Treatments of Posttraumatic Stress Disorder in Civilian Populations
Purpose of Review
Posttraumatic stress disorder is a chronic, heterogeneous disorder for which a multitude of psychotherapies, pharmaceuticals, and immerging treatment programs are available. Majority of efficacy studies focus on Caucasian male military populations, which may be a reason why not all patients respond to treatment with long-term positive outcomes. Additionally, effects of treatment on symptom clusters have been neglected. This work reviews treatment of PTSD and its symptom clusters exclusively in civilian populations, which have been historically under-examined in the literature.
Exposure therapy stands at the forefront of successful PTSD treatment and offers a more cost-effective solution to pharmacotherapy; however, refugees and patients with comorbid depression may not experience such strong benefits. For exposure therapy and other forms of psychotherapy, non-inferiority studies point to promise of internet-delivered and telemedicine-based methods for reaching populations that may not have access to in-person care.
SSRIs are the most widely used pharmaceutical treatment for PTSD; moderate initial benefits are observed yet long-term retention and outcomes may be enhanced by adjunct treatment. Again, refugees are a group that experiences lesser benefit. Research has begun to explore efficacy of treatments for individual symptom clusters, with hyperarousal benefiting most from currently available modalities. Avoidance, intrusion, negative thoughts and beliefs, and dissociation are symptoms requiring more research for focused interventions.
Treatment of PTSD has evolved to (1) include equivalent proportions of men and women, along with focused female-exclusive cohorts; (2) explore novel methods of treatment online and in various cultural contexts; and (3) less focus on medication as evidenced by current clinical trials. In addition to further efficacy and safety studies in more diverse ethnic populations, work is needed to examine what therapies are best for targeting specific symptom clusters of PTSD. This research will drive precision treatment, and such research is beginning to point towards underlying mechanisms of pathology and change.
KeywordsPTSD Psychotherapy Pharmacotherapy Precision medicine Trauma Alternative therapy
The editors would like to thank Dr. Jennifer Severe for taking the time to review this manuscript.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 2.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.Google Scholar
- 4.Women, Trauma, and PTSD. n.d. Retrieved July 23, 2018, from https://www.ptsd.va.gov/public/PTSD-overview/women/women-trauma-and-ptsd.asp.
- 5.• Search of: Recruiting, Not yet recruiting, Active, not recruiting, Enrolling by invitation Studies | Interventional Studies | PTSD | United States - List Results - ClinicalTrials.gov. n.d. Retrieved July 17, 2018, from https://clinicaltrials.gov/ct2/results?cond=PTSD&cntry=US&recrs=b&recrs=a&recrs=f&recrs=d&age_v=&gndr=&type=Intr&rslt=&Search=Apply. Findings from ongoing trials may lead to new directions in psychiatric care. Two themes stood out from reviewing the registry: new methods of delivery through telemedicine and online resources; primary focus on pharmacotherapy and alternative therapy, with pharmacotherapy being used mainly to facilitate exposure therapy and in fewer studies than we have previous seen.
- 6.Acarturk C, Konuk E, Cetinkaya M, Senay I, Sijbrandij M, Gulen B, et al. The efficacy of eye movement desensitization and reprocessing for post-traumatic stress disorder and depression among Syrian refugees: results of a randomized controlled trial. Psychol Med. 2016;46(12):2583–93. https://doi.org/10.1017/S0033291716001070.CrossRefPubMedGoogle Scholar
- 12.• Buhmann CB, Nordentoft M, Ekstroem M, Carlsson J, Mortensen EL. The effect of flexible cognitive-behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial. Br J Psychiatry J Ment Sci. 2016;208(3):252–9. https://doi.org/10.1192/bjp.bp.114.150961 Traditionally effective treatments CBT and sertraline may not be effective for refugee populations. This was the largest refugee cohort identified and one of the longest studies. More research in this group is required to identify successful treatment strategies. CrossRefGoogle Scholar
- 14.• Ehlers A, Hackmann A, Grey N, Wild J, Liness S, Albert I, et al. A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. Am J Psychiatry. 2014;171(3):294–304. https://doi.org/10.1176/appi.ajp.2013.13040552 Demonstrated non-inferiority of intensive cognitive therapy to standard 3-month care, which may lead to better retention and reduced costs for patients. CrossRefPubMedPubMedCentralGoogle Scholar
- 16.Feder A, Parides MK, Murrough JW, Perez AM, Morgan JE, Saxena S, et al. Efficacy of intravenous ketamine for treatment of chronic posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71(6):681–8. https://doi.org/10.1001/jamapsychiatry.2014.62.CrossRefPubMedGoogle Scholar
- 19.Ghafoori B, Fisher D, Korosteleva O, Hong M. A randomized, controlled pilot study of a single-session psychoeducation treatment for urban, culturally diverse, trauma-exposed adults. J Nerv Ment Dis. 2016;204(6):421–30. https://doi.org/10.1097/NMD.0000000000000512.CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Hien DA, Levin FR, Ruglass LM, Lopez-Castro T, Papini S, Hu MC, Cohen LR, Herron A. Combining seeking safety with sertraline for PTSD and alcohol use disorders: A randomized controlled trial. J Consult Clin Psychol. 2015;83(2):359–369. https://doi.org/10.1037/a0038718.
