PTSD: Treatment

Text adapted from: "The adult patient with posttraumatic stress disorder," in Psychiatry in primary care  by Francesca L. Schiavone and Ruth A. Lanius (CAMH, 2019).

Treatment Options

People with PTSD need holistic and individualized treatment that considers their needs and preferences. Focus on safety (physical and emotional) as  an initial intervention. This includes addressing suicidality and referring patients to a higher level of care where necessary (Lanius et al., 2016). Establishing safety can also mean helping patients obtain food, shelter and financial resources, and helping them seek physical safety from further abuse.

Next, offer specific treatment for PTSD symptoms. Psychological therapies have a larger effect size than pharmacotherapy, but both are reasonable first-line treatment options, depending on availability and patient preference (Hoskins et al., 2015). Immigrant and refugee populations may have specific cultural beliefs and practices about trauma recovery that need to be identified and incorporated into treatment.

Psychotherapy

Psychological treatments for PTSD have consistently demonstrated moderate to large effect sizes (Najavits, 2007; Wampold et al., 2010). A wide range of specialized therapies is available, each based on a particular construction of posttraumatic psychopathology, but there is no clear evidence that any one modality is superior. Much of the therapeutic effect is likely due to common factors such as having a coherent therapeutic rationale, providing psychoeducation and establishing a safe and trusting therapeutic relationship.

Psychological treatments can be divided into present-focused and past- focused therapies (see Table 1). Both are effective, but they differ in their area of concentration. Present-focused therapies, such as cognitive therapy, emphasize building coping skills that are necessary to improve functioning; for example, the ability to regulate emotions, tolerate distress and solve day-to-day problems. Past-focused therapies, such as prolonged exposure, involve recounting the trauma narrative and processing the memories and emotions that arise (Najavits, 2007).

Further research is needed to determine what patient characteristics suggest suitability for a particular psychotherapy. In general, patients whose lives are more unstable, or who have experienced the most severe traumas, may be unable to tolerate the intense emotions evoked by past-focused therapies. They may be better suited, at least initially, to present-focused treatments that address longstanding skills deficits and build coping resources (Najavits, 2007). These patients may later choose to engage in past-focused therapies.

Some patients also have strong personal preferences about working directly with traumatic memories, and these preferences should be respected.

Table 1 Types of Psychotherapy for PTSD 

• The Primary Care Practitioner Role
• Screening & Assessment
• Diagnosis
• Treatment
  • Pharmacotherapy
• Clinical Tools
• Resources and References