Post-traumatic stress disorder

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Although some people with PTSD may recover with no (or limited) intervention, many who do not receive effective treatment will over time develop chronic problems. Most people presenting with PTSD have usually had symptoms for many months, or even years. The duration of the disorder in itself does not prevent people from benefiting from effective treatment. The severity of the initial response to the trauma is a reasonable indicator of the need for early intervention. PTSD responds to a variety of psychological and pharmacologic interventions.

Goals of treatment

The goals of treatment are to:[68]

Reduce severity of symptoms
Prevent or treat trauma-related comorbid conditions that are present or may emerge
Improve adaptive functioning and restore sense of safety and trust
Prevent relapse
Limit generalization of the danger experienced as a result of the traumatic event.

General principles of treatment

All patients should be treated with respect, trust, and understanding, with technical language kept to a minimum. Healthcare professionals should be familiar with the cultural background of the patient and take appropriate steps to overcome barriers presented by language or cultural differences: for example, by the use of interpreters and bicultural therapists. Practical support delivered in an empathetic manner is important in promoting recovery following traumatic events.[43]
All treatments should be delivered by competent, appropriately trained individuals, and underpinned by the provision of psychological education. This should include information about common reactions to trauma (including the symptoms of PTSD and its course and treatment), and about the likely course of the treatment. Individuals delivering treatments should receive appropriate supervision.[43]
Health and social care workers should be aware of the psychological impact of traumatic incidents in their immediate postincident care of survivors and offer practical, social, and emotional support to those involved.
Treatment should not be withheld or delayed because of court proceedings or applications for compensation.[43]
Patients are likely to be anxious about engaging in treatment. Healthcare professionals should recognize the challenge that this presents, and respond appropriately: for example, by following up people who miss scheduled appointments. Trauma-focused psychological treatments should normally only be considered when the patient considers it safe to proceed.[43]
Families and caregivers play a central role in supporting people with PTSD. As is the case with other psychiatric conditions, particularly long-term ones, it is important to recognize the burden that this places on caregivers. Depending on the nature of the trauma and its consequences, families may also need support themselves. Healthcare professionals should be aware of the impact of PTSD on the whole family and, where appropriate, ensure that the families of PTSD patients are informed about common reactions to traumatic events, including the symptoms of PTSD and its course and treatment.[43]
Recovery from PTSD can be facilitated by ensuring that patients and their families receive appropriate practical and social support, particularly in the immediate aftermath of the trauma. If necessary, help or advice should be offered on how to reduce or remove continuing threats related to the traumatic event.[43]
To guide and inform intervention and prevention efforts in the early and midterm stages after mass trauma, 5 empirically supported intervention principles have been set out: (1) a sense of safety, (2) calming, (3) a sense of self- and community efficacy, (4) connectedness, and (5) hope.[46]

Active monitoring

Recommended in patients with subthreshold symptoms of PTSD within 1 month of a traumatic event. A follow-up contact should be arranged within 1 month.[43] Some patients with moderate symptoms may be considered for therapies usually reserved for severe symptoms; however, this is largely determined by patient choice.

Psychological interventions

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

When symptoms are severe (i.e., the distress caused is felt to be unmanageable by the patient, and/or symptoms cause significant impairment in social and/or occupational functioning, and/or there is considered to be significant risk of suicide, harm to self, or harm to others) and have been present for <3 months after the trauma, trauma-focused cognitive behavioral therapy (TFCBT) is recommended.[44][69][70][72][73]

Patients with any severity of symptoms present for 3 months or longer should also be offered TFCBT.[74] However, an alternative trauma-focused psychological treatment, eye movement desensitization and reprocessing (EMDR), is also recommended in this patient group.[44][73][75]

Patients who have no (or only limited) improvement with this treatment should be offered an alternative form of trauma-focused psychological treatment, or a course of pharmacologic treatment.