- 23.Johnson DM, Johnson NL, Perez SK, Palmieri PA, Zlotnick C. Comparison of adding treatment of PTSD during and after shelter stay to standard care in residents of battered women’s shelters: results of a randomized clinical trial. J Trauma Stress. 2016;29(4):365–73. https://doi.org/10.1002/jts.22117.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Kwako LE, George DT, Schwandt ML, Spagnolo PA, Momenan R, Hommer DW, et al. The neurokinin-1 receptor antagonist aprepitant in co-morbid alcohol dependence and posttraumatic stress disorder: a human experimental study. Psychopharmacology. 2015;232(1):295–304. https://doi.org/10.1007/s00213-014-3665-4.CrossRefPubMedGoogle Scholar
- 27.Langkaas TF, Hoffart A, Øktedalen T, Ulvenes PG, Hembree EA, Smucker M. Exposure and non-fear emotions: a randomized controlled study of exposure-based and rescripting-based imagery in PTSD treatment. Behav Res Ther. 2017;97:33–42. https://doi.org/10.1016/j.brat.2017.06.007.CrossRefPubMedGoogle Scholar
- 30.• Littleton H, Grills AE, Kline KD, Schoemann AM, Dodd JC. The From Survivor to Thriver program: RCT of an online therapist-facilitated program for rape-related PTSD. J Anxiety Disord. 2016;43:41–51. https://doi.org/10.1016/j.janxdis.2016.07.010 Success of internet-delivered care with long-term benefit to patients. CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Meredith LS, Eisenman DP, Han B, Green BL, Kaltman S, Wong EC, et al. Impact of collaborative care for underserved patients with PTSD in primary care: a randomized controlled trial. J Gen Intern Med. 2016;31(5):509–17. https://doi.org/10.1007/s11606-016-3588-3.CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Mitchell KS, Dick AM, DiMartino DM, Smith BN, Niles B, Koenen KC, Street A. A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress. 2014;27(2):121–128. https://doi.org/10.1002/jts.21903.
- 35.Morath J, Gola H, Sommershof A, Hamuni G, Kolassa S, Catani C, et al. The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: evidence from a randomized controlled trial. J Psychiatr Res. 2014;54:1–10. https://doi.org/10.1016/j.jpsychires.2014.03.016.CrossRefPubMedGoogle Scholar
- 37.Nieminen K, Berg I, Frankenstein K, Viita L, Larsson K, Persson U, et al. Internet-provided cognitive behaviour therapy of posttraumatic stress symptoms following childbirth-a randomized controlled trial. Cogn Behav Ther. 2016;45(4):287–306. https://doi.org/10.1080/16506073.2016.1169626.CrossRefPubMedGoogle Scholar
- 39.• Popiel A, Zawadzki B, Pragłowska E, Teichman Y. Prolonged exposure, paroxetine and the combination in the treatment of PTSD following a motor vehicle accident. A randomized clinical trial - The “TRAKT” study. J Behav Ther Exp Psychiatry. 2015;48:17–26. https://doi.org/10.1016/j.jbtep.2015.01.002 The largest study of exposure therapy; the most common treatment for PTSD is in this review. PE has higher rates of remission than pharmacotherapy, and with lower rates of refusal to treatment than paroxetine. CrossRefPubMedGoogle Scholar
- 42.Rosaura Polak A, Witteveen AB, Denys D, Olff M. Breathing biofeedback as an adjunct to exposure in cognitive behavioral therapy hastens the reduction of PTSD symptoms: a pilot study. Appl Psychophysiol Biofeedback. 2015;40(1):25–31. https://doi.org/10.1007/s10484-015-9268-y.CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Sack M, Zehl S, Otti A, Lahmann C, Henningsen P, Kruse J, et al. A comparison of dual attention, eye movements, and exposure only during eye movement desensitization and reprocessing for posttraumatic stress disorder: results from a randomized clinical trial. Psychother Psychosom. 2016;85(6):357–65. https://doi.org/10.1159/000447671.CrossRefPubMedGoogle Scholar
- 48.Spence J, Titov N, Johnston L, Jones MP, Dear BF, Solley K. Internet-based trauma-focused cognitive behavioural therapy for PTSD with and without exposure components: a randomised controlled trial. J Affect Disord. 2014;162:73–80. https://doi.org/10.1016/j.jad.2014.03.009.CrossRefPubMedGoogle Scholar
- 49.Ter Heide FJJ, Mooren TM, van de Schoot R, de Jongh A, Kleber RJ. Eye movement desensitisation and reprocessing therapy v. stabilisation as usual for refugees: randomised controlled trial. Br J Psychiatry J Ment Sci. 2016;209(4):311–8. https://doi.org/10.1192/bjp.bp.115.167775.CrossRefGoogle Scholar
- 50.van den Berg DPG, de Bont PAJM, van der Vleugel BM, de Roos C, de Jongh A, Van Minnen A, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72(3):259–67. https://doi.org/10.1001/jamapsychiatry.2014.2637.CrossRefPubMedGoogle Scholar
- 55.Zatzick D, O'Connor SS, Russo J, Wang J, Bush N, Love J, Peterson R, Ingraham L, Darnell D, Whiteside L, Van Eaton E. Technology-enhanced stepped collaborative care targeting posttraumatic stress disorder and comorbidity after injury: a randomized controlled trial. J Trauma Stress. 2015;28(5):391–400. https://doi.org/10.1002/jts.22041.
