatment for PTSD should be an individual, manualized trauma-focused psychotherapy. Research found that these trauma-focused psychotherapies impart greater change and longer lasting improvements in the core symptoms of PTSD when compared to pharmacotherapies. However, when unavailable or not preferred by the patient, pharmacotherapy or individual non-trauma focused psychotherapy are still recommended as viable alternatives.[ Reference 1 ]

Psychotherapy for PTSD

According to the VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder (VA/DoD PTSD CPG), the empirically-supported trauma-focused psychotherapies use cognitive, emotional, or behavioral techniques to facilitate processing a traumatic experience. The trauma focus is a central component of the therapeutic process. Most involve 8-16 sessions with varying combinations of the following core techniques:

  • Exposure to traumatic images or memories through narrative or imaginal exposure
  • Exposure to avoided or triggering cues in vivo or through visualization
  • Cognitive restructuring techniques focused on enhancing meaning and shifting problematic appraisals stemming from the traumatic experience

Below summarizes effective trauma-focused approaches for the treatment of PTSD, which are further detailed in the VA/DoD PTSD CPG.

Prolonged Exposure (PE)

  • Emphasizes imaginal exposure through repeatedly recounting the traumatic narrative out loud
  • In vivo exposure
  • Emotional processing of the narrative experience

Cognitive Processing Therapy (CPT)

  • Emphasizes cognitive restructuring through Socratic dialogue to examine problematic beliefs, emotions, and negative appraisals stemming from the event, such as self-blame or mistrust

Eye Movement Desensitization and Reprocessing (EMDR)

  • Especially emphasizes breathing retraining and muscle relaxation. May also include cognitive approaches and exposure techniques

Brief Eclectic Psychotherapy (BEP)

  • Strong psychodynamic perspective
  • Incorporates imaginal exposure, written narrative processes, cognitive restructuring through attention to meaning and integration of the experience, relaxation techniques, and a metaphorical ritual closing to leave the traumatic event in the past and foster a sense of control

Narrative Exposure Therapy (NET)

  • Imaginal exposure through a structured oral life-narrative process that helps to integrate and find meaning in multiple traumatic experiences across the lifespan

There is lesser support for several individual, manualized non-trauma-focused therapies for patients diagnosed with PTSD, such as Stress Inoculation Training (SIT), Present-Centered Therapy (PCT), and Interpersonal Psychotherapy (IPT). While these treatments are not strongly recommended, evidence finds these treatments are better than receiving no treatment. Similarly, though limited data shows group therapy for PTSD is less effective than individual manualized group therapy, it is still suggested if the alternative is no treatment.

Pharmacotherapy for PTSD

The updated VA/DoD PTSD CPG provides even more specificity regarding recommended medications and those not recommended for the treatment of PTSD. This information is summarized in multiple tables throughout the guideline, as well as more succinctly in the VA/DoD PTSD CPG – Pocket Card. Some highlights include:

  • There is no evidence to recommend use of medication in the early period following a trauma to prevent development of PTSD
  • Initial pharmacological approach should include a first-line monotherapy trial of sufficient time for response and providers should monitor patients for outcomes and side effects
  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) continue to be the only medication classes strongly recommended as monotherapy for PTSD for patients who choose not to engage in or are unable to access trauma-focused psychotherapy
  • Recommended SSRIs include sertraline, paroxetine, or fluoxetine, and the SNRI, venlafaxine
  • There are many medications that are suggested or recommended against, including use of atypical antipsychotics as a monotherapy for management of PTSD, as well as the medications divalproex, tiagabine, guanfacine, risperidone, benzodiazepines, ketamine, hydrocortisone, or D-cycloserine
  • Cannabis or cannabis derivatives are not recommended, to treat PTSD given the lack of evidence for efficacy, known adverse effects, and associated risks. For additional information, see PHCoE Psychological Health Evidence Brief, Cannabis for Posttraumatic Stress Disorder
  • Benzodiazepines relatively contraindicated for patients with history of TBI, sleep apnea, chronic obstructive pulmonary disorder (COPD) or who have high rates of comorbid alcohol misuse and substance use disorder (SUD), particularly veterans with combat-related PTSD
  • Evidence does not support use of anticonvulsants or atypical antipsychotics as a monotherapy for management of PTSD
  • Providers should consider patient’s response or side effect history, and comorbidities, when choosing medication and dosage

References

  1. Management of Posttraumatic Stress Disorder Work Group. (2017). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder (Version 3.0). Washington, DC: Veterans Health Administration, Department of Defense.