Flowchart For The Algorithm
Fig. 2 provides an overview of the algorithm, in which each numbered node begins with a question about the patient’s condition serving to delineate patient populations progressing from medication-naive to medication-resistant. The reasoning behind each question and recommendations at each node is described in the sections below.
Dropout Side Effect And Adverse Effects
One common concern with trauma-focused treatment is dropout and rates of dropout appear to be similar across PE, CPT and trauma-focused CBT . A substantial minority of individuals drop out of PTSD treatment . Imel et al. conducted a meta-analysis of treatment dropout in PTSD treatment. The aggregate proportion of dropout across all active treatments was 18.28%, however, there was a large amount of variability across studies. The dropout rate varied between active interventions for PTSD across studies, but the differences were primarily driven by differences between studies. In addition, an increase in trauma focus did not predict an increase in the dropout rate. Imel et al. did find evidence across three relatively large trials that dropout is lower in present centered therapy compared to trauma specific treatments .
Unfortunately, few studies explicitly report on side effects and adverse effects of PTSD psychotherapy . The American Psychological Association guidelines recommends that research be conducted on side effects. When examining the results of large controlled trials there is no evidence that trauma-focused treatments are associated with a relative increase in adverse side effects . Clearly more research should examine and report on side effects and adverse effects of PTSD treatment.
Other Medications For Ptsd
Topiramate is in the anti-epileptic category of medications and is thought to modulate glutamate neurotransmission. There has been recent interest in its use for PTSD. The systematic review that served as the evidence base for the guideline development panel reported moderate strength of evidence for a medium to large magnitude effect for PTSD symptom reduction.
However, the panel concluded that there was insufficient evidence to make a recommendation because the potential side effects/harms for topiramate are greater than they are for SSRI antidepressants. It is not uncommon for patients taking topiramate to note side effects of cognitive dulling. Topiramate has also been found helpful in reducing alcohol consumption in those with an alcohol use disorder, which frequently accompanies PTSD.
Adapted from with original content written by Matt Jeffreys, MD. Matthew J. Friedman, MD, PhD, Thomas Mellman, MD and Jeffrey Sonis, MD, MPH also contributed.
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Implications And Future Directions
PE, CPT and trauma-focused CBT have been strongly recommended as treatments for PTSD in treatment guidelines by the APA and the VA/DoD. Each of these treatments have a large evidence base supporting their effectiveness in treating PTSD. Although exposure-based therapies have the largest and strongest research evidence base , research and meta-analyses comparing PE, CPT and trauma-focused CBT do not find that one treatment outperforms the other .
The guidelines and strong research evidence suggest that PE, CPT and trauma-focused CBT should be the first line of treatment for PTSD whenever possible, considering patient preferences and values and clinician expertise. Research examining patient preferences suggests that individuals prefer PE, CPT and trauma-focused CBT to other treatments. Analog studies have demonstrated that participants have preferences for CT and exposure therapy over psychodynamic psychotherapy, EMDR, and therapies using novel technologies . In addition, results from studies examining clinical samples show that patient prefer psychotherapy, such as PE and CBT, to medication . Findings are similar among veteran and military samples, with soldiers showing greater preference for PE and virtual reality exposure to paroxetine or sertraline and veterans in a PTSD specialty clinic showing greater preference for CPT to other psychotherapies, PE to nightmare resolution therapy and PCT, and both PE and cognitive-behavioral conjoint therapy were preferred to VRE .
Cbt Treatment For Ptsd
Cognitive-behavioral therapy is to gold standard treatment for PTSD, with a wealth of research supporting it as the most effective treatment for the disorder. Most individuals with PTSD no longer meet the criteria for the disorder after as few as 12 sessions of trauma-focused CBT. The American Psychological Association also recently determined that licensed psychologists are the most expert providers of care for PTSD. Several CBT treatments for PTSD exist:
Prolonged Exposure: Prolonged exposure is a treatment that helps people no longer experience the anxiety and distress associated with the trauma, by helping people repeatedly expose themselves to memories of the trauma. This treatment has been the subject of numerous scientific studies, and has been found to significantly reduce the re-experiencing symptoms, anxiety arousal, and avoidance of feared stimuli that go along with PTSD. Prolonged exposure makes use of homework assignments designed to help people habituate, to thoughts of the trauma until people no longer become upset by them. Often this happens by the third exposure session, which represents a huge advancement in psychotherapy techniques.
