Post-traumatic stress disorder (PTSD) is defined by the mental health system as a “disorder” caused by exposure to a severe traumatic event. The “symptoms” include nightmares, flashbacks, fear when reminded of the trauma, and avoidance of reminders of the trauma. It has also been suggested that these are the normal human responses to intense, traumatic experiences.
The medical model uses biology to explain why some people experience some of the “symptoms” of PTSD after a traumatic event, while others do not—although no such biological mechanism has been found. The psychosocial model, on the other hand, emphasizes that because of different life contexts, social supports, and other aspects of psychological well-being, no two people experience trauma the same way, and therefore it makes perfect sense that some experience life-altering avoidance and fear, while others appear to have less severe reactions.
Nonetheless, when these experiences impair the ability to live a full and purposeful life, interventions may be sought to either reduce these specific symptoms, or to re-engage with a meaningful life.
A. Early Intervention
Critical incident stress management (CISM) and psychological debriefing (PD) are used by many organizations (such as the Red Cross and other international aid organizations) immediately following exposure to traumatic events. The intervention includes a group discussion and psychoeducation about normal experiences after trauma.
The intervention has been controversial, however, after studies emerged suggesting that it did not reduce the likelihood of PTSD symptoms or a later PTSD diagnosis. However, proponents of the intervention suggest that it was never intended to help with these things, and instead should be used to identify those who are beginning to experience PTSD symptoms, so they can receive further services.
Thus, expectations should be clear when engaging in CISM or PD: it probably won’t help reduce the experiences associated with PTSD, but it might teach a person about how PTSD is defined and whether they should seek further interventions for it.
B. For Nightmares
Treatment of nightmares in particular has involved myriad pharmaceutical interventions. Recently, evidence emerged that prazosin—until now the most commonly prescribed for PTSD-related nightmares—is not as effective as once believed. A current trend in research is THC and synthetic cannabinoids for the treatment of nightmares. In small, open-label studies, they have shown promise. However, there has been very little research, and none of it includes comparison groups or long-term follow-up, so any current use of that drug is experimental at best.
One psychosocial intervention for nightmares is imagery rescripting therapy (IRT), which involves vividly imagining the feared outcome, then changing the ending so that it has a positive spin. In small, open-label studies, this intervention shows promise. Further research needs to be done to determine risks and benefits.
C. Treatments for PTSD
There are two broad forms of psychotherapy that have been used with people with the PTSD diagnosis. The first are symptom-focused therapies, which are based on the idea that traumatic experiences alter the way the individual thinks and behaves (for instance, feeling unsafe when reminded of the traumatic event, or misjudging how safe everyday experiences are). These therapies focus on restoring “normal” ways of thinking and behaving. The second type is holistic, and is based on the idea that traumatic experiences interfere with the ability to make meaning of life, relationships with others, and one’s place in the world. These therapies are focused on helping to integrate the traumatic experience with a meaningful understanding of life.
Research studies rarely report adverse effects of psychotherapy. However, people tend to re-experience the trauma more after beginning therapy, which can be particularly distressing and lead to dropping out of therapy.
These types of therapy appear to significantly reduce PTSD symptoms, as measured by clinician rating scales. When considering patient-reported PTSD symptoms, however, the therapies are less effective. Because they reduce clinician-reported symptoms, they are associated with likelihood of no longer having the PTSD diagnosis after treatment. All these therapies were about equally effective as each other, according to a study that compared them. Most of the data on effectiveness for these interventions is short-term, up to five months after treatment.
1. Exposure Therapy/Prolonged Exposure (PE)
PE is probably the most common psychotherapy for PTSD, particularly in the US Department of Veterans Affairs (VA). It’s based on the idea that the traumatic experience becomes associated with the images, thoughts, and feelings that surrounded it, so similar cues trigger the fear response again. The intervention focuses on exposing the person to the cues, but in a safe environment, thus allowing the person to re-learn that the cues themselves are distinct and safe.
2. Cognitive Behavioral Therapy (CBT)
This includes trauma-focused cognitive-behavioral therapy (TFCBT) and group cognitive-behavioral therapy. Both of these focus on identifying and altering “distorted cognitions” about the self and the world (for instance, belief that one is in more danger than is logical). CBT includes homework, in which the client identifies when these thoughts arise, and challenges them using logic and alternative explanations.
3. Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is based on the theory that trauma impedes communication between the two hemispheres of the brain. As yet, that theory remains unproven. The therapy involves the use of “bilateral” stimulation, such as a finger that both eyes must follow, similar flashing lights, or audio cues that alternate ears. However, the therapy also includes many elements of CBT and exposure therapy. The therapist instructs the patient to engage in imaginal exposure (focusing on the traumatic event and recalling the sensations and emotions of the event) Because of this, some researchers believe that the bilateral stimulation component is extraneous, while others consider it the most important component.
Additional types of therapy have been studied for use with people with the PTSD diagnosis. These types of therapy generally focus on overall quality of life, self-actualization, and sense of meaning and purpose.
The first, narrative exposure therapy, uses exposure techniques but also focuses on creating an overall life “narrative” and integrating the traumatic experience into a cohesive life story. This bridges the gap between the two types of therapies, and may have the benefits of both.
Other therapies, such as supportive therapy, non-directive counseling, psychodynamic therapy, and hypnotherapy, don’t use exposure techniques. Instead, they focus entirely on the holistic understanding of the person. In terms of pure “symptom reduction” as rated by clinicians, they fare poorly compared to the symptom-focused therapies. However, they may have other benefits for overall psychological well-being.
1. Narrative Exposure Therapy (NET)
Although parts of NET include the same elements as prolonged exposure (see “Exposure Therapy” above), it features only imagining the traumatic event, rather than actually experiencing similar cues. However, the main difference is that narrative therapy additionally focuses on the client literally writing their life story. The exposure techniques are based on the idea that reducing the fear associated with these cues will help to integrate the experience into the client’s life story.
NET has been proposed as an alternative especially for people who have experienced multiple traumas or what has been termed “complex trauma,” especially refugees, asylum seekers, and people who have fled war or genocide.
NET has demonstrated success by the symptom-reduction measures that are standard in the PTSD field, likely due to its incorporation of exposure techniques. It also features holistic meaning-making elements that may help increase overall psychological well-being, beyond mere symptom reduction.
2. Supportive Therapy
Emotion-focused supportive therapy and non-directive counseling appear to be based on the rationale that clients have emotional reactions to trauma that they need to discuss and examine. A study that compared this intervention with cognitive approaches found that it compared poorly for reducing PTSD symptoms as well as quality of life. Another study found similar results.
However, studies that include this approach use it as a comparator for their intervention: exposure therapists are conducting what they call “supportive therapy” hoping that it will do worse than their intervention. It is unclear how this matches with the type of unspecified therapy that occurs in the “real world.”
3. Psychodynamic Therapy
Like narrative therapy, psychodynamic therapy focuses on integrating the experience of the traumatic event into the life story of the client. It features less of a focus on actively writing that narrative, and more focus on early experiences, such as those in childhood.
Being physically active is helpful for both physical health and psychological well-being. Engaging in exercise of some kind has been shown to reduce PTSD symptoms as well as improving overall mood. Exercise is likely not as effective as other therapeutic approaches, and has not been compared directly. Yoga also appears to have a small effect on reducing PTSD symptoms and overall mood.
Hypnotherapy involves a person willingly entering a suggestible state in order to re-contextualize the traumatic experience. Again, the goal is to integrate the experience into the life of the person. Although there is very little research on this intervention, it does appear to reduce PTSD symptoms, depression, and anxiety—at least when compared to no treatment.
Mindfulness-based stress reduction, as well as other types of mindfulness interventions, have been used with people with the PTSD diagnosis. Mindfulness focuses on awareness of the body and the present moment and attention control, which allows it to target the dissociative and re-experiencing aspects of PTSD. It is also associated with calm, soothing practice, which may help with the anxious arousal of the trauma reaction. Loving-kindness meditation, or metta mindfulness, is focused on compassion, which may help with feelings of guilt and fear after traumatic events.
In clinical trials, acupuncture has demonstrated effectiveness for reducing PTSD symptoms, with an effectiveness slightly less than psychotherapy, but far greater than no treatment. It may equal the effectiveness of pharmacological interventions. The evidence is limited, with very few studies having been conducted, however.
Some studies of various relaxation techniques have found it to be ineffective, while others have found it to significantly decrease anger and guilt after traumatic events. Relaxation training may have a small effect, or only work in some particular areas. The evidence is limited, with very few studies having been conducted.
9. Herbal Remedies
Kava and St. John’s Wort have reportedly been used to treat anxiety and depression associated with PTSD. However, both of these substances have the potential to induce severe, life-threatening health problems, particularly in combination with other medications or substances, so they are almost never recommended.
Research compiled by Peter Simons.