Treatment of PTSD

A National Center for PTSD Fact Sheet

This fact sheet describes elements common to many treatment modalities for PTSD, including education, exposure, exploration of feelings and beliefs, and coping-skills training. Additionally, the most common treatment modalities are discussed, including cognitive-behavioral therapy, pharmacotherapy, EMDR, group treatment, and psychodynamic treatment.

Common Components of PTSD Treatment

Treatment for PTSD typically begins with a detailed evaluation and the development of a treatment plan that meets the unique needs of the survivor. Generally, PTSD-specific treatment is begun only after the survivor has been safely removed from a crisis situation. If a survivor is still being exposed to trauma (such as ongoing domestic or community violence, abuse, or homelessness), is severely depressed or suicidal, is experiencing extreme panic or disorganized thinking, or is in need of drug or alcohol detoxification, it is important to address these crisis problems as a part of the first phase of treatment.

• It is important that the first phase of treatment include educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems that commonly come along with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder that occurs in normal individuals under extremely stressful conditions is essential for effective treatment.
• Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment, while also carefully examining his or her reactions and beliefs in relation to that event.
• One aspect of the first treatment phase is to have the survivor examine and resolve strong feelings such as anger, shame, or guilt, which are common among survivors of trauma.
• Another step in the first phase is to teach the survivor to cope with posttraumatic memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy but become manageable with the mastery of new coping skills.

Therapeutic Approaches Commonly Used to Treat PTSD:

Cognitive-behavioral therapy (CBT) involves working with cognitions to change emotions, thoughts, and behaviors. Exposure therapy is one form of CBT that is unique to trauma treatment.  It uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the fear and distress that was overwhelming during the trauma. In some cases, trauma memories or reminders can be confronted all at once ("flooding"). For other individuals or traumas, it is preferable to work up to the most severe trauma gradually by using relaxation techniques and by starting with less upsetting life stresses or by taking the trauma one piece at a time ("desensitization").

Along with exposure, CBT for trauma includes:

learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"),

• managing anger,
• preparing for stress reactions ("stress inoculation"),
• handling future trauma symptoms,
• addressing urges to use alcohol or drugs when trauma symptoms occur ("relapse prevention"), and
• communicating and relating effectively with people (social skills or marital therapy).

 Pharmacotherapy (medication) can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases, it may help relieve the distress and emotional numbness caused by trauma memories. Several kinds of antidepressant drugs have contributed to patient improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. At this time, no particular drug has emerged as a definitive treatment for PTSD.  However, medication is clearly useful for symptom relief, which makes it possible for survivors to participate in psychotherapy.

Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new treatment for traumatic memories that involves elements of exposure therapy and cognitive-behavioral therapy combined with techniques (eye movements, hand taps, sounds) that create an alternation of attention back and forth across the person's midline. While the theory and research are still evolving for this form of treatment, there is some evidence that the therapeutic element unique to EMDR, attentional alternation, may facilitate the accessing and processing of traumatic material.

Group treatment is often an ideal therapeutic setting because trauma survivors are able to share traumatic material within the safety, cohesion, and empathy provided by other survivors. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust. As they discuss and share how they cope with trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one's story (the "trauma narrative") and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of their lives.

Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly as they relate to early life experiences. Through the retelling of the traumatic event to a calm, empathic, compassionate, and nonjudgmental therapist, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and learns to deal more successfully with intense emotions. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.

Psychiatric disorders that commonly co-occur with PTSD

Psychiatric disorders that commonly co-occur with PTSD include depression, alcohol/substance abuse, panic disorder, and other anxiety disorders. Although crises that threaten the safety of the survivor or others must be addressed first, the best treatment results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol/substance abuse.

Complex PTSD

Complex PTSD (sometimes called "Disorder of Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. Developmental research is revealing that many brain and hormonal changes may occur as a result of early, prolonged trauma, and these changes contribute to difficulties with memory, learning, and regulating impulses and emotions. Combined with a disruptive, abusive home environment that does not foster healthy interaction, these brain and hormonal changes may contribute to severe behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), emotional regulation difficulties (such as intense rage, depression, or panic), and mental difficulties (such as extremely scattered thoughts, dissociation, and amnesia). As adults, these individuals often are diagnosed with depressive disorders, personality disorders, or dissociative disorders. Treatment often takes much longer than with regular PTSD, may progress at a much slower rate, and requires a sensitive and structured treatment program delivered by a trauma specialist.