At Cognitive Behavioral Therapy Los Angeles, we are experts in the field of evidence-based treatment for PTSD. Call or email today to schedule an appointment.
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How Cbt Can Help With Ptsd
Several theories specific to trauma explain how CBT can be helpful in reducing the symptoms of PTSD.
For example, emotional processing theory suggests that those who have experienced a traumatic event can develop associations among objectively safe reminders of the event , meaning and responses . Changing these associations that lead to unhealthy functioning is the core of emotional processing.
Social cognitive theory suggests that those who try to incorporate the experience of trauma into existing beliefs about oneself, others, and the world often wind up with unhelpful understandings of their experience and perceptions of control of self or the environment . For instance, if someone believes that bad things happen to bad people, being raped confirms that one is bad, not that one was unjustly violated.
Understanding these theories helps the therapist more effectively use cognitive behavioral treatment strategies.
Cognitive Behavioral Therapy For Substance Use Disorders
CBT-SUD is being disseminated as part of the ongoing, national VA Evidence-Based Psychotherapy Training Initiative. CBT-SUD is an evidence-based, time-limited intervention that teaches Veterans how to make and maintain changes in substance use and improve their quality of life. CBT-SUD encourages Veterans to adopt an active, problem-solving approach to cope with the many challenges associated with substance use conditions.
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Cognitive Behavioral Therapy For Depression
CBT-D is a type of therapy that is shown to be an effective treatment for depression. CBT-D treatments often focus on identifying and altering unhelpful thought patterns and behaviors that contribute to or worsen symptoms of depression.
Typically lasting from 12 to 16 sessions, CBT-D can help you reach your treatment goals. Through this therapy, you may:
- Develop more balanced and helpful thoughts about yourself, others, and the future.
- Spend more time engaging in pleasurable or productive activities.
- Learn new skills to help achieve personal goals and solve problems, improving your quality of life and overall level of functioning.
If you choose CBT-D, you will be asked to:
- Commit to attending sessions regularly.
- Work with your provider to set treatment goals.
- Address important personal issues during each session.
- Practice the new skills you learn outside of therapy sessions.
No matter what is causing your mental health condition, proven treatments and resources are available. To learn more about CBT-D, speak openly with your mental health provider about your symptoms so you can work together to determine the best treatment plan for you.
Selective Serotonin Reuptake Inhibitors
The neurotransmitter serotonin has a well-recognized role in the experience of mood and anxiety disorders. The activity of this neurotransmitter in both the peripheral and central nervous systems can be modulated by SSRIs.
The SSRIs sertraline and paroxetine are the only medications approved by the FDA for PTSD. While SSRIs are typically the first class of medications used in PTSD treatment , exceptions may occur for patients based upon their individual histories of side effects, response, comorbidities and personal preferences.
Examples of an exception would be:
- A patient with PTSD and co-occurring bipolar disorder where an antidepressant could cause mood instability that could be mitigated with a mood stabilizing medication before prescribing an SSRI.
- Intolerable sexual dysfunction or gastrointestinal side effects due to the effects of increased serotonin levels in the peripheral nervous system.
Each patient varies in their response and ability to tolerate a specific medication and dosage, so medications must be tailored to individual needs. Research indicates that maximum benefit from SSRI treatment depends upon adequate dosages and duration of treatment. Ensuring treatment adherence is key to successful pharmacotherapy for PTSD. Some typical dosage ranges for medications:
- Sertraline : 50 mg to 200 mg daily
- Paroxetine : 20 to 60 mg daily
- Fluoxetine : 20 mg to 60 mg daily
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Other Antidepressants For Ptsd
Antidepressants that affect the balance of serotonergic and noradrenergic neurotransmission, or which alter serotonin neurotransmission through other mechanisms of action, are also helpful in PTSD. Venlafaxine acts primarily as a serotonin reuptake inhibitor at lower dosages and as a combined serotonin and norepinephrine reuptake inhibitor at higher dosages. It is also a conditionally recommended treatment for PTSD. A typical dosage range is:
- Venlafaxine : 75 mg to 300 mg daily
All of the antidepressants described above are also effective in treating comorbid major depressive disorder which, depending upon the study, accompanies PTSD about 50 percent of the time. Dose-related elevations in blood pressure have been noted with venlafaxine. It should be used with caution in patients with hypertension.
