Establishing treatment goals
support (e.g., family member, partner) to establish the treatment goals. Review the goals of treatment at each visit through the direct questioning during symptom review.
Specific treatment goals may vary between patients; however, the general goals include:
- Maintain the safety of the patient and others — it is achieved through assessments of suicidality and homicidality at regularly scheduled visits.
- Reduce symptoms of distress related to intrusive re-experiencing — unwanted intrusive memories of the traumatic event vary widely from occasional unwanted thoughts to frequent nightmares or flashbacks.
- Reduce hyperarousal — these can include symptoms such as insomnia, anger, irritability, and trouble concentrating and can be very distressing.
- Reduce avoidant behaviors — avoidance of stimuli associated with the traumatic event may lead to behavior changes that affect psychosocial functioning.
- Lessen the risk of relapse of symptoms and diminish anxiety related to fear of recurrence.
- Address related comorbidities that may be present, for example, substance use disorder (SUD) or mood dysregulation.
- Improve adaptive and psychosocial functioning through psychotherapy often combined with pharmacologic management.
Treatment of PTSD
The clinical practice guideline of the Department of Veterans Affairs and the Ministry of Defense on the treatment of post-traumatic stress disorder and acute stress disorder suggests that the trauma-focused individual psychotherapy should be the first line of treatment for PTSD. Studies have shown that trauma-focused psychotherapy causes more significant changes and longer-lasting improvements in the basic PTSD symptoms versus pharmacologic therapy. However, if the trauma-focused psychotherapy is not available or not of interest to the patient, the drug treatment or individual non-trauma-focused psychotherapy is recommended as the alternative treatment.
Summary of the clinical practice guideline on the pharmacologic therapy:
- No evidence recommends using medicinal products early after a trauma to prevent PTSD.
- The initial pharmacologic approach should include an attempt of the first-line monotherapy for sufficient time to achieve a response, and healthcare professionals should monitor patients for the therapeutic outcomes and side effects.
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are still the only class of medicinal products that are strongly recommended as the monotherapy for PTSD for the patients who do not want or are unable to receive the trauma-focused psychotherapy.
- There are many medicinal products, the use of which is not prescribed or not recommended for PTSD, including atypical antipsychotics as monotherapy for PTSD treatment, and also products of the valproic acid, tiagabine, guanfacine, risperidone, benzodiazepines, ketamine, hydrocortisone or D-cycloserine.
- Cannabis or cannabis derivatives are not recommended for PTSD treatment due to the lack of evidence of efficacy, known side effects and associated risks.
- Benzodiazepines are relatively contraindicated in the patients with a history of traumatic brain injury, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), or high rates of comorbid alcohol misuse and substance use disorde (SUD), especially in the veterans with combat related PTSD.
- Evidences do not support using anticonvulsants or atypical antipsychotics as monotherapy for PTSD treatment.
- Selecting the medicinal product and dosage it is necessary to consider the patient response or history of the side effects and concomitant diseases.
- Psychotherapy in PTSD. A lot of effective trauma-focused approaches to PTSD treatment are described.
Summary of the psychotherapy in PTSD
Trauma-focused psychotherapeutic methods using cognitive, emotional or behavioral techniques to facilitate the processing of the traumatic experience are empirically supported. Trauma-focus is a central component of the therapeutic process. Most therapies involve 8‒16 sessions with the different combinations of the following basic methods:
- Exposure to traumatic images or memories using narrative or imaginal exposure.
- Exposure to avoidance signals or provoking in vivo signals or using visualization.
- Cognitive restructuring techniques aimed to enhance the sense and change the problematic assessments arising from the traumatic experience.
Effective trauma-focused approaches to PTSD treatment include:
Prolonged exposure therapy
- Involves the imaginal exposure with the repeatedly revisiting the traumatic experience in memory describing the event aloud in detail.
- In vivo exposure.
- Emotional processing of narrative experience.
Cognitive processing therapy
- Involves the cognitive restructuring through the Socratic dialogue to explore the problematic cognitions, emotions and negative assessments arising from the event, such as self-blame or distrust.
Eye movement desensitization and reprocessing (EMDR)
- Focused on the breathing retraining and muscle relaxation. May also include cognitive approaches and exposure techniques.
Brief eclectic psychotherapy (BEP)
- Strong psychodynamic perspective.
- Involves imaginal exposure, written narrative processes, cognitive restructuring considering the sense and experience integration, relaxation techniques and metaphorical ritual closing to leave trauma behind and improve feel of control.
Narrative exposure therapy (NET)
- Imaginal exposure through a structured oral life-narrative process; helps patient integrate and find meaning of multiple traumatic experiences during lifetime.
There is less evidence supporting some individual non-trauma-focused psychotherapies for patients diagnosed with PTSD, such as stress inoculation training (SIT), present-centered therapy (PCT) and interpersonal psychotherapy (IPT). Although these treatment methods are not recommended, there is evidence that they are better than no treatment. Similarly, though limited evidence suggests that group therapy for PTSD is less effective than individual therapy, it is still recommended when no treatment is an alternative.
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