The management of post-traumatic stress disorder commonly involves psychotherapy and antidepressants.
Psychotherapy Evidence-based, trauma-focused psychotherapy is the first-line treatment for PTSD.U.S. Dep't of Veterans Affs. & Dep't of Def., VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder , ver. 3, p. 46, 2017. Psychotherapy is defined as a treatment where a therapist and patient build a therapeutic relationship and focus on the patient's thoughts, attitudes, affect, behavior, and social development to lessen the patient's psychopathologies and functional impairment.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) focuses on the relationship between someone's thoughts, feelings, and behaviors. It helps people understand the discrete nature of their thoughts and feelings, and to be better able to control and relate to them. It began with the work of American psychologist Albert Ellis in the late 1950s, and was notably expanded on by American psychiatrist Aaron Beck.
CBT involves exposure to the trauma narrative in a controlled way to reduce avoidance behaviors related to the trauma. Education about the effects of trauma and stress management techniques are common aspects of CBT. There is evidence that CBT combined with exposure therapy can reduce PTSD symptoms, lead to a loss of PTSD diagnosis, and reduce depression symptoms.
Some common CBT techniques are:
Cognitive restructuring: exchanging negative thoughts for positive ones. Exposure therapy Cognitive processing therapy: patients are encouraged to consider the factual basis of their thoughts. Stress inoculation training: patients are taught relaxation techniques such as breathing, progressive muscle relaxation skills, and communication coping skills. Eye movement desensitization and reprocessing: a back and forth eye movement that helps patients process traumatic events. Acceptance and commitment therapy: focuses on accepting the traumatic event rather than challenging it. The most applicable techniques vary from person to person, with no current front-runner showing any particular advantage over the other.
CBT is strongly recommended for treatment of PTSD by the American Psychological Association.
Trauma-focused cognitive behavioral therapy
Trauma-focused cognitive-behavioral therapy (TF-CBT) was developed by Anthony Mannarino, Judith Cohen, and Esther Deblinger in the mid-1990s to help children and adolescents with PTSD.
Individuals work through the memories of the trauma in a safe and structured environment, trying to correct negative cognitions and thoughts while also performing gradual exposure to triggers. This therapy is held over 8 to 25 sessions with the child/adolescent and their caregiver. The treatment helps correct distorted beliefs in the children while also helping parents and caregivers process their own distress and support the children.
Researchers are working to develop culturally-adapted versions of TF-CBT. Cultural adaptations may rely on targeting the unique experience of a group, such as chronic exposure to racial trauma, or culture-specific coping strategies, such as including racial socialization and community support. In recent years, psychologists have tested the effectiveness of culturally modified TF-CBT approaches with different communities, such as unaccompanied child migrants and women in war-torn countries. Research suggests that cultural adaptations to TF-CBT can improve intervention effectiveness.
TF-CBT has repeatedly demonstrated effectiveness and is currently recommended as a first-line treatment for PTSD by the American Psychological Association, Australian Centre for Posttraumatic Mental Health, and the National Institute of Clinical Excellence (NICE). The Australian Psychological Society considers it a Level I (strongest evidence) treatment method.
Cognitive therapy for PTSD (Ehlers and Clark)
In 2000, husband-and-wife Anke Ehlers and David M Clark developed a cognitive model that explains what prevents people from recovering from traumatic experiences and thus why people develop PTSD. The model suggests that PTSD develops when individuals process the traumatic event in a way that makes them feel that there is serious current threat. This perception of a threat is followed by reexperiencing arousal symptoms and persistent negative emotions like anger and sadness. Differences in how the individual appraises the event ("I cannot trust anyone anymore" or "I should have prevented what happened") and the poor integration of the most intense moments of the trauma into memory contribute to the distorted way people with PTSD make sense of what happened to them.
Ehlers, Clark and others developed a cognitive therapy based on this model, the details of which were first published in 2005. It is a form of cognitive behavioural therapy that involves developing and believing a new, less threatening understanding of the trauma experiences. Patients gain an increased understanding of how they perceive themselves and the world around them, and how these beliefs motivate their behavior, before beginning the process of changing these thought patterns. Thus, three goals drive cognitive therapy for PTSD:
Modify negative appraisals of the trauma Reduce reexperiencing symptoms by discussing trauma memories and learning how to differentiate between types of trauma triggers Reduce behaviors and thoughts that contribute to the maintenance of the "sense of current threat"
One specific practice is imagery rescripting where the therapist guides the patient to reimagine their traumatic memory in a way that gives them control so that they can create new outcomes. For example, adult patients with childhood trauma are encouraged to imagine their trauma from the point-of-view of an adult rescuing and protecting the vulnerable child.