Acceptance And Commitment Therapy For Depression
ACT-D is a therapy that can help transform and improve the lives of people experiencing depression. ACT-D aims to help you live in a way thats more closely aligned with your values, improving your relationships with yourself, others, and the world.
Through this therapy, youll learn to accept your thoughts and emotions, choose and commit to actions that align with your values, and take action to achieve what matters most to you. ACT-D typically requires 10 to 16 individual sessions, but it can be tailored to your treatment preferences and priorities. This therapy can lead to:
- A decrease in negative thoughts and feelings.
- Increased awareness and focus that helps you to fully connect with others and live in the moment.
- The ability to clarify your values and take action to achieve what means the most to you in life.
If you choose ACT-D, you may be asked to:
- Commit to attending sessions regularly.
- Set treatment goals with your provider at the onset of therapy.
- Speak openly about your depression, the challenges youre facing, and your values.
To determine whether ACT-D may be right for you, speak with your mental health provider about your symptoms so you can work together to create the most effective treatment plan.
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Integrative Behavioral Couples Therapy
IBCT is a therapy for couples that focuses on reducing marital distress and improving relationship satisfaction. This therapy develops increased emotional understanding, effective communication strategies, and improved behavioral responses between loved ones. By accepting your differences and understanding your partners sensitivities and stressors, you can work together to overcome the challenges youre facing.
IBCT typically ranges from 11 to 26 sessions, but your treatment plan will be tailored to your needs and has no fixed number of sessions. The therapy may teach you how to negotiate and set goals together with your partner, friend, or family member in two phases: evaluation and treatment.
- The evaluation phase usually consists of a joint session, an individual session with each partner, and a feedback session for the therapist to explain their understanding of the couples problems and outline next steps for treatment.
- The treatment phase consists of the therapists work with the couple to alter and improve the way they interact with and understand each other.
Through this therapy, you may:
- Experience increasing relationship satisfaction.
- See an improvement in your communication skills and emotional closeness with your partner.
- Recognize and change problematic patterns of interaction.
- Increase your positive interactions and connection.
Placing Clinical Practice Guidelines In Context
Provision of high quality, effective care that reduces symptoms and helps the patient return to higher levels of functioning is a shared goal for patients and their families, practitioners, policy makers, and administrators. But knowing which information to trust and prioritize is not easy, and synthesizing available research and determining preferable care options can be daunting. Clinical practice guidelines are an essential tool to guide clinical decision-making and make it easier for patients to get the care they need. Clinical practice guidelines are intended to be a centralbut clearly not the onlydeterminant of treatment choice. Other factors include patients preferences and histories, providers expertise and judgment, nonspecific factors in psychotherapy, and patients individual differences.
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Cognitive Behavioral Therapy For Ptsd
Another strongly recommended therapy by APA and the VA/DoD is CBT for PTSD. The VA/DoD includes only trauma-focused CBT. APA included both trauma-focused and non-trauma-focused CBT in its recommendations including CBT-mixed, which included studies using cognitive behavioral techniques that did not fit in well with other categories, and CT, which included CT studies that were not specifically CPT. Brief trauma-focused CBT categorized by the VA/DoD included studies examining trauma-focused cognitive and/or behavioral techniques that were not specifically PE or CPT. Thus in this section, we will discuss brief therapies using trauma-focused behavioral and/or cognitive techniques as these are included in both sets of guidelines as strongly recommended.