There is some evidence for the benefit of non-trauma-focused cognitive behavioral therapy (CBT)-based interventions.[73][76] This evidence is not as strong as that for TFCBT or EMDR.[77] Non-trauma-focused psychological interventions such as CBT and interpersonal psychotherapy may have a particular role in the treatment of people with PTSD who are not ready to engage with trauma-focused interventions or are unlikely to tolerate them.[73][75] Emerging evidence suggests that interpersonal therapy may be effective in patients with a history of sexual trauma, although these findings require replication in a prospective trial.[78]

Trauma-focused cognitive behavioral therapy (TFCBT)

If treatment starts within the first month after the trauma, shorter interventions (i.e., 5 sessions) may be effective. Otherwise, duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event.
Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed. This is more likely after traumatic bereavement, or multiple traumatic events, where there is chronic disability resulting from the trauma, and where significant comorbid disorders or social problems are present. In such instances, stabilization work or intervention to help regulate emotions and interpersonal relationships may be required before trauma-focused work begins.
Treatment sessions should be regular and frequent (i.e., usually at least once a week), and longer sessions (e.g., 90 minutes) are often necessary when the trauma is discussed in the treatment session. It may initially be too difficult for people to disclose details of their traumatic event. In such cases, it may be necessary to devote several sessions to establishing a trusting therapeutic relationship and emotional stabilization before addressing the traumatic event.

Eye movement desensitization and reprocessing (EMDR)

Based on the theory that the dysfunctional intrusions, emotions, and physical sensations experienced by trauma victims are due to the improper storage of the traumatic event in implicit memory.
EMDR procedures are based on stimulating the person's own information processing in order to help integrate the targeted event as an adaptive contextualized memory. People are made ready to attend to the memory and associations while their attention is also engaged by a bilateral physical stimulation (e.g., eye movements, taps, or tones). Many of the procedures used overlap with those used in TFCBT. Replacing negative cognitions associated with the trauma with positive cognitions overlaps with cognitive therapy.
Duration of therapy should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed. This is more likely after traumatic bereavement, or multiple traumatic events, where there is chronic disability resulting from the trauma, and where significant comorbid disorders or social problems are present. In such instances, stabilization work or intervention to help regulate emotions and interpersonal relationships may be required before trauma-focused work begins.

Cognitive behavioral therapy (CBT)

All non-trauma-focused CBT programs for PTSD include an element of psychological education as well as cognitive therapy and/or stress management.
- Cognitive therapy: the therapist helps patients to identify and modify unhelpful thoughts and beliefs that lead to disturbing emotions and impaired functioning. Cognitive treatment of PTSD focuses on the identification and modification of interpretations of the trauma and its aftermath that lead the patient to overestimate threat.
- Stress management: aims to help people develop a sense of mastery over their stress through learning a range of coping skills, which they then practice in a graduated fashion.

Overlap of therapies

There is considerable overlap across psychological interventions in therapeutic approaches and techniques, and there is no consensus on how these psychotherapies should be categorized.[44] CBT draws on psychological models describing the relationship between thoughts, emotions, and behavior. It uses a range of therapeutic techniques aimed at reducing distressing emotions through changing thoughts, beliefs, and/or behavior. Such approaches have been shown to be effective for a range of mental health problems, and in recent years, specific programs for particular disorders have been developed. Treatment is regarded as TFCBT if it is mainly focused on the trauma memory and its meaning and, therefore, exposure-based CBTs such as cognitive processing therapy and prolonged exposure therapy are encompassed by the term TFCBT.
There is some overlap in treatment techniques between TFCBT and stress management. In TFCBT, people with PTSD sometimes receive training in stress management strategies; similarly, stress management may involve discussion of the meaning of the traumatic event in later sessions, overlapping with the cognitive elements of TFCBT.

There is no convincing evidence for a clinically important effect of other forms of psychological treatment (hypnotherapy, psychodynamic therapy, or systemic psychotherapy) for PTSD.[42][44][70][72][73][75] However, there is some emerging evidence suggesting that present-centered therapies (e.g., supportive therapy/nondirective therapy) can be beneficial to PTSD sufferers, although they are less effective than trauma-focused interventions.[70][79] [ ] Preliminary studies indicate that couples-based therapy may reduce PTSD symptoms for the person with PTSD; however, it is unclear whether it benefits their partner or relationship.[80]

The available evidence is sparse, but it suggests that both psychological treatment as well as the combination of psychological therapy plus pharmacotherapy are superior to pharmacotherapy alone in improving PTSD symptom severity in the long term.[81][82]

Pharmacotherapy

Owing to the relatively small effect sizes demonstrated in systematic reviews of randomized controlled trials, pharmacotherapy should be considered for the treatment of PTSD only after trauma-focused psychological treatment has been initiated, or in the following situations:[42][43][44][83][84]

Where a person expresses a preference not to engage in a trauma-focused psychological treatment, or cannot start a psychological therapy because of serious ongoing threat of further trauma (e.g., where there is ongoing domestic violence)
For patients who have failed to respond to or could not tolerate a course of trauma-focused psychological treatment
Where there is a lack of availability of timely psychological treatments
As an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that significantly impacts on a person's ability to benefit from psychological treatment.