Imagery rehearsal therapy helps people with nightmares by documenting their dreams and creating new endings to them. They then write down their dreams, monitor them, and regularly act out the improved dream scenarios.
"Cognitive therapy" of this kind should not be confused with the earlier established cognitive therapy of Aaron Beck.
Ehlers and Clark inspired cognitive therapy is strongly recommended for treatment of PTSD by the American Psychological Association.
Prolonged exposure therapy
Prolonged exposure therapy (PE) was developed by Edna Foa and Micheal J 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 was chair of the PTSD work group of the DSM-IV.
Prolonged exposure therapy typically consists of 8 to 15 weekly, 90 minute sessions. Patients will first be exposed to a past traumatic memory (imaginal exposure), after which they immediately discuss the traumatic memory and then are exposed to, "safe, but trauma-related, situations that the client fears and avoids".
Slowed breathing techniques and psychoeducation are also touched on in these sessions.
PE is theoretically grounded in emotional processing theory, which proposes "a hypothetical sequence of fear-reducing changes evoked by emotional engagement with the memory of a significant event, particularly a trauma." While PE has received substantial empirical support for its efficacy (albeit with high dropout rates), emotional processing theory has received mixed support.
PE is strongly recommended as a first-line treatment for PTSD by the American Psychological Association.
Cognitive processing therapy
Cognitive processing therapy (CPT) was developed by Patricia Resick from 1988. It is an evidence-based treatment aimed at individuals diagnosed with PTSD. This therapy focuses on processing and working through the trauma, designed using techniques from Cognitive Behavioral Therapy discussed previously. CPT is founded on the principle that generally, individuals can gradually recover from traumatic events over time, but in those diagnosed with PTSD, this recovery pathway is impaired. During therapy sessions, clients write and recite written passages either related to why the individual thinks they were exposed to the traumatic event, or narratives outlining the event in explicit detail. CPT is typically completed over 12 one-hour weekly sessions with a practitioner.
The first phase of treatment is psychoeducation. During this part of therapy, individuals learn about the relationship between thoughts and emotions, and importantly, they look for "automatic thoughts" that are detrimental to their recovery. This initial phase ends as patients write their understanding of the causes of the traumatic event and its impacts.
The second phase is concerned with processing the trauma: outlining the traumatic experience and continuing to discuss the experience and feelings over the following sessions. During this stage, the therapist tries to identify and correct negative cognitions that may lead to continued PTSD symptoms.
The final phase assists the individual in strengthening beliefs, skills, and strategies to combat the symptoms of the trauma when they arise.
CPT is a strongly recommended treatment for PTSD by the American Psychological Association.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) was developed by Francine Shapiro in 1988 as a method to diminish the impacts of traumatic memories. During treatment, patients are asked to focus on specific distressing memories while at the same time undergoing bilateral stimulation. This is usually performed through eye movements or other forms of stimulation to both sides of the body such as tones and tapping. The patient discusses their distressing thoughts as the therapist reinforces positive cognitions and utilizes strategies such as a body scan. These sessions are usually once or twice a week for about 6 to 12 weeks. By the end of these sessions, individuals usually demonstrate reduced emotional distress related to the traumatic event.
The methodology behind EMDR focuses on the Adaptive Information Processing model of PTSD in which the PTSD symptoms are caused by the impaired processing of the traumatic memory. The symptoms arise when the memories are triggered, bringing back the emotions and sensations of the trauma. Therapy with the incorporation of EMDR has been shown to aid patients in processing distressing memories and reducing their harmful effects.
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". The bilateral stimulation facilitated by EMDR "shifts the brain into a memory processing mode", reintegrating the traumatic events with more positively reinforced cognitions. The information can then be integrated completely to lessen the symptoms of triggers. The restoration of the pathway can help with recovery from traumatic events.
A 2018 review reported EMDR for PTSD was supported by moderate quality evidence as of 2018. It is a conditionally recommended treatment for PTSD by the American Psychological Association. The Australian Psychological Society considers it a Level I (strongest evidence) treatment method. Some social scientists argue that EMDR is a purple hat therapy.
Narrative exposure therapy