What Are Some Evidence
While many existing evidence-supported or promising practices for the treatment of PTSD are being adapted and tested for efficacy with individuals living with severe mental illness, currently available evidence highlights Cognitive Behavioral Therapy , Cognitive Processing Therapy Prolonged Exposure Therapy , and Eye movement Desensitization and Reprocessing as the most evidence-supported trauma therapies for adults living with a disabling mental health condition. Before you begin any of the below interventions, seek out the appropriate training and supervision.
Cognitive Behavioral Therapy : CBT methods includes education about post traumatic stress disorder, normalization of the experience, and teaching coping tools for in the moment distress. View this article for more information on a 3 session therapy that is designed for people who have SMI: A Brief Intervention for Posttraumatic Stress Disorder in Persons with a Serious Mental Illness.
Cognitive Processing Therapy : CPT is a type of cognitive behavioral therapy that helps patients learn how to modify and challenge unhelpful beliefs related to the trauma. Visit the American Psychological Association for more information.
Prolonged Exposure Therapy : Prolonged exposure is a specific type of cognitive behavioral therapy that teaches individuals to gradually approach trauma-related memories, feelings and situations. Visit the American Psychological Association for more information.
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Eye Movement Desensitization Reprocessing For Ptsd
EMDR has been shown to reduce symptoms of posttraumatic stress disorder . This treatment pairs patients eye movements with their processing of traumatic memories. A patient pays attention to a back-and-forth movement or sound while they recall a traumatic memory until the distress associated with that memory decreases. Eventually, they focus on a positive belief or feeling while they hold the memory in their mind.EMDR typically consists of six to 12 sessions. Through this therapy, you:
- Learn emotional management techniques, such as relaxation techniques.
- Follow emotional management with in-depth processing of traumatic memories and the beliefs and physical symptoms attached to those memories.
To determine whether EMDR is right for you, talk with your mental health provider about your symptoms so you can work together to create the most effective treatment plan.
Five Efficacious Treatments For Posttraumatic Stress Disorder: An Empirical Review
David M. Blankenship Five Efficacious Treatments for Posttraumatic Stress Disorder: An Empirical Review. Journal of Mental Health Counseling 1 October 2017 39 : 275288. doi:
Posttraumatic stress disorder is known to be a debilitating disorder and for some a lifelong complaint. Although there are many treatment options, determining which treatments are not only recommended but show high efficacy rates is vital for clinicians. This review examines current treatment endorsements for PTSD and identifies five treatment modalities consistently recommended in the literature as most efficacious for PTSD: prolonged exposure therapy, cognitive processing therapy, trauma-focused cognitive behavioral therapy, stress inoculation training, and eye movement desensitization and reprocessing therapy. Comparison studies of each modality, limitations, and training requirements are reviewed. Research overall shows no significant differences in rates of efficacy between treatments, with mental health counselors recommended to select the approach that best fits the client population and professional goals based on identified strengths and limitations of each therapy. Additional recommendations for future directions are discussed.
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Implementing Ptsd Treatment Guideline Recommendations In Practice
It seems highly likely that more people with PTSD would benefit from medication if it were prescribed according to the current evidence base. Guidelines should facilitate this but, sadly, rarely provide sufficient detail to allow clinicians to determine the optimal way to prescribe recommended drugs. This probably contributes to their lack of widespread implementation and to sub-optimal prescribing. To address this gap, we developed the Cardiff PTSD Prescribing Algorithm to help clinicians make appropriate decisions about the pharmacological treatment of people with PTSD, primarily based on the ISTSS evidence-based recommendations. The algorithm is designed for PTSD as opposed to complex PTSD but, given the absence of evidence with respect to the pharmacological treatment of CPTSD specifically, and the overlap between PTSD and CPTSD, it also represents an evidence-informed approach to the pharmacological treatment of CPTSD.
To determine appropriate guidance for the algorithm, we considered the dosing regimens used in all the RCTs included in the meta-analyses that led to the ISTSS and NICE recommendations. Interestingly, the mean doses of all the recommended drugs used approached the maximum dose determined in the British National Formulary.4 This suggests that a significant number of people with PTSD will only benefit optimally from recommended pharmacological treatments if they take higher doses of them.