- 56.Zang Y, Hunt N, Cox T. Adapting narrative exposure therapy for Chinese earthquake survivors: a pilot randomised controlled feasibility study. BMC Psychiatry. 2014;3(14):262–263. https://doi.org/10.1186/s12888-014-0262-3.
- 57.Zoellner LA, Telch M, Foa EB, Farach FJ, McLean CP, Gallop R, et al. Enhancing extinction learning in posttraumatic stress disorder with brief daily imaginal exposure and methylene blue: a randomized controlled trial. J Clin Psychiatry. 2017;78(7):e782–9. https://doi.org/10.4088/JCP.16m10936.CrossRefPubMedGoogle Scholar
- 58.Cognitive Behavioral Therapy (CBT) for Treatment of PTSD. n.d. Retrieved July 17, 2018, from http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx.
- 59.Cognitive Processing Therapy (CPT). n.d. Retrieved July 17, 2018, from http://www.apa.org/ptsd-guideline/treatments/cognitive-processing-therapy.aspx.
- 61.Raes F, Williams JMG, Hermans D. Reducing cognitive vulnerability to depression: a preliminary investigation of MEmory specificity training (MEST) in inpatients with depressive symptomatology. J Behav Ther Exp Psychiatry. 2009;40(1):24–38. https://doi.org/10.1016/j.jbtep.2008.03.001.CrossRefPubMedGoogle Scholar
- 62.EMDR Institute. Retrieved July, 2018, from http://www.emdr.com/
- 63.Najavits LM. Seeking safety: a treatment manual for PTSD and substance abuse. New York: Guilford Press; 2002.Google Scholar
- 65.Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults: (501872017-001). [Data set]. American Psychological Association. 2017. https://doi.org/10.1037/e501872017-001.
- 67.Zatzick D, Jurkovich G, Rivara FP, Russo J, Wagner A, Wang J, et al. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Ann Surg. 2013;257(3):390–9. https://doi.org/10.1097/SLA.0b013e31826bc313.CrossRefPubMedPubMedCentralGoogle Scholar
- 68.Berger W, Mendlowicz MV, Marques-Portella C, Kinrys G, Fontenelle LF, Marmar CR, et al. Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review. Prog Neuro-Psychopharmacol Biol Psychiatry. 2009;33(2):169–80. https://doi.org/10.1016/j.pnpbp.2008.12.004.CrossRefGoogle Scholar
- 69.Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) | National Heart, Lung, and Blood Institute (NHLBI). n.d. Retrieved July 17, 2018, from https://www.nhlbi.nih.gov/science/antihypertensive-and-lipid-lowering-treatment-prevent-heart-attack-trial-allhat.
- 70.Nestler EJ, Hyman SE, Holtzman DM, Malenka RC. Reinforcement and addictive disorders. In Molecular Neuropharmacology: A Foundation for Clinical Neuroscience. 3rd ed. New York: McGraw-Hill Education; 2015. Retrieved from https://neurology.mhmedical.com/content.aspx?aid=1105916764 Google Scholar
- 72.Le QA, Doctor JN, Zoellner LA, Feeny NC. Cost-effectiveness of prolonged exposure therapy versus pharmacotherapy and treatment choice in posttraumatic stress disorder (the optimizing PTSD treatment trial): a doubly randomized preference trial. The Journal of Clinical Psychiatry. 2014;75(3):222–30. https://doi.org/10.4088/JCP.13m08719.CrossRefPubMedGoogle Scholar
- 74.Van Der Kolk BA. Trauma and memory. Psychiatry Clin Neurosci. 1998;52:S52–64. https://doi.org/10.1046/j.1440-1819.1998.0520s5S97.x.CrossRefGoogle Scholar
- 75.• Michopoulos V, Powers A, Gillespie CF, Ressler KJ, Jovanovic T. Inflammation in Fear- and Anxiety-Based Disorders: PTSD, GAD, and Beyond. Neuropsychopharmacology. 2017;42(1):254–70. https://doi.org/10.1038/npp.2016.146 The relationship between inflammation and symptom severity is a new target both for treatment and as use for predicting development of trauma-related disorders shortly following a trauma. Somatically engaging interventions may be well-suited to address inflammation. CrossRefPubMedGoogle Scholar
- 77.Dai W, Kaminga AC, Tan H, Wang J, Lai Z, Wu X, et al. Comorbidity of post-traumatic stress disorder and anxiety in flood survivors. Medicine. 2017;96(36). https://doi.org/10.1097/md.0000000000007994.