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Treatments for Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

As described below, different treatment approaches exist for people who are experiencing psychological symptoms caused by a traumatic experience. These approaches are based primarily on how soon after the event the person comes for treatment, and they include psychotherapy and medications as the main types of interventions.

PsychVisit also provides detailed treatment guidelines for PTSD in a separate page.

Psychological First-Aid following Trauma Exposure

It makes sense to think that victims of traumatic events should be offered some sort of psychological intervention as soon as possible after the event in order to help ease their distress and prevent them from developing posttraumatic symptoms. However, so far no such interventions have been developed that have been clearly shown to work, and there are even a few such kinds of interventions that have been found to cause more harm than good. As a result, many experts suggest that it is not necessary to offer formal treatment automatically to all trauma victims [ref].

However, one approach that is gaining increasing acceptance is the emphasis on lowering a victim's overall level of anxiety following a trauma, as this can help to reduce the chances that the individual will develop posttraumatic symptoms, especially for those individuals who start to experience high and sustained levels of anxiety [ref].

Single-session debriefing interventions, where participants are asked to discuss their feelings and emotional reactions to the event, are not recommended, for they have been shown to increase posttraumatic symptoms, probably because they serve to increase the person's level of anxiety.

On the other hand, offering psychoeducation, which involves explaining to the victim that their anxiety and distress is a normal reaction to an abnormal situation, may be beneficial [ref]. The individual should also be encouraged to participate in activities that will foster positive and calming emotions. Techniques of Applied Relaxation can also help to reduce a person's anxiety.

Using substances to lower anxiety, such as benzodiazepines or alcohol, is not recommended, for this may worsen symptoms in the long-run [ref].

In general, experts suggest that victims of trauma, especially those exposed to mass trauma such as natural disasters or terror attacks, can be helped by measures that promote a sense of safety, of calm, of self- and collective-efficacy, of connectedness, and of hope [ref].

Treatments for Acute Stress Disorder (ASD)

For individuals who meet the diagnostic criteria for Acute Stress Disorder (ASD), they may benefit from a course of Cognitive Behavioral Therapy (CBT) [ref], especially if the symptoms have been present for a couple of weeks, or have been serious, or the individual has risk factors for developing PTSD. There is not much evidence that using medications is helpful for ASD.

Psychotherapy for PTSD

Once PTSD has developed, the two forms of psychotherapy with the most evidence for being effective are Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) [ref]. The kind of CBT that seems helpful tends to make use of behavioral techniques like Systematic Desensitization and Applied Relaxation Training, as well as cognitive techniques that attempt to alter the meaning of the traumatic event for the client and foster a sense of self-efficacy and of hope in the future.

Other forms of psychotherapy have not been well-studied in PTSD. However, clinical experience would suggest that Psychodynamic Psychotherapy could potentially help individuals with this condition come to better terms with the trauma by arriving at a more manageable understanding of the event.

There has not been much research done to address the question of whether "booster-sessions" of psychotherapy are helpful to prevent a relapse of the PTSD in the months after the therapy has been completed.

Medications for PTSD

Medications have also been found to be effective for treating PTSD. Among these, antidepressants are considered first-line choices, but other classes of medications can also be helpful.

Antidepressants for PTSD

There has been a lot of research showing that the SSRI Antidepressants are effective for treating the symptoms of PTSD [ref]. Given that this body of research is quite a bit larger than for other antidepressants, the SSRIs are considered a first choice medication option for PTSD.

However, some studies have found that SSRIs tend to be less effective when used for treating PTSD symptoms among combat veterans, as compared with victims of non-combat-related trauma [ref]. The reasons for this are not clear, but may have to do with the severity or duration of symptoms among combat veterans being greater than for other individuals [ref]. It is not known whether other medications are also less effective for combat-related PTSD.

Other antidepressants that have also been found to be effective for treating PTSD include Venlafaxine, Mirtazapine, some Tricyclic Antidepressants and Phenelzine (an MAOI).

Atypical Antipsychotics for PTSD

Atypical Antipsychotics have been found to be helpful for augmenting the effects of antidepressants for treating PTSD. They are generally not used alone for treating this condition, but only in combination with an antidepressant. Most of the evidence for this comes from studies using Risperidone.

Prazosin for nightmares and insomnia in PTSD

Prazosin is a medication that is used in general medicine for treating high blood pressure, but studies have found that it can also help for individuals with PTSD, especially in reducing nightmares and improving sleep [ref, ref]. It can be added to other medications such as those listed above.

Benzodiazepines for PTSD

In clinical practice benzodiazepines are often prescribed to individuals with PTSD in order to help control some of the reexperiencing and hyperarousal symptoms, including panic attacks and sleep difficulties. However, there are actually very few studies to support this practice. Some of the studies that have been done have shown that benzodiazepines do not help very much with most of the core symptoms of PTSD, and that they can also cause a rebound of symptoms once they are stopped [ref]. Other studies have found that using benzodiazepines early-on after trauma exposure can actually increase the chances of a person developing PTSD [ref]. For these reasons, benzodiazepines are not generally recommended for use in PTSD.

Other medications for PTSD

Beta-blockers, which are medications normally used for high blood pressure, and various anticonvulsants including Topiramate, Tiagabine and Valproic Acid, have all been tested for use in PTSD in a limited number of studies. None of these medications have been shown to be very effective.

Continuing medications to prevent a relapse of PTSD

There has not been much research looking at how long medications should be continued once they have worked to help treat the symptoms of PTSD. One study found that individuals had a significantly lower rates of relapse if they continued their antidepressant for another 6 months [ref].

Combining Psychotherapy with Medications

There has not been much research done on comparing the effectiveness of psychotherapy with medications for PTSD, or on evaluating whether there is any advantage to combining these two forms of treatment from the outset rather then choosing just one of them.

However, there are many authorities in the field who believe that psychotherapy should be the first choice option for treating PTSD, and only in cases where the psychotherapy alone is not adequate, or where it does not fit with the patient's preferences, should medications be tried [ref, ref]. These recommendations make intuitive sense, for psychotherapy does not pose the same risk of side-effects as do medications, and there is also the expectation that individuals undergoing psychotherapy will be able to take-away important lessons and strategies from the therapy that they could continue to use long after the therapy has ended.

Treating Complex PTSD

Treatments for Complex PTSD have not yet been well defined in empirical studies, but they would likely include long-term psychotherapy that incorporates elements of therapy for Borderline Personality Disorder as well CBT. One study found that a two-phase CBT-based psychotherapy program, combining an initial preparatory phase of skills training in affect and interpersonal regulation, followed by an exposure phase, can be effective for individuals with this condition [ref]. Due to the chronic and severe nature of Complex PTSD, medications would likely be necessary to treat the posttraumatic symptoms or the depressive symptoms.

 

Except where otherwise indicated, the above information is derived from the APA Practice Guidelines [ref, ref, ref].

Course & Prevalence

Treatment Guidelines