The strongest evidence is for the selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline, although it is acknowledged that these agents have low effect.[75][85][86][87][88] An SSRI licensed for panic disorder should be offered first-line.[43] If there is no response to a particular SSRI, consider increasing the dose (within approved limits), switching to a different SSRI, or starting on the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. Venlafaxine reduces PTSD symptoms as well as functional disability, and may also be an appropriate option for patients who do not tolerate SSRIs.[85][89] In the absence of an adequate response, SSRI or venlafaxine therapy may be augmented with risperidone, quetiapine, or the alpha-1 adrenoceptor antagonist prazosin.[89] Quetiapine and risperidone are both atypical antipsychotics. Risperidone has shown some promising results as an augmentation treatment for patients with PTSD who have shown a partial response to an SSRI, although a large study of veterans did not find risperidone to be superior to placebo.[83][88][90][91] Prazosin has shown efficacy in specifically reducing the severity and frequency of trauma-related nightmares.[88] Owing to its proven efficacy as monotherapy, quetiapine may be used alone if neither SSRIs nor venlafaxine are tolerated.[89]

If clinically significant symptoms are still evident despite treatment with an SSRI, venlafaxine, risperidone (adjunct), prazosin (adjunct), or quetiapine (adjunct or monotherapy), a less evidence-based treatment may be considered.[89] Three single randomized controlled trials found evidence of superiority over placebo for the tricyclic antidepressant amitriptyline, the monoamine oxidase inhibitor phenelzine, and the newer tetracyclic antidepressant mirtazapine.[92][93][94] Due to the small size of these individual studies, amitriptyline, phenelzine, and mirtazapine are considered less preferred options. One Cochrane review concluded that amitriptyline and mirtazapine may improve PTSD symptoms based on low-certainty evidence.[85]

Length of drug treatment for PTSD has not been adequately addressed in the research literature; in the authors’ clinical experience, if there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal. The results of one large systematic review and meta-analysis of 28 studies suggested that in patients with anxiety disorders (including PTSD) who respond to treatment with antidepressants, treatment for at least one year is associated with reduced rates of relapse, and is well tolerated. The studies included in the meta-analysis had a treatment duration of up to one year only, so no evidence was available on the efficacy and tolerability of treatment beyond this point; the authors stressed that this lack of evidence after this period should not be interpreted as explicit advice to discontinue antidepressants after one year.[95]

Pregnant or breast-feeding women

Psychological interventions are the treatment of choice in these patients. Pharmacotherapy is not recommended due to the risk some drugs pose to the developing fetus or infant.

Treatment of comorbidities

Depression:

When a person presents with PTSD and depression, healthcare professionals should consider treating the PTSD first, as depression often improves when PTSD is successfully treated.
If the depression is so severe as to make psychological treatment of PTSD very difficult (e.g., when the person has extremely low energy, poor concentration, inactivity, or high suicide risk), depression should be treated first.
When assessment identifies a high risk of suicide or harm to others, healthcare professionals should first focus on managing this risk.
See Depression in adults for more information.

Alcohol or drug misuse:

Where alcohol or drug use or dependence is likely to significantly interfere with effective treatment, the drug or alcohol problem should be treated first. There is some evidence that trauma-focused psychological therapies with adjunctive interventions for substance use disorder may be effective.[96] [ ]
See Overview of substance use disorders and overdose for more information.

Personality disorder:

Duration of treatment may need extending when the person with PTSD has comorbid personality disorder.
See Personality disorders for more information.

Psychosis

There is evidence that individuals with current psychotic disorders comorbid with PTSD can benefit from TFCBT or EMDR.[97]

Grief:

When a person has lost a close friend or relative due to an unnatural or sudden death, he or she should be assessed for PTSD and traumatic grief. In most cases, PTSD should be treated first, although without avoiding discussion of the grief.

Specialist referral

In considering whether to refer to a specialist, healthcare professionals should be mindful of the principle that all treatments should be underpinned by the provision of psychological education, and delivered by competent, appropriately trained individuals who are in receipt of appropriate supervision. Where these conditions are not in place, specialist referral is advisable.

Other circumstances in which specialist referral may be advisable are where the clinical picture is complicated by the presence of comorbid conditions: for example, severe depression, or alcohol/drug dependence. It is also advisable where there is considered to be a significant risk of suicide, harm to self, or harm to others, and the resources are not available for the risk to be effectively managed.

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